A Challenging Journey Through A Panophtalmia Secondary To A Severe Fungal Keratitis

Although less prevalence exists in the developed world, cases of fungal keratitis for almost half of all keratitis are occurring in the developing countries. There are various challenges to the treating ophthalmologist, such as Managing both inflamed and infected eye  delayed presentation, long waiting time for culture positivity, limited availability effective antifungal drugs, prolonged duration for response to therapy, a highly variable spectrum of anti-fungal drug sensitivity and a high recurrence rate following keratoplasty
This case report highlitghts by the description of a resistant fungal keratitis: Corneal perforation is a devastating complication in corneal melting, some surgery techniques to improve prognosis by earlier treatment

To report the clinical, microbiological profile, and outcomes of a patient with fungal keratitis associated to a panophthalmia in a patient with dry eye and ocular surface disease. We received a 35yo working farmer, in the ophthalmological emergency department. The patient consults for an acute visual acuity decline appearing since 5days, with a history of antecedent ocular trauma  from vegetable object while cutting wood outdoors, and previous use of corticosteroids. The BCVA was hand motion. 

 A 35yo farmer sustained a full-thickness, stellate corneal laceration. Slit-lamp examination showed severe dry conditon eyelid edema, meibomian gland dysfunction, BUT<5sec, Schirmer <10mm,a severe keratitis with descemetocoele at the apex of the original stellate, with feathery edges. In addition to conjunctival hyperemia and circumciliary congestion, on the cornea there was a deep purulent 7mm infiltrate with a large corneal abscess: epithelial fluorescein staining, stromal oedema around the ulcer defect with an important thinning involving >50% of the stroma

Culture confirmed fungal elements: Fusarium. Oral and topical voriconazole were initiated. The control on the 2nd day revealed a severe evolution : perforation of half cornea with iris prolapse :  an hemi-cornea missing at the inferior part, we could notice directly the iris prolapse into the conjunctiva. The AS-OCT revealed the complete disappearance of all cornea layers at the inferior half cornea. 
We choose first to perform a  full-thickness conjunctival flap covering surgery combined with amniotic membrane transplantation, as a transitional surgery preventing the evisceration, to control the infection before a keratoplasty

Regarding the diversity of fungal aetiology and the emergence of drug resistance in somespecies, proper identification using molecular methods and antifungal susceptibility testing could provide useful results.If not diagnosed and treated from the onset of the symptoms, it can lead to severe visual loss, or even blindness