THE COMPREHENSIVE TREATMENT OF FUNGAL KERATITIS BASED ON CORNEAL COLLAGEN CROSS-LINKING AND KERATOPLASTY.

To develop an effective algorithm of fungal keratitis treatment based on corneal collagen cross-linking and keratoplasty. 

S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russian Federation.

A 63-year-old Caucasian male with past history of recurrent herpetic keratitis since 1989 with relapses each 5-6 years, presented with complains of low visual acuity, pain, photophobia, excessive lacrimation from the right eye for few weeks. Before the visit to ophthalmologist patient began to use topical antibiotics. At first examination BCVA on right eye was proectio lucis certae, on left eye - 0.03 (equivalent to 20/600) due to amplyopia. Slit lamp biomicroscopy revealed a corneal ulcer of approximately 3 mm х 4 mm in size, a hypopyon 3 mm in hight, opacification of the cornea and lens. Scraping from the cornea was collected for microbiological analysis on blood agar and Sabouraud dextrose agar (SDA). Grown in SDA culture was identified as Candida albicans. The patient was prescribed intravenous Fluconazole, oral Terbinafine. After hypopyon regression corneal collagen cross-linking was performed as adjuvant therapy. A month later, according to the results of anterior segment OCT, progressive thinning and opacity almost to the entire depth of the cornea was revealed. It was decided to perform penetrating keratoplasty and simultaneously phacoemulsification of cataract with implantation of an intraocular lens (IOL).  It is planned to carry out an three-step optical-reconstructive surgery. By first step, using femtosecond laser opacified superficial layers of cornea were removed to improve visualization for the next step. By second step, a “closed-globe” uncomplicated phacosurgery was performed. And after all, by third step, to remove opacified residual layers of the cornea penetrating keratoplasty was successfully performed. 2 months later the eye is not irritated, the graft is transparent, the IOL is in the correct position.

Corneal collagen cross-linking seems to be a safe and effective procedure for the management of fungal keratitis, and together with subsequent anterior lamellar or penetrating keratoplasty may allow to achieve good anatomic and functional outcomes.