Keratitis Following Penetrating Keratoplasty Cause by Rare, Manageable Bacteria

Following Patients As They Receive Sight-Saving Care With Orbis In Peru
TRUJILLO, PERU – APRIL 20: A screen shows a live feed of an eye operation taking place on Reis-Buckler syndrome patient Diana, aged 17, onboard the Orbis Flying Eye Hospital on April 20, 2018 in Trujillo, Peru. Reis-Buckler corneal dystrophy is a rare genetic condition which causes the Bowman’s layer of the cornea to disintegrate. Diana’s mother Rosa has the same syndrome and has struggled with sight loss since the age of nine. After suffering with the condition since the age of three, Diana was chosen for a penetrating keratoplasty procedure (cornea transplant) during a programme run by Orbis, the ophthalmic training organisation. Founded in 1982 by ophthalmologist David Paton, Orbis trains eyecare teams across Africa, Asia and Latin America to improve the standard of eyecare in the region. As well as working in local hospitals, the charity also has a self-sufficient surgical unit on the Orbis Flying Eye Hospital, a converted McDonald-Douglas MD10 aircraft. (Photo by Leon Neal/Getty Images)
Most of these events resolve with medical intervention, the report shows.

Enterobacter cloacae keratitis is rare, occurs after penetrating keratoplasty (PKP), and typically resolves with medical management, A retrospective review of medical records published in Cornea demonstrates.

The researchers collected patient data from between 2009 and 2019. The reviewed records for positive E cloacae keratitis. Patient characteristics, ulcer characteristics, and treatment outcomes were evaluated.

Among the 7787 microbial keratitis cases, 10 cases of E cloacae keratitis in 9 patients were identified. The patient who presented with 2 cases had a second occurrence in the same eye 1 week after a corneal transplant, the records show.

The patients were aged 41 to 70 years and 77.78% were men. More than half (55.56%) of patients were from a low socioeconomic background, the report says.

Patients reported experiencing symptoms for 1 to 30 days, and all but 1 case had visual acuity worse than 20/400. Most eyes (90%) had undergone PKP, among which all grafts except 1 had failed. The mean time from PKP to E cloacae keratitis was 39.32 days and all eyes were on concomitant topical corticosteroids.

The ulcer mean area was 17.54 mm2 and was located peripherally (50%), centrally (30%), or involved the entire cornea (20%). Infiltrates were dense and extended to the posterior stroma (60%) or were patchy (40%).

Two isolates were found to have multidrug resistant E cloacae keratitis, 1 which was sensitive to chloramphenicol and azithromycin and the other to colistin and azithromycin. Most isolates were sensitive to chloramphenicol (90%), colistin (87.5%), and gentamicin (80%).

Most eyes (90%) were treated successfully with medical management and minor surgical intervention within an average of 56.55 days. The final visual acuity remained the same (n=5), decreased (n=3), and improved (n=2).

This study was limited by the small number of cases.

“The risk factors for the development of E cloacae keratitis in our series were post-PKP with concomitant use of topical steroids and ocular surface breakdown, possibly triggered by poor personal hygiene,” researchers explain. “The infection resolved with medical management in most cases, although adjunctive tarsorrhaphy or cyanoacrylate adhesive application was necessary to enhance the healing process.”


Rajarajan M, Madduri B, Mohan N, Fernandes M. Enterobacter cloacae keratitis: clinicomicrobiological profiles, risk factors, and outcomes. Cornea. Published online May 13, 2022. doi:10.1097/ICO.0000000000003036