Complex Management Of Herpetic Keratitis And Corneal Abscess In A Pregnant Patient With A History Of Dalk With Impending Perforation: A Therapeutic Challenge.

To describe the clinical and surgical management of complex herpetic keratouveitis with aggressive bacterial superinfection (Streptococcus pneumoniae) in a 17-week pregnant patient with a history of deep anterior lamellar keratoplasty (DALK). To emphasize diagnostic challenges and therapeutic limitations associated with pregnancy, as well as the utility of anterior segment optical coherence tomography (AS-OCT) and multilayer amniotic membrane transplantation (AMT) for corneal stabilization

Specialized department of ophthalmology within a university hospital, with established obstetric collaboration.

Case report. A 17-week pregnant patient with a history of DALK in the right eye due to herpetic keratitis presented with an initial diagnosis of recurrent herpetic keratouveitis. The clinical course was torpid, progressing to a central corneal abscess and hypopyon despite intensive topical and oral antiviral and steroid treatment. Management involved close monitoring with AS-OCT and a pregnancy-tailored strategy, including corneal scraping for culture, fortified antibiotic therapy, and modifications to systemic therapies based on contraindications during pregnancy.

Corneal cultures isolated Streptococcus pneumoniae sensitive to cefotaxime and vancomycin, guiding fortified topical antibiotic therapy. Facing fulminant stromal lysis and doxycycline contraindication during pregnancy, oral amoxicillin-clavulanate was optimized and topical insulin added to promote re-epithelialization. Despite these measures, progressive thinning culminated in a superior descemetocele. Rapid progression precipitated immediate intervention with tissue adhesive tamponade and a protective contact lens as a stabilizing bridge, followed by multilayer AMT one week later. At one month, AS-OCT confirmed corneal layer compaction, descemetocele resolution and evolution into a thickened leucoma without active inflammation.

This case illustrates the complexity of managing herpetic and bacterial keratitis in patients with prior lamellar keratoplasty within the context of pregnancy. AS-OCT constitutes a fundamental tool for non-invasive monitoring of impending stromal lysis and perforation. Given the impossibility of utilizing standard systemic anti-collagenase drugs due to the pregnancy, progressive corneal thinning may require prompt surgical stabilization. In this scenario, multilayer amniotic membrane transplantation emerged as an effective surgical strategy to restore ocular integrity and promote stromal healing.