Candida Parapsilosis Keratitis Following Intracorneal Ring Segment Implantation (Icrs) For Keratoconus : About Eight Cases

To describe the clinical, anatomical, bacteriological and therapeutic aspects of Candida Parapsilosis keratitis following intracorneal ring segment implantation (ICRS) for keratoconus.

Fungal keratitis can be a potentially sight-threatening complication associated with intracorneal ring segments. It is a major diagnostic and therapeutic challenge for the ophthalmologist. We report eight cases referred to Cheikh Zaid International Hospital, Eye center, Rabat, MOROCCO.

This is a descriptive study of eight cases who underwent intra-corneal ring segment implantation for keratoconus and referred to our department for the management of microbial keratitis between April 2021 and January 2022. The medical history, initial clinical presentation (visual acuity assessment by a semiquantitative method, slit lamp examination, depth of the corneal infiltrate by anterior segment optical coherence tomography, endophthalmitis assessment by B-scan ocular ultrasound),   bacteriological (direct examination, aerobic culture and Lowenstein-Jensen medium) and anatomopathological aspects were described.

The mean time of onset of symptoms was of 2 months [range 1-6 months]. Initial visual acuity was limited to Hand motion (2.3LogMar) in 6 patients, and Light Perception in two patients. The clinical appearance consisted of large, deep, white flaky corneal infiltrates , with an initial presentation of acute corneal melt and large keratitis in two patients requiring therapeutic keratoplasty. The corneal infiltrate extended to the posterior stroma on corneal imaging. Microbiological analysis confirmed the presence of Candida parapsilosis. A personalized and individualized treatment regimen for each patient included topical and/or intravenous antifungal therapy and/or intrastromal injections.

Sporadic cases of fungal keratitis after intra-corneal ring implantation have been reported in the literature. However, this is the only case series describing an infection with Candida parapsilosis associated with ICRS. This study allows us to insist on the need to respect standardized practices for the management of medical devices in the ophthalmic operating room, and reflects the therapeutic difficulties in the management of fungal keratitis. In the presence of corneal infiltrates, it is crucial to distinguish sterile corneal infiltrates from infectious ones. A lack of improvement after antibiotic treatment or worsening after corticosteroid therapy should strongly suggest a fungal infection.