title: Comparative evaluation of topical versus intrastromal voriconazole as an adjunct to natamycin in recalcitrant fungal keratitis.
abstract: OBJECTIVE
  To compare the efficacy of topical voriconazole and topical natamycin with that of intrastromal voriconazole and topical natamycin in patients with recalcitrant fungal keratitis.
  
  
  METHODS
  Randomized clinical trial.
  
  
  METHODS
  Forty eyes of 40 patients with fungal keratitis (positive smear or culture results or both) larger than 2 mm, involving up to two thirds of the stromal depth, and not responding to topical natamycin therapy for 2 weeks were recruited.
  
  
  METHODS
  The patients were randomized to receive either topical 1% voriconazole therapy (n = 20) or intrastromal injections of voriconazole 50 μg/0.1 ml (n = 20). The patients in both groups continued topical natamycin 5% every 4 hours until the ulcer healed.
  
  
  METHODS
  Primary outcome measure was best spectacle-corrected visual acuity (BSCVA) 3 months after intervention, and secondary outcome measures were time to healing and the size of the scar.
  
  
  RESULTS
  The patients in both groups had comparable baseline parameters. The mean BSCVA after treatment was 1.295 ± 0.5 logarithm of the minimum angle of resolution (logMAR) units in the topical group and 1.692 ± 0.29 logMAR units in the intrastromal group. The visual acuity after treatment was significantly better in the topical voriconazole group (P = 0.008). Nineteen patients receiving topical voriconazole and 16 patients who were given intrastromal voriconazole healed with therapy.
  
  
  CONCLUSIONS
  Topical voriconazole seems to be a useful adjunct to natamycin in fungal keratitis not responding to topical natamycin. Intrastromal injections did not offer any beneficial effect over topical therapy.
authors.affiliation: Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. namrata.sharma@gmail.com
authors.forename: Namrata
authors.initials: N
authors.lastname: Sharma
authors.forename: Jacob
authors.initials: J
authors.lastname: Chacko
authors.forename: Thirumurthy
authors.initials: T
authors.lastname: Velpandian
authors.forename: Jeewan S
authors.initials: JS
authors.lastname: Titiyal
authors.forename: Rajesh
authors.initials: R
authors.lastname: Sinha
authors.forename: Gita
authors.initials: G
authors.lastname: Satpathy
authors.forename: Radhika
authors.initials: R
authors.lastname: Tandon
authors.forename: Rasik B
authors.initials: RB
authors.lastname: Vajpayee
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000008:administration & dosage; D003319:Corneal Stroma; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D015821:Eye Infections, Fungal / Q000188:drug therapy* / Q000382:microbiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007267:Injections; D007634:Keratitis / Q000188:drug therapy* / Q000382:microbiology; D008297:Male; D008875:Middle Aged; D010866:Natamycin / Q000008:administration & dosage*; D009883:Ophthalmic Solutions; D011743:Pyrimidines / Q000008:administration & dosage*; D016896:Treatment Outcome; D014230:Triazoles / Q000008:administration & dosage*; D065819:Voriconazole
chemical_list: D000935:Antifungal Agents; D009883:Ophthalmic Solutions; D011743:Pyrimidines; D014230:Triazoles; D010866:Natamycin; D065819:Voriconazole