CASE REPORT Microbial Keratitis After Descemet Stripping Automated Endothelial Keratoplasty Namrata Sharma, M.D., Prakash Chand Agarwal, M.D., Chandra Shekhar Kumar, M.D., Rashim Mannan, M.D., and Jeewan S. Titiyal, M.D. Background: To report two cases of corneal infection after Descemet stripping automated endothelial keratoplasty (DSAEK). Methods: Two eyes of two patients demonstrated varying clinical presentations of microbial keratitis after DSAEK. At the initial presentation, the keratitis involved the host cornea alone in case 1, whereas in case 2, the posterior lamellar disk alone was involved. A pair of microvitrectomy scissors was used in case 2 from the side port to obtain a 2-mm sample of the posterior lamellar disk for microbiologic evaluation. The keratitis did not respond to medical therapy, and therapeutic penetrating keratoplasty was performed to resolve the infection in both the eyes. The main outcome measures were resolution of infection, absence of recurrence of keratitis, graft clarity, and visual outcome. Results: There was complete resolution of infection after full thickness therapeutic grafts with best-corrected visual acuities of 20/60 and 20/40, respectively. Conclusions: Initial presentation of microbial keratitis after DSAEK may involve either the host or the posterior lamellar disk alone. A micro- vitrectomy scissors through the side port may be used for biopsy of posterior lamellar disk in recalcitrant infection. Key Words: DSAEK—Keratitis—Descemet stripping automated endothe- lial keratoplasty—Endothelial keratoplasty. (Eye & Contact Lens 2011;37: 320–322) D escemet stripping automated endothelial keratoplasty (DSAEK) is a transplant surgery indicated in cases of endothelial decompensation. 1 Because of the presence of few sutures, the chances of suture-related infections may be decreased compared with a full-thickness transplant. We report two different presentations of microbial keratitis that may occur after DSAEK and describe a new method to obtain samples for microbiologic evaluation in cases of endothelial keratoplasty. CASE 1 A 62-year-old man underwent an uneventful DSAEK for pseudophakic bullous keratopathy in his left eye. An 8.0-mm posterior lamellar disk was inserted through a 4.0-mm corneal tunnel incision. Five weeks postsurgery, the patient reported redness, pain, decreased vision, and photophobia. The patient was on topical Prednisolone acetate (1%) two times a day at the time of presentation. On examination, the best corrected visual acuity (BCVA) was 20/400 in the left eye there was a corneal ulcer with an infiltrate size of 6.0 3 6.6 mm and an overlying epithelial defect of 4.0 3 4.4 mm along with a hypopyon of 1.2 mm. The posterior lamellar disk was clinically clear and apparently not involved. The patient was started on concentrated cefazolin sodium (5%) and tobramycin sulfate (1.3%) eyedrops hourly along with cycloplegics. Corneal scraping was obtained from the leading edge of the ulcer, which was directly plated on blood agar and Sabouraud agar. Culture examination revealed the presence of coagulase negative Staphylococcus. After 8 days of treatment, the keratitis worsened. On anterior segment optical coherence tomography, anterior stromal thinning was seen overlying the posterior lamellar disk (Fig. 1A–D) . The donor corneal rim culture from which the posterior lamellar disk was obtained was sterile. Therapeutic penetrating keratoplasty was performed using a 9.0-mm graft. Postoperatively, the patient received topical gatifloxacin sesquihydrate (0.3%) drops four times a day, topical prednisolone acetate (1%) four times a day with cycloplegics and lubricants. The microbiologic examination of the anterior host tissue revealed the presence of Staphylococcus aureus, whereas that of the posterior donor disk did not reveal the growth of any organism. At 6 months’ follow-up, the graft was clear (Fig. 2), and the BCVA was 20/60 OS. CASE 2 A 62-year-old man with bilateral Fuch endothelial dystrophy and immature senile cataract underwent uneventful DSAEK with phacoemulsification and intraocular lens implantation in the right eye, 4 months before. An 8.5-mm posterior lamellar disk had been trans- planted through a 4.0-mm corneal tunnel incision. At 3 months’ follow- up, the graft was clear, and the patient had a BCVA of 20/40. However, 1 month later, the patient presented with diminution of vision, pain, and redness. The patient was on topical Prednisolone acetate (1%) three times a day at the time of presentation. The posterior lamellar graft was edematous and opaque with an overlying epithelial defect of 6.2 3 6.6 mm, infiltrate size of 8.0 3 8.6 mm, and a hypopyon of 1 mm. The graft clarity was decreased, and the BCVA dropped to 20/400 OD (Fig. 3). Corneal scraping was obtained from the site of the epithelial defect and directly plated on blood agar and Sabouraud agar; the culture was sterile. The patient was started on concentrated cefazolin sodium (5%) and tobramycin sulfate (1.3%) eyedrops hourly with cycloplegics. The From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. The authors have no proprietary interest or financial interest to disclose. Address correspondence and reprint requests to Namrata Sharma, M.D., Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India; e-mail: namrata103 @hotmail.com Accepted January 4, 2011. DOI: 10.1097/ICL.0b013e31820e7144 320 Eye & Contact Lens  Volume 37, Number 5, September 2011 Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.