Adjunctive topical versus intrastromal voriconazole in mycotic keratitis

Abstract

Evaluation of: Sharma N, Chacko J, Velpandian T et al. Comparative evaluation of topical versus intrastromal voriconazole as an adjunct to natamycin in recalcitrant fungal keratitis. Ophthalmology 120(4), 677–681 (2013).

Topical natamycin is generally considered first-line treatment for mycotic keratitis. The authors of the paper being evaluated have reported earlier that intrastromal voriconazole is effective therapy for recalcitrant deep mycotic keratitis. The paper being evaluated extends those observations, while emphasizing that voriconazole is probably best considered as an adjunct to natamycin in recalcitrant mycotic keratitis; moreover, intrastromal injections were not obviously more beneficial than topical therapy. The ulcers receiving intrastromal voriconazole were possibly more severe than those in the topical voriconazole treatment group if mean sizes of epithelial defect and stromal infiltrate and presence of hypopyon are considered. Studies on additional patients may elucidate differences that were not apparent due to the relatively small number of patients treated.

Keywords::

• fungal keratitis
• intrastromal injection
• mycotic keratitis
• natamycin
• voriconazole

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest or financial conflict with the subject matter or materials discussed in this manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Topical natamycin 5% continues to be the treatment of choice for mycotic keratitis, particularly that due to filamentous fungi, and especially Fusarium species.

• • Voriconazole is a triazole antifungal that is potentially useful to treat mycotic keratitis since it can be applied by a variety of routes and has a relatively broad spectrum of antifungal activity.

• • Voriconazole tends to have poor activity against Fusarium species and, hence, cannot be used as monotherapy to treat keratitis due to Fusarium species.

• • Voriconazole monotherapy may suffice for relatively superficial, non-severe ulcers due to fungi other than Fusarium species.

• • Intrastromal voriconazole has been found effective in treatment of recalcitrant mycotic keratitis.

• • The potential benefit of intrastromal voriconazole, in comparison with that of topical voriconazole, to treat relatively severe forms of mycotic keratitis, particularly those due to Fusarium species, needs to be clarified in a large series of patients.