Alternaria Keratitis after Deep Anterior Lamellar Keratoplasty
A 30-year-old male patient presented with the complaints of decreased vision in both eyes for 25 years. His best corrected visual acuity (BCVA) was 20/60, N6 and 20/80, N10 in the right and left eyes respectively. On examination, he had bilateral central, leucomatous, vascularized corneal opacity, which was larger in the left eye [] as compared with the right eye. The rest of the ocular and systemic examination was normal. Patient was not a diabetic or hypertensive.\nPatient underwent deep anterior lamellar keratoplasty (DALK) in the left eye. Post-operatively, patient was prescribed topical 0.5% moxifloxacin, 0.3% tobramycin, 0.1% dexamethasone and 2% hydroxypropyl methyl-cellulose 6 times/day and 1% atropine once at night. Patient developed a recurrent epithelial defect over the next 3 months with a BCVA of 20/60. The defect was treated with a bandage contact lens (BCL). At the 3 month follow-up visit, patient presented with reduced vision in the left eye (BCVA 20/200) along with redness and pain. Patient was a driver by occupation and resumed his work 2 days prior when he had an episode of dust particles entering into the left eye. On examination, dust particles were present along with an epithelial defect in the graft. Patient was started on topical 0.3% fluconazole, 0.5% moxifloxacin 0.3% tobramycin along with 2% hydroxypropyl methyl-cellulose eye ointment 6 times/day and 1% carboxymethyl-cellulose hourly.\nOne week later, a large brown pigmented dry lesion was present on the graft []. With a working diagnosis of keratitis, corneal scrapping was performed, which showed segmented filamentous fungi on 10% potassium hydroxide mount [] as well as on lactophenol blue stain [].\nCulture on sabouraud dextrose agar at 30°C yielded colonies of Alternaria species within 7 days of incubation []. Oral fluconazole (150 mg) twice daily were started in addition to the topical medications. Patient did not respond to medical therapy and had to undergo a repeat DALK. After removal of the old graft button, four drops of amphotericin B (5 μ/0.1 ml) were place on Descemet's membrane. Patient was prescribed oral fluconazole 150 mg twice daily, ofloxacin 200 mg twice daily and acetazolamide 250 mg twice daily along with topical 5% natamycin, 0.5% moxifloxacin, 0.3% tobramycin, 0.1% dexamethasone, in addition to 2% hydroxypropyl methyl-cellulose 6 times/day and 1% carboxymethyl-cellulose CMC 8 times/day. A BCL was placed for the epithelial defect. Patient improved with complete epithelial healing in 2 weeks and topical 5% natamycin was changed to 1% voriconazole. At 1 month follow-up, the left eye BCVA was 20/60 that remained stable at 11 months follow-up []. The graft remained clear with no signs of recurrence of fungal infection.