[Prolonged topical natamycin 5 % therapy before and after keratoplasty for Fusarium keratitis]

A 69-year-old female patient presented with a therapy-resistant corneal ulcer due to contact lenses, which had been present in the left eye for 1 month. The best corrected visual acuity at the first visit was 0.2. Keratitis with a central corneal ulcer was found. A corneal curettage was performed followed by inpatient therapy with antibiotic eye drops. The first PCR result was negative and the microbiological culture was sterile after 48 h. The clinical findings improved during the hospital stay. There was a decrease in the size of the corneal ulcer and an increase of best corrected visual acuity up to 0.4 so that the patient was discharged.

After 8 weeks the patient presented again with a painful eye and visual decline to 0.1. The left eye showed a fulminant keratitis with corneal abscess so that a second course of therapy was initiated. The PCR of the second corneal curettage was positive for Fusarium. Antifungal therapy with natamycin 5 % eye drops (via the international pharmacy) and systemic antifungal therapy with voriconazole (2 × 200 mg) were initiated. Due to personal circumstances the patient rejected corneal transplantation, therefore, local and systemic antifungal outpatient treatment was continued for another 2 months until keratoplasty à chaud of the left eye could be performed. At this time there was a clear reduction of inflammation but a descemetocele developed. The patient was treated with local and systemic antifungal therapy (under control of liver and kindney parameters in blood) for 3 months postoperatively in addition to administration of local and systemic steroids.

In cases of therapy-resistant keratitis, a Fusarium keratitis should always be considered. Corneal curettage ahead of therapy is very important.

Natamycin 5 % eye drops are the first choice of topical antifungal medication in cases of Fusarium keratitis. Even though intensive local and systemic therapy are performed, patients often require corneal transplantation. Due to a high rate of recurrence a longer local and systemic antifungal therapy is required.

In the case described here, there was a clear corneal graft without Fusarium recurrence 1 year after surgery and it is presumed the prolonged antifungal therapy before and after surgery was an important factor for this clinical outcome.