Combined Intrastromal Voriconazole and Amphotericin B Treatment for Persistent Fungal Keratitis

Purpose: To evaluate the clinical outcomes of combined intrastromal voriconazole and intrastromal amphotericin B for the treatment of persistent fungal keratitis. Method: Patients who received combined corneal intrastromal voriconazole (0.05 mg/0.1 mL) and intrastromal liposomal amphotericin B (0.01 mg/0.1 mL) injections in addition to topical therapy for treatment of persistent fungal keratitis were included in the study. Persistence was described as no improvement or progression in the clinical findings despite treatment with combined topical voriconazole (1 mg/0.1 mL) and topical amphotericin B drops (0.15 mg/0.1 mL) hourly for at least 10 days. The healing of keratitis was considered as the complete closure of epithelial defect with complete resolution of a corneal infiltrate. Results: Thirty-two eyes of 32 patients who met the inclusion criteria were included in this study. Predominant organisms in fungal isolates were Aspergillusspecies. Combination therapy of intrastromal amphotericin B and intrastromal voriconazole in addition to topical therapy resulted in complete resolution of persistent fungal keratitis in 28 (87.5%) patients. The mean number of intrastromal injections was 9.3 +/- 6.4 and ranged from 1 to 18. The mean best-corrected visual acuity values improved from 2.17 +/- 0.43 to 1.76 +/- 0.77 logarithm of the minimum angle of resolution units (P=0.003). The mean duration of complete epithelial closure was 45.3 +/- 16.3 days. Four patients required therapeutic penetrating keratoplasty because of persistence of fungal keratitis (3 patients) and progression of keratitis (1 patient). There was no need for evisceration. Conclusion: Combination therapy with intrastromal voriconazole and intrastromal amphotericin B may be an effective adjunct treatment for persistent fungal keratitis.