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 µg/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 µg/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.