Clinical Scorecard: Keratoplasty may salvage severe corneal melt

At a Glance

Key Highlights

• Corneal scrapings and contact lens cultures grew P aeruginosa susceptible to amikacin and ceftazidime.
• Acanthamoeba PCR was negative, while in vivo confocal microscopy showed cystic structures suggestive of infection.
• After about 2.5 months of intensive antibacterial and antiamoebic treatment, corneal instability and neovascularization progressed.
• Therapeutic penetrating keratoplasty with adjunctive intrastromal bevacizumab was followed by a stable, clear graft and no reported recurrent infection at 3 months.
• Pinhole visual acuity improved to 6/10 at the 3-month postoperative assessment; the single case cannot establish the independent effect of bevacizumab.

Guideline-Based Recommendations

Diagnosis

• In this case, assessment included slit-lamp examination, corneal and contact lens cultures, PCR testing, and in vivo confocal microscopy.
• The authors noted that negative Acanthamoeba PCR did not eliminate clinical suspicion when confocal microscopy showed suggestive cystic structures.

Management

• Initial treatment included intensive topical amikacin and vancomycin, intravenous ceftazidime, and oral tetracycline; polyhexamethylenebiguanide and hexamidine were added for suspected Acanthamoeba infection.
• Therapeutic penetrating keratoplasty was performed after progressive disease and substantial risk of perforation despite prolonged antimicrobial treatment.
• Intrastromal bevacizumab was administered during surgery and twice during follow-up to address neovascularization; because it was used with keratoplasty, the report cannot establish its independent effect.
• Postoperative treatment included oral ciprofloxacin, topical ofloxacin, tapering topical dexamethasone, and ocular lubricants.

Monitoring & Follow-up

• The clinical course was assessed with slit-lamp examinations and confocal microscopy; postoperative assessment included corneal tomography and endothelial cell analysis.
• At 3 months, the graft was clear and structurally stable, with reduced neovascularization and no reported recurrent infection or graft rejection.

Risks

• Progressive stromal thinning and tissue dissolution raised concern for corneal perforation and loss of structural integrity.
• The report describes one patient; suspected Acanthamoeba infection was not PCR-confirmed, excised tissue was not examined histopathologically, and follow-up was limited to 3 months.

Patient & Prescribing Data

A 27-year-old woman with severe left-eye keratitis who wore monthly soft contact lenses and reported extended use, occasional overnight wear, and inconsistent replacement of storage solution.

After about 2.5 months of intensive antibacterial and antiamoebic therapy, progressive corneal destruction led to therapeutic penetrating keratoplasty. Intrastromal bevacizumab was given at 1.25 mg/0.05 mL during surgery and in two additional postoperative injections.

Clinical Best Practices

• In this case, microbiological and imaging findings were considered together despite discordant PCR and confocal microscopy findings.
• The authors advised that surgical escalation, including therapeutic penetrating keratoplasty, should be considered promptly in complex refractory cases.
• Interpret the reported postoperative outcome cautiously: keratoplasty and bevacizumab were used together, and longer-term graft outcomes were not reported.

Related Resources & Content

• Cornea Open case report; source URL not provided