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C.M. Delany, T. John, M.E. John; "Sandwich Keratitis" (SK) after Deep Lamellar Endothelial Keratoplasty (DLEK) . Invest. Ophthalmol. Vis. Sci. 2003;44(13):1396.
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Purpose: To report a new form of keratitis, known as "sandwich keratitis"(SK), following Deep Lamellar Endothelial Keratoplasty (DLEK). SK has significant clinical and surgical implications that are different from those of a corneal ulcer. Methods: A 74 year-old women underwent bilateral DLEK (disk diameter 8.0mm), about 6 months apart, for pseudophakic bullous keratopathy. SK necessitated a therapeutic penentrating keratoplasty (TPK) in the left eye. Corneal tissues were studied by light and electron microscopy (scanning and transmission electron microscopy). Results: Six weeks after DLEK, significant SK developed, which was comprised of numerous discrete 4+ (scale 1-4+) infiltrate collections in the interface of the corneal sandwich. Unlike a corneal ulcer, the patient was disproportionately comfortable with no ocular complaints. There was minimal conjuctival injection and no lid edema. TPK is challenging in SK because the sandwich must be removed intact to prevent direct spillage of numerous organsims into the anterior chamber. Following TPK, corneal and anterior chamber fluid cultures grew Candida glabrata, and immunohistochemical staining was positive for herpes simplex in the endothelium. Pre-TPK conjunctival culture grew coagulase-negative Staphylococcus species. Electron microscopy showed inflammatory cells in the corneal sandwich. The patient was treated with antibacterial, antifungal, and antiviral agents. Conclusions: This is the first report of SK, a new clinical entity. Unlike a corneal ulcer, SK has atypical symptoms and signs and carries a surgical challenge to its management. Patients with a significant SK after DLEK may be asymptomatic, and clinicians should be aware of this new entity.
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