Adjunctive Photoactivated Chromophore for Keratitis-Corneal Cross-Linking for Refractory Pseudomonas aeruginosa Keratitis During Pregnancy: A Case Report

Abstract

Management of severe infectious keratitis during pregnancy is challenging because rapid control of a sight-threatening infection must be balanced against potential fetal exposure to antimicrobial agents and surgical interventions. Photoactivated chromophore for keratitis-corneal cross-linking (PACK-CXL) has been proposed as an adjunctive treatment for infectious keratitis associated with progressive stromal melting. A 34-year-old woman at 19 weeks of gestation presented with a two-day history of painful visual deterioration in her left eye. She was a contact lens wearer. Slit-lamp examination revealed a 5.0 × 3.5-mm paracentral corneal ulcer with a wet, necrotic appearance, an associated 3.5 × 3.5-mm stromal infiltrate, and corneal melting. Marked anterior chamber inflammation and a 0.5-mm hypopyon were present. Best-corrected visual acuity was 20/20 in the right eye and 20/200 in the left eye. Cultures of corneal scrapings and the contact lenses yielded Pseudomonas aeruginosa, whereas polymerase chain reaction testing for fungi and Acanthamoeba was negative. Following consultation with the obstetric team, intensive topical amikacin and vancomycin, topical atropine, and intravenous ceftazidime were administered. Although the hypopyon resolved and anterior chamber inflammation substantially decreased, stromal infiltration and melting persisted after 14 days of treatment. Adjunctive PACK-CXL was therefore performed using 0.1% riboflavin and ultraviolet-A irradiation at 3.0 mW/cm² for 30 minutes. The ulcer and infiltrate subsequently regressed, with complete resolution of the corneal melting. At three months, the ulcer had healed completely, leaving a paracentral stromal scar that did not significantly involve the visual axis. Best-corrected visual acuity improved to 20/28. Therapeutic penetrating keratoplasty was avoided, and the pregnancy progressed to an uncomplicated delivery. Adjunctive PACK-CXL was associated with arrest of corneal melting and satisfactory anatomical and visual recovery in a pregnant patient with refractory P. aeruginosa keratitis. However, the reproductive safety of riboflavin-ultraviolet-A cross-linking has not been established. Its use during pregnancy should therefore be considered only in exceptional, sight-threatening circumstances following multidisciplinary assessment and informed evaluation of the potential maternal benefits and unknown fetal risks.