candida interface keratitis after deep anterior lamellar keratoplasty: clinical, microbiologic, histopathologic and confocal microscopic reports

purpose: to report the clinical, histopathologic, microbiologic and confocal microscopic features of candida keratitis after deep anterior lamellar keratoplasty (dalk). patients and findings: the first patient presented with asymptomatic white to cream-colored interface deposits two months after dalk. confocal scan disclosed clusters of hyper-reflective fine granular deposits in the interface with no evidence of inflammation or hypha-like structures. with a presumptive clinical diagnosis of progressive epithelial down-growth, irrigation of the interface was performed. finally, penetrating keratoplasty was performed due to rupture in the descemet’s membrane. histopathologic examination of the cornea disclosed yeast-like structures at the interface area. microbiologic results of the irrigation fluid demonstrated candida glabrata. the second patient presented with symptomatic infiltration of the inferior interface close to the suture site 2.5 months after dalk. confocal scan disclosed foci of inflammation with clusters of hyper-reflective round-shaped structures that resembled epithelial cells. with a clinical diagnosis of epithelial downgrowth and progression of the lesion, penetrating keratoplasty was performed. histopathologic examination of the cornea revealed acute and chronic granulomatous keratitis due to yeast-like structures. the microbiologic results demonstrated infection with candida albicans. conclusion: clinical and confocal features of interface candida keratitis may resemble those of epithelial down-growth, which may postpone correct diagnosis and treatment. candida keratitis should be considered in cases of interface deposits after any form of lamellar keratoplasty.