title: Candida interface keratitis after deep anterior lamellar keratoplasty: clinical, microbiologic, histopathologic, and confocal microscopic reports.
abstract: OBJECTIVE
  To report the clinical, histopathologic, microbiologic, and confocal microscopic features of Candida keratitis after deep anterior lamellar keratoplasty (DALK).
  
  
  METHODS
  We performed clinical, confocal scan, microbiologic and histopathologic examinations on two corneas from 2 young patients who underwent DALK for keratoconus.
  
  
  RESULTS
  The first patient presented with asymptomatic white to cream-colored interface deposits 2 months after DALK. The confocal scan disclosed clusters of hyperreflective, fine granular deposits at the region of interface, with no evidence of inflammation or hyphaelike structures. The clinical presumption of possible "epithelial downgrowth" was suggested, and because of the progression of these lesions, irrigation of the interface was considered. Finally, penetrating keratoplasty was performed because of a rupture in the Descemet membrane. Histopathologic examination of the cornea disclosed yeastlike structures within the interface area. The microbiologic results of the irrigation fluid showed Candida glabrata. The second patient presented with a symptomatic infiltration of the inferior interface close to the suture site 2.5 months after DALK. The confocal scan showed foci of inflammation with clusters of hyperreflective round-shaped structures that resembled epithelial cells. Clinically, there was a suggestion of epithelial downgrowth, and subsequently, penetrating keratoplasty was performed because of the progression of the lesion. Histopathologic examination of the cornea disclosed an acute and chronic granulomatous keratitis caused by yeastlike structures. The microbiologic results revealed infection with Candida albicans.
  
  
  CONCLUSIONS
  These are the first reported occurrences of interface Candida keratitis after DALK and with different confocal features. The clinical and the confocal features of interface Candida keratitis may be similar to those seen in epithelial downgrowth, which may postpone correct diagnosis and treatment. Candida keratitis should be considered in cases of interface deposits after any form of lamellar keratoplasty.
authors.affiliation: Labbafinejad Ophthalmic Research Center, Shaheed Beheshti Medical University, Tehran, Iran. info@iraneyebank.org
authors.forename: Mozhgan Rezaei
authors.initials: MR
authors.lastname: Kanavi
authors.forename: Ali Reza
authors.initials: AR
authors.lastname: Foroutan
authors.forename: Mohsen Rahmati
authors.initials: MR
authors.lastname: Kamel
authors.forename: Nikoo
authors.initials: N
authors.lastname: Afsar
authors.forename: Mohammad Ali
authors.initials: MA
authors.lastname: Javadi
mesh_terms: D000328:Adult; D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D002176:Candida albicans / Q000302:isolation & purification; D041221:Candida glabrata / Q000302:isolation & purification; D002177:Candidiasis / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D003315:Cornea / Q000382:microbiology; D016039:Corneal Transplantation / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D015821:Eye Infections, Fungal / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D006801:Humans; D007634:Keratitis / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D007640:Keratoconus / Q000601:surgery; D015948:Keratoplasty, Penetrating; D007654:Ketoconazole / Q000627:therapeutic use; D008297:Male; D018613:Microscopy, Confocal; D010866:Natamycin / Q000627:therapeutic use; D011183:Postoperative Complications
chemical_list: D000935:Antifungal Agents; D000666:Amphotericin B; D010866:Natamycin; D007654:Ketoconazole