헤르페스 각막염 치료 중 발생한 홍채 후면 칸디다 진균구

Fungal Abscess in Posterior Iris during Herpes Keratitis Treatment

Purpose: To report a case of fungal infection in posterior iris during medical and surgical management of herpetic keratitis. Case summary: A 44-year-old women diagnosed with a dilated cardiomyopathy was presented with decreased visual acuity in the left eye. Best corrected visual acuity was 0.05 in the left eye and slit-lamp examination revealed peripheral ulcerative dendritic keratitis with stromal infiltration. The anti-viral agents and steroid eye drops were initiated under impression of herpetic keratitis and corneal endothelitis. The inflammatory reactions in anterior chamber were increased and the thinning of ulcerative lesion was aggravated at 6 months after treatment. The amniotic membrane transplantation (AMT) was done in the left eye. Despite the continuous medical management, ulcerative thinning readily progressed and the hypopyon in anterior chamber with anterior protrusion of iris in inferonasal portion was observed at 3 months after AMT. The corneal perforation occurred during secondary AMT and iris exposure was observed as perforated region enlarged. The primary closure with conjunctival flap was performed and the penetrating keratoplasty (PKP) was done at 3 days later. The whitish abscess pocket with 1 to 2 mm diameter was found in the posterior portion of protruded iris and the fungal keratitis was confirmed following biopsy. The intravitreal amphotericin B injection was done and fortified voriconazole eye drops were maintained for 4 months after PKP. Both anterior and posterior segment showed no inflammatory reaction and recurrence for 20 months follow-up period after PKP. Conclusions: Infective keratitis that do not respond to treatment after long-term use of anti-viral agents and steroids in immune-suppressed patients may also be accompanied by fungal infection and abscess in posterior iris.