In Vivo Confocal Microscopy and Anterior Segment Optical Coherence Tomography in Optimizing Diagnosis and Therapeutic Management in Fungal Keratitis: Case Reports and Literature Review

<b>Background</b>: Fungal keratitis remains a serious threat to vision, often progressing despite medical therapy and requiring surgical intervention. Therapeutic deep anterior lamellar keratoplasty (DALK) and therapeutic penetrating keratoplasty (TPK), are frequently required but carry risks of infection recurrence and graft rejection. As timely identification of the etiological agent is essential for improving the outcomes in infectious keratitis, in vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) are instrumental in providing insights that can guide better therapeutic decision-making and improving outcomes in fungal keratitis. <b>Case Description</b>: We report the cases of two previously healthy patients (case one, 56-year-old woman; case two, 38-year-old man), who have presented in our service with unilateral infectious keratitis after ocular trauma with vegetable matter during outdoor activities, with a visual acuity of counting fingers and hand motion, respectively. Slit-lamp examination revealed unilateral extensive corneal infiltrates suggestive for fungal etiology in both cases. In vivo confocal microscopy (HRT-3, Heidelberg Retina Tomograph 3/Rostock Cornea Module, Heidelberg Engineering, Heidelberg, Germany) identified lesions suggestive for Candida Albicans and Acanthamoeba coinfection in case one and filamentous fungal keratitis in case two. Anterior segment optical coherence tomography (MS-39, CSO, Italy) was used to monitor the extent and morphology of the infiltrates. The patients underwent therapeutic DALK and TPK, respectively, with good results at the one-year follow-up. <b>Conclusions</b>: Our cases illustrate the advantages of incorporating IVCM and AS-OCT as complementary imaging techniques into clinical practice. IVCM and AS-OCT in fungal keratitis could lead to an earlier diagnosis, more accurate dynamic treatment response evaluation, and the identification of high-risk features for aggressive fungi for a more tailored medical and surgical management.