Anterior Segment OCT in Fulminant Pseudomonas aeruginosa Corneal Ulcer with Stromal Melting Requiring Emergency Penetrating Keratoplasty

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Authors have submitted manuscript entitled "Fulminant Infectious Keratouveitis with Corneal Melting Requiring Emergency Penetrating Keratoplasty" I have following comments to offer.

1 Severe infective keratitis is always associated with inflammation in the anterior chamber. The title is misleading. It should be changed to " Severe Psedudomoas Corneal Ulcer with Melting Requiring Emergency Penetrating Keratoplasty"

2 Authors need to add how their case is different from the routine cases and what new information it adds to the diagnosis and treatment of the condition.

3 Authors need to add whether the patient was immune competent or immune compromised. Authors need to add the senstivity report obtained on cultures.

4 Authors need to add the information on the status of anterior chamber angle in the post op AS OCT picture.

5 Authors need to intraocular pressure in the post op period.

6 Three months follow up is too short to determine the outcome of the case. The minimum follow up for such a patient should be 12 months. 

Comments on the Quality of English Language

English quality need to be improved.

Author Response

Comment 1: Severe infective keratitis is always associated with inflammation in the anterior chamber. The title is misleading. It should be changed to "Severe Pseudomonas Corneal Ulcer with Melting Requiring Emergency Penetrating Keratoplasty".

Response: We thank the Reviewer for this important and insightful comment. We agree that anterior chamber inflammation is a common and expected feature of severe infectious keratitis, and that the term “keratouveitis” may therefore be insufficiently specific and potentially misleading in this context.

In response to this suggestion, we have revised the title to improve both terminological precision and scientific clarity, while also emphasizing the imaging modality central to this report. The updated title reads:

“Anterior Segment OCT in Fulminant Pseudomonas aeruginosa Corneal Ulcer with Stromal Melting Requiring Emergency Penetrating Keratoplasty.”

This revision more accurately reflects the microbiological etiology, highlights the key role of anterior segment optical coherence tomography in clinical decision-making, and aligns with the “Interesting Images” format of Diagnostics.
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Comment 2: Authors need to add how their case is different from the routine cases and what new information it adds to the diagnosis and treatment of the condition.

Response: We thank the Reviewer for this valuable comment. In response, we have explicitly clarified the novelty and clinical relevance of our case. Specifically, we emphasized the unusually rapid progression of stromal melting despite intensive antimicrobial therapy and highlighted the added diagnostic value of anterior segment optical coherence tomography (AS-OCT) in detecting structural corneal changes not fully appreciable on slit-lamp examination.

We have revised the Abstract and figure legends (Figures 1 and 5) to clearly state how this case differs from routine presentations and to underline the contribution of multimodal imaging to early identification of impending corneal perforation and timely surgical decision-making. These modifications strengthen the clinical and diagnostic implications of the report in line with the Reviewer’s suggestion.
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Comment 3: Authors need to add whether the patient was immune competent or immune compromised. Authors need to add the sensitivity report obtained on cultures.

Response: We thank the Reviewer for this important and clinically relevant comment. We have revised the manuscript to include detailed information regarding both the patient’s immune status and the microbiological findings.

The patient was immunocompetent, with no history of systemic disease or immunosuppressive therapy. In addition, we have incorporated the results of antimicrobial susceptibility testing, which demonstrated that the isolated Pseudomonas aeruginosa strain was sensitive to ciprofloxacin, levofloxacin, gentamicin, and amikacin, with borderline susceptibility to piperacillin and tobramycin.

These data have been added to the revised Figure 3 legend to improve the clinical completeness and transparency of the case. At the same time, in accordance with the Interesting Images format, detailed therapeutic regimens were condensed to maintain focus on the imaging findings and their clinical implications.
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Comment 4: Authors need to add the information on the status of anterior chamber angle in the post op AS OCT picture.

Response: We thank the Reviewer for this valuable and insightful suggestion. We have revised the description of the postoperative AS-OCT findings in Figure 5 to include a detailed assessment of the anterior chamber configuration and angle status.

Specifically, we report that the anterior chamber appears relatively shallow, with focal narrowing of the anterior chamber angle visible in selected regions on AS-OCT. We have also clarified that this finding is likely multifactorial, potentially reflecting postoperative corneal edema with increased corneal thickness, as well as lens-related anterior segment crowding.

This addition provides a more comprehensive and clinically accurate interpretation of the postoperative anterior segment anatomy and further strengthens the imaging-based value of the report.
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Comment 5: Authors need to intraocular pressure in the post op period.

Response: We thank the Reviewer for this important comment. We have revised the manuscript to include information on postoperative intraocular pressure. Specifically, we report that intraocular pressure remained stable at 12 mmHg, as measured by Goldmann applanation tonometry. This information has been added to the postoperative description in Figure 5 to provide a more comprehensive assessment of clinical outcomes.
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Comment 6: Three months follow up is too short to determine the outcome of the case. The minimum follow up for such a patient should be 12 months.

Response: We thank the Reviewer for this important comment. We agree that long-term follow-up is essential for a comprehensive assessment of outcomes after penetrating keratoplasty.

However, we would like to emphasize that this manuscript was prepared in the format of Interesting Images, which focuses on the presentation of clinically relevant imaging findings and acute decision-making rather than long-term outcomes typical of full case reports. In this context, our primary aim was to illustrate the role of multimodal imaging, particularly AS-OCT, in the early identification of corneal structural instability and timely surgical intervention in a fulminant course of infectious keratitis.

To address the Reviewer’s concern, we have clarified in the revised manuscript that the patient remains under regular long-term follow-up, with ongoing monitoring of graft status and visual function. We agree that extended follow-up is important and will be evaluated in the future.
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Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I wish to submit my review for the papers titled: Fulminant Infectious Keratouveitis with Corneal Melting Requiring Emergency Penetrating Keratoplasty.

The report, in its current form, requires substantial proofreading to enhance clarity and provide further insights. The figure captions are too lengthy and should be shortened to emphasize only the key findings. The diagnosis of keratouveitis should be supported by specific clinical findings of anterior uveal inflammation, which are currently not described. In vivo confocal microscopy is mentioned as part of the multimodal imaging assessment, but no images or findings are presented.

The overall structure should be reformatted to provide a structured, detailed day-by-day/staged workflow. It is not clear the detailed escalation of the events, how long the medical therapy was administered, and when/how the clinical scenario determined the decision to perform urgent transplantation. Therefore, I suggest reshaping the manuscript to include a specific timeline (from first evaluation to discharge) and a related description of examinations and clinical decisions.

The antimicrobial regimen (even the empirical one) reported appears unusual for severe keratitis, as no hourly fortified antibiotic therapy (including overnight administration) is described. The rationale for the selected treatment protocol, including the use of chlorhexidine and topical voriconazole, should be clarified. Finally, the manuscript states that deterioration occurred “despite aggressive medical therapy.” However, the reported regimen (fortified gentamicin 1.3% and moxifloxacin every two hours) does not appear consistent with the intensive hourly fortified antibiotic therapy typically recommended for severe keratitis.

Although labeled as an "Interesting images" report, the case presentation and description lack important details. It would be helpful to include detailed reports of every examination finding and management, along with an introduction that references published literature, the rationale for the study, why these images can be considered as "interesting" for a cornea specialist, what it adds to the current literature, a discussion of the case in relation to existing studies, and any insights into the reported paper. 

Author Response

Comment 1: The report, in its current form, requires substantial proofreading to enhance clarity and provide further insights. The figure captions are too lengthy and should be shortened to emphasize only the key findings. The diagnosis of keratouveitis should be supported by specific clinical findings of anterior uveal inflammation, which are currently not described. In vivo confocal microscopy is mentioned as part of the multimodal imaging assessment, but no images or findings are presented.

Response: We thank the Reviewer for this comprehensive and constructive comment. The manuscript has been thoroughly revised to improve clarity, consistency, and overall readability.

In response to the concern regarding figure captions, all figure legends have been carefully reviewed and refined to reduce redundancy and improve focus on key imaging findings, while preserving essential clinical context in accordance with the Interesting Images format.

Regarding the use of the term “keratouveitis”, we agree that the available clinical documentation does not provide sufficient specific evidence of anterior uveal inflammation to support this diagnosis. Therefore, the manuscript has been revised accordingly, and this term has been replaced with more precise terminology referring to severe infectious keratitis with anterior segment involvement.

In addition, we have addressed the comment concerning in vivo confocal microscopy by including a representative confocal microscopy image as a separate figure (Figure 2). The corresponding figure legend has been expanded to describe the observed microstructural features, including hyperreflective inflammatory cellular elements and disruption of normal stromal architecture.

These revisions ensure consistency between the described multimodal imaging approach and the presented data, and further strengthen the imaging-based and diagnostic value of the manuscript.
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Comment 2: The overall structure should be reformatted to provide a structured, detailed day-by-day/staged workflow. It is not clear the detailed escalation of the events, how long the medical therapy was administered, and when/how the clinical scenario determined the decision to perform urgent transplantation. Therefore, I suggest reshaping the manuscript to include a specific timeline (from first evaluation to discharge) and a related description of examinations and clinical decisions.

Response: We thank the Reviewer for this valuable suggestion. We agree that clarification of the temporal progression and clinical decision-making is important.

However, we would like to emphasize that the manuscript was prepared in the format of Interesting Images, which focuses primarily on key imaging findings and critical clinical decision points rather than providing a detailed day-by-day case report.

To address the Reviewer’s concern, we have revised the manuscript to include a concise description of the clinical course. Specifically, we clarified that empiric topical therapy was initiated upon admission and that rapid clinical deterioration occurred within 48 hours, leading to the decision to perform urgent therapeutic penetrating keratoplasty.

This modification improves the clarity of the clinical timeline and decision-making process while maintaining the concise, image-focused structure of the manuscript.
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Comment 3 : The antimicrobial regimen (even the empirical one) reported appears unusual for severe keratitis, as no hourly fortified antibiotic therapy (including overnight administration) is described. The rationale for the selected treatment protocol, including the use of chlorhexidine and topical voriconazole, should be clarified. Finally, the manuscript states that deterioration occurred “despite aggressive medical therapy.” However, the reported regimen (fortified gentamicin 1.3% and moxifloxacin every two hours) does not appear consistent with the intensive hourly fortified antibiotic therapy typically recommended for severe keratitis.

Response: We thank the Reviewer for this important and clinically relevant comment. We agree that the rationale for the initial empiric treatment should be explained more clearly and that the wording used to describe treatment intensity should be more precise.

In the present case, the initial topical regimen was selected in the context of ocular trauma caused by organic material, where a mixed bacterial–fungal infection could not be excluded at presentation. For this reason, in addition to antibacterial treatment, chlorhexidine and topical voriconazole were introduced empirically to provide broader antimicrobial coverage while awaiting microbiological results. We have clarified this rationale in the revised manuscript.

We have also revised the wording describing the treatment course and replaced the previous phrasing with a more accurate formulation referring to intensive empiric topical therapy, rather than implying a standard hourly fortified antibacterial protocol for culture-proven bacterial keratitis.

Finally, we clarified that despite this empiric broad-spectrum topical treatment, the clinical condition deteriorated rapidly over 48 hours, with progressive stromal melting and increasing risk of perforation, which ultimately prompted urgent therapeutic penetrating keratoplasty.
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Comment 4: Although labeled as an "Interesting images" report, the case presentation and description lack important details. It would be helpful to include detailed reports of every examination finding and management, along with an introduction that references published literature, the rationale for the study, why these images can be considered as "interesting" for a cornea specialist, what it adds to the current literature, a discussion of the case in relation to existing studies, and any insights into the reported paper.

Response: We thank the Reviewer for this thoughtful and important comment. We agree that the manuscript should more clearly explain its clinical rationale, imaging relevance, and relationship to the existing literature.

At the same time, we would like to emphasize that the present submission was prepared in the format of Interesting Images, which is intended to focus on clinically meaningful imaging findings and their diagnostic or therapeutic implications, rather than to provide the full breadth of detail expected in a conventional case report.

To address the Reviewer’s concern while preserving the structure appropriate for this article type, we have substantially revised the manuscript in several ways. First, we added a concise Introduction supported by relevant literature to provide background on severe infectious keratitis, the role of multimodal imaging, and the indications for therapeutic penetrating keratoplasty. Second, we clarified the rationale for presenting this case as an “Interesting Images” report by emphasizing the image-based documentation of rapidly progressive stromal melting and the role of AS-OCT in identifying structural instability that supported urgent surgical intervention. Third, we strengthened the concluding interpretative section to explain what this case adds to the current literature, particularly in relation to the practical diagnostic value of multimodal imaging in fulminant infectious keratitis. We also added a separate “Clinical Relevance” section to summarize the relationship of this case to the existing literature and to clarify its practical contribution to the current understanding of advanced infectious keratitis.

In addition, the figure legends and case descriptions were revised to improve clarity and to better highlight the key examination findings and the sequence of management decisions, while maintaining the concise, image-focused character of the manuscript.
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We believe these revisions have substantially improved the scientific framing, clinical relevance, and educational value of the report in line with the Reviewer’s suggestions.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I wish to submit my review for the paper titled:   Anterior Segment OCT in Fulminant Pseudomonas aeruginosa Corneal Ulcer with Stromal Melting Requiring Emergency Penetrating Keratoplasty

The manuscript has improved; however, some key clinical aspects still need clarification. The rationale for broad-spectrum empiric therapy is well explained and appreciated. However, the intensity and dosing frequency of the antimicrobial regimen are not clearly described. Providing this information would help the reader better interpret the reported rapid clinical progression.

Finally, a brief, clear statement outlining what makes this case particularly “interesting” for a cornea specialist would further strengthen the manuscript.

 

Author Response

Comment: The manuscript has improved; however, some key clinical aspects still need clarification. The rationale for broad-spectrum empiric therapy is well explained and appreciated. However, the intensity and dosing frequency of the antimicrobial regimen are not clearly described. Providing this information would help the reader better interpret the reported rapid clinical progression.

Finally, a brief, clear statement outlining what makes this case particularly “interesting” for a cornea specialist would further strengthen the manuscript.

Response: We thank the Reviewer for this positive and constructive comment. We are pleased that the rationale for the broad-spectrum empiric therapy was considered clear and appropriate.

In response to the Reviewer’s suggestion, we have revised the legend of Figure 3 to specify the intensity and dosing frequency of the empiric topical regimen. We now clarify that fortified gentamicin 1.4% and topical moxifloxacin were administered alternately every hour, while topical voriconazole was given every 2 hours and chlorhexidine five times daily as adjunctive empiric antifungal coverage. This addition provides a clearer clinical context for interpreting the reported rapid progression despite treatment.
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In addition, we have revised the concluding part of Figure 5 to include a brief and explicit statement clarifying what makes this case particularly relevant for cornea specialists. Specifically, we now state that, of particular interest to cornea specialists, this case illustrates how AS-OCT may help define the optimal window for urgent penetrating keratoplasty by detecting structural decompensation before frank perforation, thereby enabling earlier and more controlled surgical management of fulminant infectious keratitis.
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We believe these revisions further improve the clinical clarity and educational value of the manuscript.