IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 19, Issue 5 Ser.5 (May. 2020), PP 36-39 www.iosrjournals.org DOI: 10.9790/0853-1905053639 www.iosrjournal 36 | Page Therapeutic Deep anterior lamellar keratoplasty for a case of non-resolving microbial keratitis Dr. Anushri Agrawal 1 , Dr. Jagadeesh Kumar Reddy 1 , Dr. K. S. Siddharthan 1 , Dr. Pooja CM 1 , Dr. Vandhana Sundaram 1 1 (Cornea, Sankara eye hospital, Coimbatore, India) Abstract: Microbial keratitis is a potentially vision threatening condition that requires prompt diagnosis and treatment to prevent untoward outcomes. Here we describe the successful outcome of DALK performed for a case of fungal keratitis unresponsive to medical treatment. A 38 years old man who presented to us with fungal keratitis was started on topical antifungal treatment. There was no significant improvement after 1 month of treatment. Since the infiltrate was extending upto deep corneal stroma but not upto Descemet’s membrane, heunderwent Deep lamellar keratoplasty (DALK) as a surgical alternative to penetrating keratoplasty in the management of non-healing fungal keratitis. Our patient had fast postoperative recovery with no evidence of recurrence of infection till with the lamellar graft remaining clear. At last follow-up, 6 months after surgery, the graft remained clear with a BCVA of 6/24. Hence, therapeutic DALK with total removal of infected stromal tissue down to Descemet membrane may be performed in cases of severe, unresponsive microbial keratitis as a viable alternative to conventional penetrating keratoplasty. Key Words: Deep anterior lamellar keratoplasty, Fungal keratitis, Therapeutic keratoplasty, Microbial keratitis --------------------------------------------------------------------------------------------------------------------------------------- Date of Submission: 29-04-2020 Date of Acceptance: 13-05-2020 --------------------------------------------------------------------------------------------------------------------------------------- I. Introduction An estimate of 1.5 to 2 million cases of corneal ulcers occur annually in the developing countries.(1)The severity of microbial keratitis usually depends on the underlying condition of the cornea and the virulence of the infecting microbes. The prognosis is poor if an appropriate and aggressive therapy is not initiated immediately.(2) Advanced ulcers which do not respond to medical treatment require surgical intervention. However, therapeutic grafts are considered at high risk for subsequent failure due to multiple factors like recurrence of infection, severe vascularization and stromal inflammation in the graft bed, leading to subsequent endothelial rejection and failure.(3)However, recently, attempts have been made to perform lamellar keratoplasty in cases of nonperforated bacterial and fungal keratitis. DALK has several advantages over penetrating keratoplasty since the endothelium is retained, obviating the risk of endothelial rejection.(4–6) Here we describe the successful outcome of DALK performed for a case of fungal keratitis unresponsive to medical treatment. II. Case Report The 38 years old man presented to the Cornea services outpatient department with complaints of redness in the right eye for 5 days; accompanied with eye pain, photophobia, and blurred vision. He gave history of injury with a stone 5 days back. On examination, his best corrected visual acuity(BCVA) was HM+ with accurate projection of rays in right eye and 6/6 in left eye. Slit-lamp biomicroscopic examination revealed a central 4.0*4.0 mm deep corneal stromal infiltrate with ill-defined margins covering the pupillary area. A hypopyon of 1 mm was also noted. Corneal smear was performed, and the scrapings were sent for bacterial and fungal cultures. KOH mount came positive for fungal hyphae. Patient was diagnosed with Fungal keratitis and admitted in the hospital. He was started on 5% Natamycin eyedrops hourly, 1% Ketoconazole eyedrops 2-hourly and cycloplegics. There was slight improvement in the infiltrate size with healing margins. The culture report showed growth of Aspergillus flavus. After careful observation over a week, the patient was discharged and kept on weekly reviews. Despite this aggressive combination therapy, there was no significant improvement in his condition with persistence of ulceration covering the visual axis and intense stromal inflammation. At the end of 1 month, no further improvement in infiltrate was noted and the hypopyon increased to 2mm (Fig. 1). In view of the poor response after 4 weeks of intensive treatment, we decided to intervene surgically. The patient was planned for a therapeutic DALK. Superficial trephination of 7.0mm was done followed by manual dissection of host stroma. Infiltrate could be removed completely with clear margins with the use of blunt-tipped corneal scissors, without Descemet perforation. Inspection of Descemet membrane confirmed its