Challenging case of treating fungal keratitis

Objective: Treating fungal keratitis is always a challenge due to limited antifungal medication, their poor penetration, and often, the delay in diagnosis. The purpose of this study is to present new routes of medication delivery, such as intrastromal application for advanced cases not responding to topical therapy. Methods: A 60-year-old female presented with fungal keratitis, complaining of decreased vision, redness in her left eye followed by frequent pain, which got worse a few days prior. Visual acuity was limited to hand motion. Slit-lamp examination showed advanced conjunctival hyperemia, a very deep white feathery lesion in the central cornea, with satellite lesions on the periphery, and pseudohypopyon of 3 mm in the anterior chamber. She was started on oral fluconazole 100 mg b.i.d, followed by corneal debridement and topical hourly voriconazole eye drops and intrastromal voriconazole application as her local findings did not show any improvement. Results: After repeating the procedure three times, the inflammatory reaction was decreased, the central ulcer healed, satellite lesions disappeared and pseudohypopyon did not recur even after discontinuation of the topical therapy. Conclusion: Intrastromal voriconazole application showed its safety and efficacy in treating advanced fungal keratitis with deep intrastromal lesions. Abbreviations: NSAID = non-steroid anti-inflammatory drugs, BCVA = best corrected visual acuity, MIC = mean inhibitory concentration.