Successful management of refractory fungal keratitis with photoactivated chromophore for keratitis–corneal cross-linking (PACK-CXL)

We report a case of a 44-year-old lady with recalcitrant fungal keratitis despite intensive antimicrobial therapy. Adjunctive photoactivated chromophore for keratitis–corneal cross-linking (PACK-CXL) was performed using an accelerated protocol at a fluence of 7.2 J/cm². This resulted in clinical improvement and complete re-epithelialization within three weeks. Definitive visual rehabilitation was subsequently achieved with deep anterior lamellar keratoplasty and cataract surgery, restoring the best corrected visual acuity to 6/12 at two years post-diagnosis. This case demonstrates PACK-CXL as a safe and effective adjunct in the management of refractory fungal keratitis, potentially reducing the need for high-risk therapeutic keratoplasty.