Candida Parapsilosis Keratitis: An Unusual Case With A 10 Year Journey From Corneal Interstitial Scarring To Endothelial Failure

Candida keratitis is a rare presentation with a highly heterogenous presentation and frequently poor visual outcomes in a significant proportion of patients. We hope this unusual presentation of a slowly progressing infection, with approximately 10 years between first experiencing symptoms and eventual diagnosis, raises awareness of this sight-threatening condition and the potentially insidious appearance.

This patient was managed in the eye department of the James Paget University Hospital, United Kingdom.

A 63-year old man presented with a 1 year history of gradual left eye blurring, associated with intermittent watering and photophobia. Visual acuity was 6/5 Snellen in the right eye and 6/9 in the left eye. Examination revealed a small area of superior corneal stromal scarring in the left eye with associated microcystic oedema.

After management with sodium chloride ointment, the oedema eventually cleared. The scarring and vision remained stable after a year and a half of monitoring, and the patient was subsequently discharged from the hospital eye service.

Approximately 6 years later, he re-presented with a large reduction of vision in the left eye to 6/19. There was new superior corneal oedema and reduced corneal sensation, and a working diagnosis of disciform keratitis was made. The patient was trialled on a course of topical steroid with topical and oral anti-viral treatment. A viral conjunctival swab returned as negative and the corneal oedema worsened with vision subsequently dropping to 6/30.

The patient was offered a combined cataract surgery and descemet’s membrane endothelial keratoplasty, and underwent uneventful surgery. An aqueous sample was sent for microbiological analysis and Candida parapsilosis was subsequently cultured.

Vision in the left eye remained excellent at 6/7.5, with a clear graft and non-inflamed eye. Thus the patient was not commenced on any anti-fungal treatment only monitored closely, showing good long-term progress so far.

While known to present sub-acutely over several weeks or months, with pain a classic symptom, we highlight an unusual presentation of a largely painless presentation of Candida keratitis that progressed over several years from mild stromal scarring to endothelial failure.

Extensive investigation - including anterior chamber paracentesis - is invaluable in cases of corneal endothelial failure where there is no obvious cause