Intracamaral recombinant tissue plasminogen activator as a treatment for refractory fibrin reaction following penetrating keratoplasty: A case report

We report a case of severe fibrin reaction following penetrating keratoplasty (PKP) that was successfully treated with intracameral recombinant tissue plasminogen activator (r-TPA). A 62-year-old male with a history of herpetic keratitis and retinal detachment surgery presented with corneal scarring in the left eye. He underwent PKP combined with cataract extraction and intraocular lens (IOL) implantation. One month postoperatively, he developed an intense anterior chamber reaction with fibrin accumulation, endothelial plaque formation on the graft, and creamy-white iris infiltrates, raising suspicion of fungal keratitis. Therapeutic PKP was performed due to treatment-resistant ulcerative keratitis, and the patient subsequently received an intracameral injection of r-TPA (25 µg/0.05 cc) for persistent fibrinoid reaction. At the 24-hour follow-up, the fibrin had markedly resolved, and the graft appeared clear. While topical or subconjunctival steroids may be sufficient in mild to moderate cases, intracameral r-TPA may serve as a valuable adjunct in refractory cases, offering long-term morphological and functional improvement.