Management of recurrent Paecilomyces lilacinus keratitis.

A 72-year-old man presented with Paecilomyces keratitis subsequent to immunosuppressive treatment. Despite medical therapy with voriconazole, perforation occurred requiring a tectonic keratoplasty of 10 mm. Despite oral, topical and intracameral voriconazole, there was recurrent stromal infiltration. A corneoscleral graft of 15 mm was undertaken. Two weeks later, hyphae were seen on the anterior lens capsule with hypopyon requiring phacoemulsification and anterior chamber washout. Six weeks later, there was evidence of endophthalmitis. Pars plana vitrectomy, capsulectomy and intravitreal injection of voriconazole were performed. Voriconazole treatment was continued for a further 10 months and then ceased. At 16 months following the last recurrence of Paecilomyces, there was no evidence of infection. After 20 months, the patient had a sutured intraocular lens with an artificial iris. Vision is 6/36 unaided and 6/24 pinhole.