Intraoperative Photoactivated Chromophore for Infectious Keratitis–Corneal Cross-Linking (PACK-CXL) During Penetrating Keratoplasty for the Management of Fungal Keratitis in an Immunocompromised Patient

INTRODUCTION: To present a novel intraoperative application of photoactivated chromophore for infectious keratitis–corneal cross-linking (PACK-CXL) in the management of post-penetrating keratoplasty (PKP) multiresistant fungal keratitis in a patient with irradiation-related local immunosuppression. CASE REPORT: A 62-year-old female underwent uneventful PKP for the management of post-irradiation actinic keratopathy. Three months postoperatively, she presented with a diffuse corneal melting abscess that was infiltrating the donor-recipient junction. Despite intensive antibiotic and antifungal therapy, corneal melting progressed to graft perforation. A repeat PKP combined with intraoperative PACK-CXL was performed. PACK-CXL was applied initially on the infected graft, involving the corneoscleral rim and then following placement of the donor button. No intra- or postoperative graft-related complications were encountered. No signs of infection were noted, and the graft remained clear during the 9-month follow-up period. CONCLUSION: Intraoperative PACK-CXL combined with PKP appears to be a safe and effective technique for the management of post-PKP resistant fungal keratitis.