**5.4 Amniotic membrane transplantation**

Amniotic membrane transplantation (AMT) has emerged as an option to delay or prevent PK secondary to fungal keratitis. Amniotic membranes have been used to facilitate ocular surface reconstructions in other ocular surface conditions. AMT support re-epithelialization of tissue, and the active components present in the membrane like nerve growth factors are thought to reduce pain [103]. In a study, 23 culture-proven, acute fungal keratitis patients with non-healing corneal ulcers, or impending corneal perforation underwent AMT to prevent PK or to promote reepithelialization. Following AMT, 25% of patients with persistent positive culture for fungus required PK. The final visual outcome was BCVA > 20/400. It improved in 17, did not changed in four and worsened in two patients [104].

In an inflamed eye, there is increased risk of infection to be introduced into the anterior chamber or vitreous after PK and the use of corticosteroids, to prevent corneal graft rejection, may increase the risk of recurrence of fungal infection. Delay in PK can avoid these complications.

## **5.5 Lamellar Keratoplasty**

Lamellar keratoplasty (LK) is emerged as an alternate surgical procedure for fungal keratitis in which only diseased layers of the corneal surface are excised and replaced by donor cornea. In a study from China, reported the leading indication for LK in 2008 was infectious keratitis, and fungal keratitis constituted 67% of the infectious keratitis cases [105]. In another study, 55 antifungal refractory patients underwent LK with intensive topical and oral antifungal medication. In 93% of the patients, the fungal infection was eradicated. The remaining four patients were treated by a secondary PK. Visual acuity ranged from 20/20 to 20/63 with a few complications after 6–18 months follow-up [106].
