Intrastromal voriconazole for deep recalcitrant fungal keratitis: a case series

Aim To evaluate the outcomes of treating deep recalcitrant fungal keratitis with intrastromal voriconazole injection. Methods Twenty-five patients with culture proven fungal keratitis, not responding to a combination of topical 5% natamycin and 1% voriconazole were treated with intrastromal voriconazole (50 mu g/0.1 mL) injected in five divided doses around the infiltrate to form a depot of the drug around the circumference of the lesion. Results The mean age of the patients was 52.52 +/- 12.21 years and mean time to presentation was 17.12 +/- 13.75 days from the onset of symptoms. The mean area of the infiltrate was 30.41 +/- 17.2 mm(2), hypopyon was present in 88% and all cases had infiltrates that extended beyond the mid-stromal level. Intrastromal voriconazole helped to resolve the infection in 18 (72%) patients and about 15% of these needed more than one injection. Smaller ulcers responded better to treatment. Fusarium spp were responsible for six of the seven cases that failed treatment. Conclusions Targeted delivery of voriconazole by intrastromal injection (50 mg/0.1 mL) is a safe and effective way to treat deep recalcitrant fungal keratitis, though some may need repeated injections. Fusarium keratitis may show suboptimal response but this needs further study.