15 How to rescue a pancorneal melting caused by a pyocyanic endophthalmitis after a cataract surgery?

Purpose A 70-year-old man underwent a 1.8mm clear corneal temporal incision cataract surgery with toric lens. His background was bilateral high-myopia and non-controlled advanced chronic open-angle glaucoma (topical quadritherapy). He was referred in emergency for pain and redness of his left eye (LE) 11 days (D) after cataract surgery: LE was complicated by a pseudomonas aeruginosa endophthalmitis. Vision was limited to light perception. Intraocular pressure (IOP) was 40 mmHg. Despite appropriate care, no local improvement occurred: there was a progressive purulent pancorneal melting. Considering the bilateral sight threatening, the patient agreed to attempt a rescue corneoscleral transplantation rather than primary evisceration at D14.

Methods (Fig. step1) A 14mm Flieringa ring stabilized the globe. We made a fastidious 360° limbal peritomy, a wide recipient’s trephination (9.5 mm), a corneoplasty as close as possible to the trabeculum, and an anterior segment’s repair. The prepared 13mm therapeutic corneoscleral graft (baseline ECD 1580cell/mm²) was sutured with separate stitches, then a conjunctival reconstruction, a new AMG and IVT series of antibiotics. No adverse event occurred.

Results Residual astigmatism was 1.3diopters and vision improved without primary graft failure (ECD 1000cell/mm² at M6): 20/400 far and 20/160 near at 2 weeks, 20/200 far and 20/80 near at 6 months. IOP was 14 mmHg under topical preservative-free double therapy with stable visual field. Fluorometholone 0.1% and ciclosporin 2% drops were pursued.

At M15, a complicated abscess was identified, caused by multiple germs (Candida parapsilosis + Propionibacterium acnes + Staphylococcus epidermidis). Healing was obtained after 3 months of sequential treatments.

At M18, initial corneoscleral graft was globally opacified (vision: hands motion) with recurrent epithelial ulcers, and 200° deep stromal neovessels. We attempted a new graft on this unique terrain in order to decrease the infectious risk, and increase the comfort and vision if possible: custom DMEK (HLA A B DR matched) + AMG + limbal allograft (Fig. Step 2).

Conclusions 30 months after the initial corneoscleral transplantation, 12 months after this first in human custom DMEK, structural and functional rescue (20/200) has been extended. The patient had normal IOP, no pain and normal macular profile, with a relatively minimal postoperative treatment (only fluorometholone 0.1%, ciclosporin 2%, autologous serum drops).