A case of polymicrobial keratitis violating an intact lens capsule

Purpose: To report a case of polymicrobial keratitis resistant to topical and intraocular antibiotics with recurrence after penetrating keratoplasty. Methods: Case report. Results: We report a case of polymicrobial keratitis caused by Phialophora verrucosa, Candida tropicalis, and Propionibacterium acnes. Initial treatment included topical vancomycin, tobramycin, amphotericin B, voriconazole, and oral fluconazole, as well as subconjunctival amphotericin B. Penetrating keratoplasty was performed, and the infection seemed to have resolved until 4 weeks after keratoplasty. A second penetrating keratoplasty was performed, followed by 4 weekly intracameral injections of voriconazole. Two weeks after the fourth intracameral injection, the infection manifested as an active anterior-chamber reaction. The patient's eye was subsequently enucleated. Histopathologic evaluation showed penetration of the crystalline lens by fungus at the site of synechiae between the intact lens capsule and iris. Conclusions: To our knowledge, this is the first documented case of a polymicrobial keratitis caused by a bacterium, yeast, and a fungus. It is the first histopathologic demonstration of fungal penetration of intact lens capsule from infected iris.