An Extremely Rare and Devastating Complication of Penetrating Keratoplasty: Postoperative Endophthalmitis Because of Carbapenem-Resistant Klebsiella pneumoniae

To report the second case report in the literature of early-onset endophthalmitis caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) after penetrating keratoplasty (PK). The associated diagnostic and therapeutic challenges are highlighted, and the precautions that can be applied are emphasized. A 69-year-old woman with bullous keratopathy underwent elective PK. Within 24 hr postoperatively, stromal infiltration and partial separation at the superior quadrant of the graft and anterior chamber reaction were observed. Urgent rekeratoplasty was performed, and microbiologic culture of the donor tissue revealed extensively drug-resistant CRKP resistant to multiple antibiotics. Despite rapid surgical revision and intensive antimicrobial therapy (topical, intrastromal, intravitreal, and systemic), the infection progressed to orbital cellulitis and systemic involvement, ultimately requiring evisceration. Carbapenem-resistant Klebsiella pneumoniae was also isolated from the excised globe. Donor-derived contamination was strongly suspected because of the early clinical course but could not be confirmed microbiologically because the donor margin tissue was not preserved. Furthermore, retrospective medical data review of the donor did not reveal any similar microorganism and clinical follow-up of PK from the other corneal partner showed no infection. This case constitutes the second documented instance of CRKP-related endophthalmitis after PK in the literature. It emphasizes the importance of donor screening, continuous monitoring of the storage environment, preservation of donor margin tissue, and vigilant monitoring for systemic dissemination and severe postoperative complications.