Donor Rim Culture-positive Candida glabrata After “Triple DMEK” With Interface Keratitis Progressing to Endophthalmitis and Recurrence

Purpose: To describe a case of fungal keratitis after Descemet membrane endothelial keratoplasty combined with cataract extraction and intraocular lens implantation (DMEK triple procedure). Methods: This is a case report of a 78-year-old man with Fuchs corneal endothelial dystrophy and cataract who underwent uneventful DMEK triple procedure in the right eye. Days later, the corneoscleral rim cultures from the donor graft returned positive for Candida glabrata . Results: Despite immediate initiation of prophylactic oral fluconazole in the absence of clinical findings, the patient developed suspected fungal keratitis manifest as a lamellar/interface infiltrate between the DMEK graft and the host stroma. Intrastromal and intracameral antifungals were administered to the right eye; however, the infection progressed to endophthalmitis, necessitating pars plana vitrectomy with intravitreal antibiotics and antifungals to clear the infection. The patient demonstrated initial clinical improvement but months later experienced recurrence of inflammation, assumed to be infectious, after attempts of tapering the oral fluconazole. This patient is currently stable with no recurrence of infection for several months on a maintenance dose of oral fluconazole and will likely remain on the medication indefinitely. Conclusions: Interface fungal keratitis is a rare but serious complication of DMEK. Continued research is vital to guide evidence-based prevention and management.