Bipolaris (dematiaceous) Fungal Keratitis Masquerading as Herpetic Keratouveitis with Hypopyon and Secondary Ocular Hypertension.

The aim of the study was to report an uncommon presentation of dematiaceous fungal keratitis caused by Bipolaris spp. in a 40-year-old male, initially resembling herpetic keratouveitis, and to describe the diagnostic course and multimodal management. A 40-year-old Egyptian male farmer presented with a 1-week history of left eye pain and markedly reduced vision following eye rubbing after handling vegetative material. Slit-lamp examination showed a dense central corneal infiltrate (4 mm × 3 mm) with an epithelial defect, a thick endothelial plaque, keratic precipitates, and a hypopyon. Initial microbiologic workup was negative, and the clinical impression favored herpetic keratouveitis. Despite antiviral therapy and systemic steroids, the clinical course worsened with total hypopyon and elevated intraocular pressure. Repeat sampling, anterior chamber wash, and corneal biopsy ultimately identified Bipolaris spp. Therapy was escalated to intensive topical and systemic antifungals, with adjunct intracameral and intrastromal antifungal injections, resulting in infection control. The cornea healed with a visually significant central scar, and the patient later underwent optical penetrating keratoplasty with a clear graft and no recurrence at 14 months. Fungal keratitis, particularly dematiaceous species, can mimic viral keratouveitis and may remain culture-negative early. In cases with atypical features or poor response to empiric therapy, clinicians should maintain a low threshold for repeat sampling, deeper tissue diagnostics, and early targeted antifungal escalation. Multimodal therapy may be required when there is stromal and anterior chamber involvement.