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PHOTO ESSAY
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 257-258

Accelerated photoactivated chromophore for infectious keratitis-collagen cross-linking in deep mycotic keratitis


Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission10-Jul-2021
Date of Acceptance01-Sep-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Jagat Ram
Advanced Eye Centre, Sector 12, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_998_21

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  Abstract 


Keywords: Accelerated PACK-CXL, PACK-CXL in fungal keratitis, PACK-CXL in fungal ulcer


How to cite this article:
Khurana S, Gupta PC, Gupta A, Sharma S, Ram J. Accelerated photoactivated chromophore for infectious keratitis-collagen cross-linking in deep mycotic keratitis. Indian J Ophthalmol Case Rep 2022;2:257-8

How to cite this URL:
Khurana S, Gupta PC, Gupta A, Sharma S, Ram J. Accelerated photoactivated chromophore for infectious keratitis-collagen cross-linking in deep mycotic keratitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 16];2:257-8. Available from: https://www.ijoreports.in/text.asp?2022/2/1/257/334998



A 40-year-old diabetic farmer presented with a 1-month history of decreased vision in the right eye after the fall of a foreign body while working in the field. Slit-lamp examination revealed a dry-looking, full-thickness corneal ulcer with feathery margins, measuring 6 × 6 mm, and a fixed, convex hypopyon of 2 mm, suggestive of fungal ulcer. Though the initial corneal scrapings were negative, the patient was started on maximal anti-fungal medications: systemic itraconazole with topical natamycin 5% and voriconazole 1%. After 2 weeks, the epithelial defect had decreased, but the hypopyon remained the same [Figure 1]a. Rescrapings at this visit were diagnostic of septate hyphae [Figure 1]b. “Targeted” antifungal therapy was given in the form of repeated intracameral amphotericin B (10 Ug/0.1 ml) over the next 3 weeks, without any significant response in the hypopyon [Figure 1]c. The eye was then subjected to “accelerated” eccentric photoactivated chromophore for infectious keratitis-collagen cross-linking (PACK-CXL). Under topical anesthesia, after localized epithelial debridement, the cornea was loaded with 0.1% isotonic riboflavin without dextran (Peshke M, Peschke Trade GmbH, Huenenberg, Switzerland) for 30 min and then irradiated for 10 min by UV-A light at 9 mW/cm2. After a week, the ulcer had healed completely [Figure 1]d, and the treatment was stopped after 2 weeks.
Figure 1: (a) Full-thickness corneal infiltrates, with a fixed hypopyon, 10 days after maximal anti-fungal medications. (b) Septate hyphae on 10% potassium hydroxide mount. (c) Persistence of hypopyon and corneal infiltrates after 5 weeks of presentation. (d) Healed corneal ulcer with resolution of hypopyon a week after PACK-CXL

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  Discussion Top


Activation of riboflavin by UV-A radiation in PACK-CXL produces free radicals, which helps in the formation of covalent bonds between the collagen fibrils, leading to increased resistance to collagenases; contributing as the primary mechanism of PACK-CXL. It also inhibits pathogen replication and reduces inflammatory cells.[1] Though the role of PACK-CXL in bacterial keratitis is well-known, its role in fungal keratitis has been controversial. As fungi are known to penetrate the anterior chamber, the effect of PACK-CXL in deep keratitis, involving the anterior chamber, is unknown.[2],[3] Our patient's fungal keratitis, especially hypopyon, was refractory to oral, topical, and intracameral antifungals; accelerated PACK-CXL helped in the complete healing of the severe fungal ulcer and resolution of hypopyon in just a week. Though Dresden protocol has been preferred in most studies for infectious keratitis, accelerated PACK-CXL has also been shown to be successful.[4] We believe PACK-CXL can help as an adjuvant treatment to accelerate healing in nonresponding, deep fungal ulcers with hypopyon.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Spoerl E, Wollensak G, Seiler T. Increased resistance of crosslinked cornea against enzymatic digestion. Curr Eye Res 2004;29:35-40.  Back to cited text no. 1
    
2.
Alio JL, Abbouda A, Valle DD, Del Castillo JMB, Fernandez JAG. Corneal cross linking and infectious keratitis: A systematic review with a meta-analysis of reported cases. J Ophthalmic Inflamm Infect 2013;3:47.  Back to cited text no. 2
    
3.
Uddaraju M, Mascarenhas J, Das MR, Radhakrishnan N, Keenan JD, Prajna L, et al. Corneal cross-linking as an adjuvant therapy in the management of recalcitrant deep stromal fungal keratitis: A randomized trial. Am J Ophthalmol 2015;160:131-4.e5.  Back to cited text no. 3
    
4.
Tabibian D, Richoz O, Riat A, Schrenzel J, Hafezi F. Accelerated photoactivated chromophore for keratitis-corneal collagen cross-linking as a first-line and sole treatment in early fungal keratitis. J Refract Surg Thorofare NJ 1995. 2014;30:855-7.  Back to cited text no. 4
    


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