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Intrastromal antimicrobial injections in microbial keratitis: Current evidence and clinical perspectives
Naazli M Shaikh1, Aaliyah S Shaikh2, Raad S Shaikh3
1Department of Ophthalmology, College of Medicine, Howard University, Washington, DC, USA.
Abstract:
Intrastromal antimicrobial injections are an emerging adjunctive treatment for severe, deep, or recalcitrant microbial keratitis when conventional topical or systemic therapies are insufficient. By delivering high local concentrations of antimicrobial agents directly into the corneal stroma, this approach may overcome limitations in tissue penetration and, in selected cases, delay or avoid the need for keratoplasty. Current evidence supporting intrastromal therapy is strongest in fungal keratitis, where it is increasingly used in deep stromal disease. In contrast, evidence for bacterial keratitis remains limited and is derived largely from case reports and small case series, typically in refractory or biofilm-associated infections. This review synthesizes the available literature on intrastromal antimicrobial injections, including indications, technique, efficacy, safety, and dosing considerations. A targeted literature review was performed using PubMed, Scopus, and Google Scholar. While intrastromal therapy shows promise, outcomes vary according to organism, antimicrobial selection, and study design. Further high-quality studies are needed to define optimal protocols, comparative efficacy, and long-term safety.
Insights
Intrastromal antimicrobial injections offer a promising adjunctive treatment for severe microbial keratitis, particularly fungal infections. While effective in delivering high local drug concentrations, further research is needed to optimize protocols for bacterial keratitis.
Area of Science:
- Ophthalmology
- Infectious Diseases
- Pharmacology
Background:
- Microbial keratitis, especially severe or recalcitrant cases, poses a significant challenge to conventional treatments.
- Limitations in topical and systemic antimicrobial penetration into the corneal stroma necessitate alternative therapeutic strategies.
Purpose of the Study:
- To review the current literature on intrastromal antimicrobial injections for microbial keratitis.
- To synthesize evidence regarding indications, techniques, efficacy, safety, and dosing of this emerging treatment modality.
Main Methods:
- A targeted literature review was conducted using major scientific databases (PubMed, Scopus, Google Scholar).
- The review focused on studies evaluating intrastromal antimicrobial injections for various forms of microbial keratitis.
Main Results:
- Intrastromal injections demonstrate the strongest evidence base in fungal keratitis, particularly for deep stromal infections.
- Evidence for bacterial keratitis is limited, primarily from case reports of refractory or biofilm-associated infections.
- Outcomes are variable, influenced by the causative organism, chosen antimicrobial agent, and study design.
Conclusions:
- Intrastromal antimicrobial injections represent a promising adjunctive therapy for severe microbial keratitis, potentially avoiding keratoplasty.
- Further high-quality research is essential to establish optimal protocols, comparative effectiveness, and long-term safety profiles.
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