Emerging treatments in fungal keratitis

Fungal keratitis is a major cause of corneal blindness, particularly in tropical and low-resource settings, and remains challenging to manage due to delayed diagnosis, limited drug penetration, emerging resistance, and host-mediated tissue damage. Conventional antifungal therapies, including natamycin and voriconazole, are often inadequate in deep, severe, or refractory infections, underscoring the need for alternative strategies. This narrative review summarizes and critically appraises emerging treatments in fungal keratitis, with a focus on recent pharmacological advances, innovative drug delivery systems, adjunctive therapies, and immunomodulatory approaches. Newer-generation azoles, echinocandins, and repurposed agents are discussed alongside advanced formulations such as liposomal amphotericin B, solubilized natamycin, nanoparticle-based delivery, and intrastromal drug administration. Adjunctive modalities, including photo-activated corneal cross-linking, photodynamic therapy, therapeutic contact lenses, and low-temperature plasma, are reviewed for their antimicrobial and corneal-stabilizing effects. The role of immunomodulators in mitigating excessive inflammation while preserving antifungal defense is also highlighted. In addition, evolving strategies for managing infections caused by emerging and fungus-like pathogens, including Pythium sp., are addressed. While many of these therapies show promising experimental and early clinical outcomes, robust randomized controlled trials and standardized treatment protocols remain limited. This review emphasizes the need for translational research, ocular-specific antifungal development, and integrated therapeutic approaches to improve visual outcomes and reduce the burden of fungal keratitis.