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Year : 2005  |  Volume : 53  |  Issue : 1  |  Page : 67-68

A Cluster of Cases of Mycobacterium chelonei Keratitis following Penetrating Keratoplasty

Aravind Eye Hospitals & Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission18-Jan-2003
Date of Acceptance24-Oct-2003

Correspondence Address:
M Srinivasan
, Aravind Eye Hospitals & Postgraduate Institute of Ophthalmology, 1 Anna Nagar, Madurai - 625 020, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.15292

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Cluster infection with Mycobacterium chelonei following penetrating keratoplasty is described. All the donor eyes were harvested from the same collection centre. This underscores the importance of adherence to sterile protocols.

Keywords: Penetrating keratoplasty, Mycobacterium chelonei keratitis, eye collection center

How to cite this article:
Srinivasan M, Prajna L, Prajna N. A Cluster of Cases of Mycobacterium chelonei Keratitis following Penetrating Keratoplasty. Indian J Ophthalmol 2005;53:67-8

How to cite this URL:
Srinivasan M, Prajna L, Prajna N. A Cluster of Cases of Mycobacterium chelonei Keratitis following Penetrating Keratoplasty. Indian J Ophthalmol [serial online] 2005 [cited 2020 Nov 27];53:67-8. Available from: https://www.ijo.in/text.asp?2005/53/1/67/15292

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Non-tuberculosis Mycobacteria (NTM), also known as atypical Mycobacteria [1] are known to cause both ocular [2],[3] and adnexal infections. We report a cluster of ocular NTM infections following penetrating keratoplasty (PK), where the source of the infection could be traced to one particular eye collection centre. One illustrative case is described and brief details of tabulated [Table - 1].

  Case report Top

A 22-year-old female patient presented with 3 mm x 3.5 mm corneal infiltration straddling the 10′o clock and 11′o clock sutures and involving both donor and recipient tissue, five months after PK was performed for macular corneal dystrophy [Figure]. The rest of the graft was clear. Gram′s stain revealed gram-positive bacilli, which was 20% acid fast by Ziehl-Neelsen, and the culture grew NTM. Topical 0.3% gentamicin and 1% amikacin was instilled in the affected eye. The infiltration healed slowly over two months, and resulted in graft failure. Regraft was performed three months after complete healing.

In all the patients described here ([Table - 1]), an 8 over 7.5 mm optical graft was performed by a single surgeon. The five corneal tissues used for grafting in these series were procured from four donors; the details are enumerated in [Table - 1]. The age group of the donors ranged from 23 to 80 years. The corneoscleral rim, isolated under a laminar flow hood and preserved in MK medium, was used for surgery within 48 hours. The patients were admitted to the hospital for five days. All patients received 0.3% ofloxacin four times per day and 0.1% dexamethasone 6 times per day. At one-month follow up, the corticosteroids were tapered to three times a day, and antibiotics were continued at the same frequency for three months. Review was done at monthly intervals for three months. None of these patients had suture removal before the onset of the present symptoms.

Gram staining revealed gram-positive bacilli. Since the morphology of the bacilli was not adhering to diptheroids or bacillus species, a 20% Ziehl-Neelsen was performed which showed acid-fast bacilli. Further material from the ulcer was scraped and plated on to blood agar, Lowenstein Jensen (LJ) medium, and potato dextrose agar. Mycobacterium species grew on blood agar and LJ medium within 3 days and a Ziehl-Neelsen staining confirmed atypical Mycobacterium . They were then speciated as Mycobacterium chelonei in a reference laboratory.

  Discussion Top

Mycobacterium chelone i keratitis is reported to develop 2-8 weeks after corneal trauma or surgery and rarely delayed onset keratitis occurring as long as two years after has also been reported.[4] In the earliest stages of keratitis, the corneal stroma is characterised by thin radiating lines, which gives the appearance of cracked glass. Satellite lesions also may develop as the infection progresses. The current recommended therapy is frequent application of amikacin 10 to 20 mg/ml. Other antibiotics reported to be effective against and M. chelonei include ciprofloxacin, ofloxacin, tobramycin and cefotoxime.

The eye bank of our institute procured 378 tissues during November 2000 - January 2001, (in which the five infectious cases were encountered). Of these, 219 optical grafts were performed at our center. The main sources for the donor tissue were from the city and five other donor collection centers from different parts of the state. A total of 35 eyes were collected from that particular eye collection centre during this period. Apart from these five cases, no other cases of post keratoplasty infection were reported from our centre during this period.

In our present series of five cases, all presented within 2 to 6 months with a corneal infiltrate. In a majority of these, the infiltrate was present in the graft-host junction. Four of these five patients presented to us after corticosteroids were completely tapered and one patient (patient no.3) presented with infiltration even while he was on tapering doses of corticosteroids. The first case was mistaken for diptheroids, because of the morphology on Gram stain. Possible misdiagnosis may result if corneal scrapings are subjected only to Gram staining.[5] But with subsequent culture and restaining with Ziehl-Neelsen stain, the presence of NTM was confirmed. After presentation of the remaining four cases, an attempt was made to identify a common source. We found that all the donor corneas were procured from a single eye collection centre. Since all these donor deaths happened at home, enucleation was performed at their respective houses by a registered physician having prior experience in enucleating eyes. After the enucleation was completed, it was transported to the hospital in moist chamber containers. The indicator did not show any colour change. A swab from the donor eye or culture of cornea scleral rim is done only in cases of suspected infection and is not routine. On detailed enquiry at this collection centre, it was found that adequate sterile precautions were not followed. The contamination during tissue retrieval may have occurred from using unsterile containers for transporting the eyeballs.

In summary, surgically acquired NTM tends to occur in clusters in surgical facilities. In our series all five were acquired from a common facility. All the isolates were sensitive to gentamicin and amikacin. This underscores the importance of absolutely sterile conditions for the collection and transportation of the eyes. Efforts should be made to emphasize the importance of sterility at the collection site and creating awareness about potential complications.

  References Top

Runyon EH. Anonymous mycobacteria in pulmonary disease. Med Clin North Am 1959;43:273-89.  Back to cited text no. 1
Richardson P, Crawford GJ, Smith DW. Mycobacterium chelonei keratitis. Aust NZ J Ophthalmol 1989;17:195-96.  Back to cited text no. 2
Roussel TJ, Stern WH, Goodman DF, Whitcher JP: Postoperative mycobacterial endophthalmitis. Am J Ophthalmol 1989;107:403-06.  Back to cited text no. 3
Samuel F.A Fulcher, Robert C Fader, RH Rosa Jr. and Gary P Holmes. Delayed onset mycobacterial keratitis after lasik. Cornea 2002;21:546-54.  Back to cited text no. 4
Garg P, Athmanathan S, Rao GN. Mycobacterium chelonei masquerading as cornybacterium in a case of infectious keratitis: a diagnostic dilemma. Cornea 1998;17:230-32.  Back to cited text no. 5


  [Figure - 1]

  [Table - 1]

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