Therapeutic Penetrating Keratoplasty For Progressive Aspergillus Lentulus Keratitis Resistant To Intensive Antifungal Therapy

To describe the management of rapidly progressive Aspergillus lentulus keratitis unresponsive to intensive antifungal therapy and treated with urgent therapeutic penetrating keratoplasty (TPK) combined with early postoperative topical cyclosporine-A.

Tertiary referral ophthalmology center with dedicated corneal and transplant services.

A 35-year-old male was referred with a 10-day history of right corneal ulcer following ocular trauma at work. Previous hospitalization included topical moxifloxacin and fluconazole without clinical improvement. Examination revealed a corneal ulcer with endothelial plaque, hypopyon, and fibrin in the anterior chamber. Corneal scrapings were obtained and antifungal therapy was initiated. Posterior segment evaluation excluded endophthalmitis. Cultures identified Aspergillus lentulus sensitive to voriconazole. Despite intensive topical and systemic voriconazole and amphotericin B, rapid clinical deterioration occurred, necessitating urgent therapeutic penetrating keratoplasty.

Penetrating keratoplasty was performed within the first week of admission. Infected corneal tissue, hypopyon, and anterior chamber fibrin were removed, followed by meticulous anterior chamber irrigation with diluted voriconazole. Postoperatively, topical cyclosporine-A 0.5% was administered instead of corticosteroids. At four months, the eye remained infection-free with best-corrected visual acuity of 20/25 and progressive visual improvement.

Therapeutic penetrating keratoplasty combined with meticulous anterior chamber debridement and antifungal lavage achieved definitive infection control in this case of medically refractory Aspergillus lentulus keratitis. Rapid progression despite microbiologically guided therapy highlights the potentially aggressive behavior of this pathogen. Timely surgical intervention can be crucial for globe preservation and functional visual recovery. Postoperative cyclosporine-A may represent a safe steroid-sparing immunomodulatory strategy in selected cases where the risk of fungal reactivation is a concern.