High-Fluence Photoactivated Chromophore For Keratitis Corneal Cross-Linking (P A C K - C X L) In Refractory Filamentous Fungal Keratitis With Infection Control And Staged Visual Rehabilitation
Published 2026 - 44th Congress of the ESCRS
Reference: PP20.09 | Type: Poster | DOI: 10.82333/bm0f-5h44
Authors: Dr Duoduo Wu 1 , Dr Chris Lim 2 , Dr Charmaine Chai 3 , Dr Dayna Yong 4 , Dr Tina Yu Ting Shen* 1 , A/Prof. Ray Manotosh 3
1Ophthalmology,National University Hospital ,Singapore,Singapore, 2Department of Ophthalmology, Cornea and Oculoplastics Units,Royal Perth Hospital,Perth,Australia, 3Ophthalmology,Yong Loo Lin School of Medicine, National University of Singapore,Singapore,Singapore, 4Ophthalmology,Royal Perth Hospital,Singapore,Singapore
Purpose
To describe the clinical course and outcomes following high-fluence photoactivated chromophore for keratitis corneal cross-linking (PACK-CXL) as an adjunctive therapy in treatment of refractory filamentous fungal keratitis with deep stromal involvement unresponsive to intensive antifungal therapy.
Setting
Department of Ophthalmology, National University Hospital, Singapore.
Methods
A 44-year-old contact lens wearer presented with severe culture-proven filamentous fungal keratitis caused by Aspergillus and Fusarium species. Despite four weeks of intensive topical natamycin and fortified antibiotics, progressive deep stromal infiltration with abscess formation persisted. High-fluence photoactivated chromophore for keratitis corneal cross-linking (PACK-CXL) was performed six weeks after presentation using an accelerated protocol delivering 7.2 J/cm² ultraviolet-A fluence. Topical antimicrobial therapy was continued post-procedure. The clinical course, epithelial healing, and visual outcomes were evaluated over two years.
Results
Following PACK-CXL, gradual clinical improvement was observed with complete re-epithelialisation at six weeks post-procedure. Infection resolved without corneal perforation or requirement for emergency therapeutic keratoplasty. Best corrected visual acuity improved from counting fingers at presentation to 6/60 after infection resolution. Subsequent deep anterior lamellar keratoplasty (DALK) and cataract surgery were performed and resulted in stable best corrected visual acuity of 6/9 at two years since the initial presentation.
Conclusions
High-fluence PACK-CXL may serve as an effective adjunct in the management of refractory filamentous fungal keratitis with deep stromal involvement. In this case, infection control was achieved after failure of intensive antifungal therapy, avoiding emergency therapeutic keratoplasty and permitting staged visual rehabilitation. Optimisation of fluence parameters, timing of intervention, and fungal species responsiveness in resistant fungal infections warrant further investigation.