Fungal interface keratitis following superficial anterior lamellar keratectomy for limbal dermoids: a case report

BACKGROUND: Infectious interface keratitis is an uncommon but potentially vision threatening complication of lamellar corneal surgery. While it has been described after deeper lamellar procedures, its occurrence following superficial anterior lamellar keratectomy (SALK) is exceedingly rare. To the best of our knowledge, such cases following limbal dermoid excision have not been previously reported. We describe two pediatric cases of fungal interface keratitis following SALK for limbal dermoids. CASE PRESENTATION: Two children, a 12-year-old girl with Goldenhar syndrome and a 6-year-old boy with isolated limbal dermoids, underwent SALK for dermoid excision. Both had an uneventful early postoperative course. At 5 weeks and 4 weeks respectively, they developed graft infiltration with interface involvement. Initial microbiological evaluation was non-contributory, and both cases showed poor response to intensive topical antibacterial therapy. Due to progressive interface infiltrates, graft removal was performed. Microbiological analysis of explanted graft and host bed samples revealed fungal filaments, with culture confirming Aspergillus niger in both cases. Targeted antifungal therapy was initiated with topical natamycin and voriconazole, resulting in resolution of infection. Final visual acuity improved from 6/36 to 6/18 in the first case and from 6/18 to 6/9 in the second case, with no recurrence during follow up. CONCLUSIONS: Fungal interface keratitis can occur following SALK, although rare, and may present with delayed onset and poor response to antibacterial therapy. Early suspicion and timely graft removal are critical for diagnosis and management. Prompt initiation of antifungal therapy can lead to favorable anatomical and visual outcomes.