Inverted In Vitro Confocal Microscopy in Mycotic Keratitis with Corneal Endothelial Epithelial Decompensation

The sensitivity of confocal microscopy ranges between 80 and 90% and thus lies above the sensitivity of pathogen identification by microbiological culture. Typically, in vivo confocal microscopy enables us to diagnose mycotic keratitis non-invasively and atraumatically on the day of admission. Herein we present a patient with an ulcer on a corneal graft, pronounced corneal endothelial epithelial decompensation and a retrocorneal fungal adhesion after repeat-keratoplasty 5 years ago - due to chronic graft rejection after keratoplasty for Fuchs endothelial corneal dystrophy. Clinically there was a suspicion of fungal keratitis. Conventional en face confocal microscopy, however, did not detect hyphae. Due to the pronounced corneal endothelial epithelial decompensation, we were able to detect the fungal hyphae only after repeat penetrating keratoplasty by means of inverted in vitro confocal microscopy on the day of surgery. Histology confirmed the diagnosis of keratomycosis.