Presumed Deep Anterior Lamellar Keratoplasty Graft Rejection Following Covid-19 Infection

We present a case of a deep anterior lamellar keratoplasty (DALK) stromal rejection two weeks post polymerase chain reaction (PCR) proven Coronavirus 2019 (COVID-19) infection. COVID-19 has impacted the lives of millions and its effect on various organs has been extensively studied. We aim to raise awareness of the ophthalmic impact of the virus, especially for those with previous corneal grafts. Although endothelial rejection post COVID-19 has been described in the literature, to the best of our knowledge, graft stromal rejection post COVID-19 has not been previously described, and DALK rejection rates are uncommon. We hope to share our management experience for this unique case.

Our patient presented to the eye casualty clinic and was reviewed several times in the corneal clinic over the course of several months to ensure resolution.

We present the case of a 45-year-old gentleman with a history of bilateral keratoconus and previous right-sided DALK corneal graft performed 10 months prior to presentation. He had been off prophylactic topical steroid treatment for several months and all corneal sutures remained in situ. He presented to eye casualty two weeks post symptomatic and PCR confirmed COVID-19 infection, with a 2-day history of right eye photophobia and epiphora. On examination there were early signs of rejection with superior conjunctival injection, a localised area of subepithelial infiltrates, suggestive of krachmer spots, and stromal haze.

He was diagnosed as acute stromal rejection and treated with preservative free dexamethasone 0.1% topical drops hourly, which were tapered slowly over several months. At the most recent follow up, four months later, the graft was clear without signs of rejection. Best corrected visual acuity was 6/24 which improved with pinhole to 6/7.5. On-going management will involve continued topical steroids and imminent suture removal.

The ocular immune privilege can be compromised by immune dysregulation following acute infection. COVID-19 has been linked to endothelial graft rejection, with cases occurring in descemet membrane endothelial keratoplasty and PK grafts reported. To the best of our knowledge, graft stromal rejection post COVID-19 has not been described in the literature and DALK rejection rates are rare. It is impossible to be certain of a direct causal effect. However, it is likely that this gentleman who was off anti-rejection treatment for several months with no hospital eye service review in this time, developed acute rejection following compromised ocular immune privilege secondary to the pro-inflammatory period induced by COVID-19 infection.