April 2009
Volume 50, Issue 13
ARVO Annual Meeting Abstract  |   April 2009
Sandwich Infectious Keratitis ("SIK") - A New Clinical Entity Following Lamellar Keratoplasty (DLEK, DSAEK, DALK, ALK)
Author Affiliations & Notes
  • T. John
    Ophthalmology, Loyola University at Chicago, Tinley Park, Illinois
    Thomas John Vision Institute, Tinley Park and Oak Lawn, Illinois
  • C. Karp
    Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida
  • E. Malbran
    Ophthalmology, Clinica Oftalmologica Malbran, Buenos Aires, Argentina
  • L. Wiley
    Ophthalmology, West Virginia University, Morgantown, West Virginia
  • M. John
    Thomas John Vision Institute, Tinley Park, Illinois
  • T. O'Brien
    Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida
  • J. Kieval
    Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida
  • R. K. Forster
    Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida
  • M. Gorovoy
    Gorovoy Eye Center, Ft. Lauderdale, Florida
  • Footnotes
    Commercial Relationships  T. John, None; C. Karp, None; E. Malbran, None; L. Wiley, None; M. John, None; T. O'Brien, None; J. Kieval, None; R.K. Forster, None; M. Gorovoy, None.
  • Footnotes
    Support  Perritt Charitable Foundation
Investigative Ophthalmology & Visual Science April 2009, Vol.50, 631. doi:
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      T. John, C. Karp, E. Malbran, L. Wiley, M. John, T. O'Brien, J. Kieval, R. K. Forster, M. Gorovoy; Sandwich Infectious Keratitis ("SIK") - A New Clinical Entity Following Lamellar Keratoplasty (DLEK, DSAEK, DALK, ALK). Invest. Ophthalmol. Vis. Sci. 2009;50(13):631.

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      © ARVO (1962-2015); The Authors (2016-present)

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Purpose: : To report sandwich infectious keratitis ("SIK") a new clinical entity of interface infections after deep lamellar endothelial keratoplasty (DLEK), Descemet stripping automated endothelial keratoplasty (DSAEK), pre-Descemetic deep anterior lamellar keratoplasty (DALK), and anterior lamellar keratoplasty (ALK).

Methods: : Four cases of SIK were identified and retrospectively reviewed.

Results: : Case 1: 74-yoF underwent DLEK OU for pseudophakic bullous keratopathy. Left SIK required a therapeutic keratoplasty (TKP). Cornea was evaluated by immunohistochemistry (IH), light, scanning and transmission electron microscopy (SEM, TEM). SIK developed 6 wks after DLEK with 4+ (scale 1-4+) interface infiltrates. Corneal and AC fluid cultures grew Candida (Torulopsis) glabrata. IH revealed endothelial herpes simplex. Conjunctival culture grew coagulase-negative Staphylococcus species. SEM and TEM revealed bacteria, fungi, and inflammatory cells in the corneal sandwich. Patient received antibacterial, antifungal, and antiviral agents. Case 2: 77-yoM developed SIK with hypopyon 3 wks after right DSAEK. Anterior chamber (AC) tap and antibiotic injection were performed. Cultures confirmed Candida glabrata. Treatment included AC injection of voriconazole 50 µm/0.1cc, topical natamycin and oral posaconazole. Later natamycin was replaced with topical voriconazole, and Prednisolone acetate 1% with cyclosporine A 2% drops. SIK resolved on medical treatment. Case 3: SIK developed 6 days after pre-Descemetic DALK for keratoconus. Smear, culture and PCR were positive for Streptococcus pneumoniae. Interface lavage, moxifloxacin, tobramycin, fortified vancomycin and lamellar keratoplasty were required. Streptococcal crystalline keratitis 17 mths later was cured with medical therapy and TKP. Case 4: 34-yoF developed SIK 19 mths post 2-stage ALK for lattice dystrophy. Culture was positive for 2 strains of coagulase-negative Staphylococcus. Moxifloxacin, fortified vancomycin and tobramycin resulted in resolution of infiltrate.

Conclusions: : SIK is a new clinical entity. Unlike a corneal ulcer, SIK has atypical symptoms and signs and is challenging to treat surgically and medically. Clinicians should be aware of this new entity.

Keywords: cornea: clinical science • keratitis • cornea: stroma and keratocytes 

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