Remarkable Clinical Recovery After Adjunctive Corneal Cross-Linking in Refractory Fungal Keratitis: Report of Two Cases

Corneal cross-linking (CXL) has been suggested as an adjunctive therapeutic option in refractory fungal keratitis. We report the clinical course and outcomes of two female patients with progressive fungal keratitis unresponsive to maximal topical and systemic antifungal therapy who were treated with adjunctive CXL using the Dresden protocol. In the first case, yeast-related fungal keratitis demonstrated progressive stromal infiltration despite intensive medical treatment. Following CXL, a transient early enlargement of the lesion was observed, followed by gradual regression, stromal stabilization, and corneal scarring with improvement in best-corrected visual acuity. The second case involved Fusarium keratitis developing after ocular trauma, which showed no clinical response to aggressive antifungal therapy. After CXL, rapid clinical improvement occurred, with regression of the corneal ulcer and formation of a stable corneal scar. In both cases, CXL appeared to halt stromal melting and prevent further progression, avoiding the need for therapeutic keratoplasty. These findings suggest that adjunctive CXL may be considered in selected cases of refractory fungal keratitis; however, larger studies are required to better define its efficacy, safety, and optimal timing.