Reverse endothelial scraping technique for refractory deep infectious keratitis: Novel surgical technique and outcome evaluation

This study describes a novel approach of corneal reverse endothelial scraping technique (REST) for the diagnosis and management of deep stromal and endothelial infectious plaques. This retrospective, interventional study included 16 patients with infectious deep stromal endothelial infiltrates that did not respond to conventional medical therapy. Briefly, under aseptic precautions, a reverse Sinskey hook was used to delicately debulk and scrape the endothelial plaque via a paracentesis incision, and the samples were sent for microbiological evaluation. Smears were prepared for Gram’s stain, 10% KOH mount, and Giemsa stain as suspected. Cultures were inoculated on blood agar, chocolate agar, and Sabouraud’s dextrose agar. Treatment was tailored according to the microbiological results. Preoperative data [age, gender, etiology of keratitis, best-corrected visual acuity (BCVA), and previous ocular surgery] and postoperative data (follow-up duration, response to treatment, BCVA, and other significant clinical ocular examination findings) were recorded and analyzed. Sixteen eyes of 16 patients with endothelial plaque underwent REST. The mean age was 41.8 ± 19.54 years, with a male predominance (75%). All cases were unilateral. Fungal etiology was the most common cause (62.5%), followed by bacterial infection (25%), while Pythium and Nocardia accounted for 6.25% each. REST enabled microbiological confirmation in all cases and guided targeted therapy. Ten patients (62.5%) responded to medical management alone, whereas four patients (25%) required therapeutic penetrating keratoplasty in addition to medical therapy; the remaining two patients (12.5%) required adjunctive surgical interventions. Resolution of infection with stabilization of the ocular surface was achieved in 93.75% of cases, while one patient (6.25%) progressed to a phthisical eye. At final follow-up, a corrected distant visual acuity of 6/18 or better was achieved in eight patients (50%). REST is a novel technique for debulking and scraping infectious endothelial plaque with facilitated targeted therapy. A tailored approach to managing these cases can help us avoid invasive procedures, such as therapeutic keratoplasty.