Original article
Evaluation of Intrastromal Injection of Voriconazole as a Therapeutic Adjunctive for the Management of Deep Recalcitrant Fungal Keratitis

https://doi.org/10.1016/j.ajo.2008.02.023Get rights and content

Purpose

To evaluate the role of intrastromal injection of voriconazole in the management of deep recalcitrant fungal keratitis.

Design

Interventional case series.

Methods

Setting: Cornea services at a tertiary care teaching hospital. Patients: Three eyes of three patients with deep stromal recalcitrant fungal keratitis not responding to topical antifungal medications. Intervention Procedure: Voriconazole 50 micrograms/0.1 ml was injected circumferentially around the fungal abscess in the corneal stroma as an adjunctive to the topical antifungal therapy. Main Outcome Measure: Main outcome measure was a reduction in size of the abscess and resolution of the infection.

Results

Before the intracorneal injection, all three eyes had gradually worsening lesions on topical medications. After the intervention, a faster reduction in the size of corneal infiltration was documented and a complete resolution of the ulcers was seen within three weeks in all cases.

Conclusion

Targeted delivery of voriconazole by intracorneal injection may be a safe and effective way to treat cases of deep-seated recalcitrant fungal keratitis responding poorly to conventional treatment modalities.

Section snippets

Methods

In this interventional case series, three cases of mycotic keratitis involving deep corneal stroma that were unresponsive to topical antifungal therapy underwent intrastromal injection of voriconazole 50 micrograms/0.1 ml. Each of the participating patients gave informed written consent for participation in the study and for the surgical and medical management.

The diagnosis of fungal infection was made on the basis of clinical evaluation, positive smear, and cultures of the fungus. At initial

Results

Each of the three patients was referred to us for management by the peripheral ophthalmic clinics with a history of recalcitrant microbial keratitis and had corneal abscesses involving up to posterior stroma. Patients had already received topical fluoroquinolone drops and antifungal agents for two to four weeks.

History of vegetative trauma was recorded in two patients, and one of these (Case 2) was treated with topical steroids (Table). In each of the three patients smears were positive for

Discussion

Corneal infections involving deeper parts of the stroma are not amenable to topical antimicrobial therapy. This is particularly true for mycotic keratitis because none of the present-day antifungal agents can optimally penetrate the deeper layers of the cornea. To overcome these problems, modalities of targeted drug delivery are being evaluated. Similar attempts of site-directed drug deposit have been made in posterior segment pathologies in the form of intravitreal injections and posterior

Gaurav Prakash, MD, is currently a Clinical Fellow in Cornea at Rajendra Prasad Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India. He did his ophthalmic residency at AIIMS. Dr Prakash research interests are in wavefront optics, refractive surgery, visual development, corneal disorders, and instrumentation designing. A peer-reviewer for international ophthalmic journals, Dr Prakash previous works have been published in reputed journals and presented in international

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Gaurav Prakash, MD, is currently a Clinical Fellow in Cornea at Rajendra Prasad Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India. He did his ophthalmic residency at AIIMS. Dr Prakash research interests are in wavefront optics, refractive surgery, visual development, corneal disorders, and instrumentation designing. A peer-reviewer for international ophthalmic journals, Dr Prakash previous works have been published in reputed journals and presented in international conferences. He wishes to pursue a career in clinical research and contribute to international academic ophthalmology.

Namrata Sharma, MD, DNB, MNAMS, is an Associate Professor of Ophthalmology at the Cornea and Refractive Surgery Services at Rajendra Prasad Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Dr Sharma has over 130 international peer-reviewed publications. She has held instruction courses in AAO, ESCRS and ASCRS. Dr Sharma received the achievement award at American Academy of Ophthalmology in 2005 and “Best of Show Award” in 2003, 2004, and 2006.

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