Simultaneous Noncentered Photoactivated Chromophore for Keratitis-Corneal Collagen Cross-Linking and Penetrating Keratoplasty for Treatment of Severe Marginal Fusarium spp. Keratitis: A Description of a New Surgical Technique

Abstract

The purpose of this article is to describe the use of simultaneous noncentered photoactivated chromophore for keratitis-corneal collagen cross-linking (PACK-CXL) combined with penetrating keratoplasty in the treatment of a severe marginal Fusarium spp. keratitis case with imminent corneal perforation. It is a retrospective case report study; it was performed by collecting clinical data, images, video, and postoperative evaluations. The clinical control of the infection was accomplished, despite difficulties in obtaining antifungal medications due to the patient's extremely poor socioeconomic status and essentially nonexistent health insurance. We can conclude that combining simultaneous decentered PACK-CXL with centered penetrating keratoplasty appears to be a safe and effective way of treating patients with fungal marginal keratitis with corneal perforation, in which regular penetrating keratoplasty alone would leave fungal elements in the receptor corneal tissue, which would predispose to infection of the graft.

Figure 1

Clinical appearance of the patient before surgery. Please note a corneal perforation surrounded by a dense infiltrate (A) associated with inferior neovascularization (B).

Figure 2

Simultaneous noncentered photoactivated chromophore for keratitis-corneal collagen cross-linking (PACK-CXL) and penetrating keratoplasty. (a) Corneal trephination. (b) Cornea removal. (c) Open-sky cataract removal. (d) Intraocular lens implantation. (e) Donor cornea suturing. (f) Riboflavin impregnation.

Figure 3

Cross-linking lamp used for the treatment of the patient (UV-X 2000, Avedro Inc., Waltham, United States).

Figure 4

Schematic representation of the areas of the eye covered by the penetrating keratoplasty procedure (blue circle, 8 mm) and the noncentered PACK-CXL (green circle, 7 mm).

Figure 5

Clinical appearance of the patient three weeks after surgery. Note some natamycin over the eye.

Figure 6

Clinical appearance of the patient two months after surgery, showing a complete resolution of infection, with conjunctivalization replacing the area that was infected in the receptor rim.