Evaluation of intrastromal voriconazole injection in recalcitrant deep fungal keratitis: case series
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Published on: May 31, 2024
Namrata Sharma1, Prakashchand Agarwal, Rajesh Sinha
1Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India. namrata103@hotmail.com
Aim:
To evaluate the efficacy of intrastromal voriconazole, as a modality of treatment for management of recalcitrant fungal keratitis.
Methods:
Twelve patients of smear and/or culture positive fungal keratitis not responding to topical and systemic antifungal therapy were treated with additional intrastromal voriconazole therapy. Patients were given one or more intrastromal injection of voriconazole (50 μg in 0.1 ml) at the junction of clear cornea and infiltrates, using a 30-gauge needle in five quadrants to form a barrage around the ulcer. All patients continued to receive topical and systemic antifungal therapy.
Results:
The mean age of the patients was 47.58 ± 15.13 years, and the mean time to presentation at the centre was 37.58 ± 10.54 days. Organisms isolated were Aspergillus species (n=8), Fusarium species (n=3) and Curvularia (n=1). Of 12 eyes, 10 eyes healed with scar formation, and the mean resolution time was 39.75 ± 7.62 days. Two corneas perforated and required therapeutic penetrating keratoplasty. The best-corrected visual acuity was less than 20/1200 in all patients at the time of presentation, which improved to better than 20/400 in 10 eyes and 20/40 in eyes that underwent penetrating keratoplasty at the end of 24.75 ± 2.14 weeks' follow-up.
Conclusion:
Intrastromal injection of voriconazole may be used as a modality of treatment for managing cases of recalcitrant fungal keratitis.
Insights
Intrastromal voriconazole injections effectively treated recalcitrant fungal keratitis in 10 of 12 patients. This approach improved visual acuity, offering a new option for difficult-to-manage fungal eye infections.
Area of Science:
- Ophthalmology
- Mycology
- Infectious Diseases
Background:
- Fungal keratitis is a serious eye infection, particularly challenging when resistant to standard treatments.
- Recalcitrant cases often require novel therapeutic strategies to prevent vision loss.
Purpose of the Study:
- To assess the effectiveness of intrastromal voriconazole for fungal keratitis unresponsive to conventional therapies.
- To evaluate visual outcomes and healing rates in patients receiving this treatment.
Main Methods:
- Twelve patients with confirmed fungal keratitis, refractory to topical/systemic antifungals, received intrastromal voriconazole injections.
- Voriconazole (50 μg in 0.1 ml) was injected into five quadrants around the corneal ulcer, alongside continued topical and systemic antifungal treatment.
Main Results:
- Aspergillus, Fusarium, and Curvularia species were the most common causative agents.
- Ten out of twelve eyes healed with scarring; two required penetrating keratoplasty due to perforation.
- Visual acuity improved significantly, with 10 eyes achieving better than 20/400 and two reaching 20/40 post-keratoplasty.
Conclusions:
- Intrastromal voriconazole serves as a viable treatment option for recalcitrant fungal keratitis.
- This localized delivery method can be crucial for managing severe, treatment-resistant fungal eye infections.
