Early Therapeutic Dalk For Stromal Candida Keratitis After Intracorneal Ring Segment Explantation

To describe the role of early therapeutic deep anterior lamellar keratoplasty (DALK) in the management of stromal Candida keratitis after intracorneal ring segment (ICRS) explantation unresponsive to medical therapy, emphasizing the importance of stromal depth assessment to eradicate infection while preserving host endothelium and improving long-term visual outcomes.

Oftalmocenter – Centro Especializado de Oftalmología, Quito, Ecuador. Tertiary referral center for advanced lamellar corneal surgery with multimodal imaging, surgical video documentation, microbiological and histopathological confirmation, and long-term follow-up.

A 27-year-old woman with keratoconus underwent ICRS implantation at another institution. The segment was explanted three months later because of infectious keratitis, but progressive stromal opacity and visual deterioration persisted despite medical therapy. Anterior segment OCT confirmed deep stromal involvement with an intact endothelium. Therapeutic DALK was performed to completely remove infected tissue. Microbiological culture and histopathology confirmed Candida guilliermondii. Postoperative course, visual outcomes, and recurrence were evaluated over 18 months.

Therapeutic DALK achieved complete removal of infected stroma without intraoperative perforation. The graft remained clear with no recurrence of infection during 18 months of follow-up. Best-corrected visual acuity improved from 20/250 preoperatively to 20/40. Histopathology demonstrated fungal elements with stromal necrosis, and culture confirmed Candida guilliermondii. Endothelial preservation allowed rapid visual rehabilitation and avoided the risks associated with penetrating keratoplasty.

Early therapeutic DALK is an effective strategy for medically unresponsive stromal fungal keratitis after ICRS explantation when the endothelium is preserved. Stromal depth evaluation is critical for surgical planning. This approach enables eradication of infection, avoids open-sky surgery, preserves host endothelium, and provides favorable long-term visual outcomes. In experienced hands, DALK should be considered a first-line surgical option in selected cases.