Fungal keratitis
Last updated: February 6th, 2022
Summary of Evidence
Antifungal choice
Natamycin was associated with significantly better clinical outcomes than voriconazole for filamentous fungal keratitis, especially in Fusarium cases; Do not use voriconazole as monotherapy in filamentous keratitis.(MUTT, 2013) {Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Prajna L, Srinivasan M, Raghavan A, Oldenburg CE, Ray KJ, Zegans ME, McLeod SD, Porco TC, Acharya NR, Lietman TM; Mycotic Ulcer Treatment Trial Group. The mycotic ulcer treatment trial: a randomized trial comparing natamycin vs voriconazole. JAMA Ophthalmol. 2013 Apr;131(4):422-9.}
There was no benefit (rate of corneal perforation/need for PK) to adding oral voriconazole to topical antifungal eyedrops in the treatment of severe filamentous fungal ulcers.(MUTT II, 2016){Prajna NV, Krishnan T, Rajaraman R, Patel S, Srinivasan M, Das M, Ray KJ, O’Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Porco TC, Acharya NR, Lietman TM, Rose-Nussbaumer J; Mycotic Ulcer Treatment Trial II Group. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol. 2016 Dec 1;134(12):1365-1372.}
In a secondary analysis of visual outcomes in subgroup with Fusarium ulcers (at 3 months) in the MUTT II trial, Fusarium keratitis may benefit (decreased risk of perforation or need for PK) from the addition of oral voriconazole to topical natamycin.(MUTT II, 2017) {Prajna NV, Krishnan T, Rajaraman R, Patel S, Shah R, Srinivasan M, Devi L, Das M, Ray KJ, O’Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J; Mycotic Ulcer Treatment Trial Group. Adjunctive Oral Voriconazole Treatment of Fusarium Keratitis: A Secondary Analysis From the Mycotic Ulcer Treatment Trial II. JAMA Ophthalmol. 2017 Jun 1;135(6):520-525.}
Corneal collagen cross-linking
There appears to be no benefit of adjuvant corneal crosslinking in the primary treatment of moderate filamentous fungal ulcers, and it may result in decreased visual acuity. {Prajna NV, Radhakrishnan N, Lalitha P, Austin A, Ray KJ, Keenan JD, Porco TC, Lietman TM, Rose-Nussbaumer J. Cross-Linking-Assisted Infection Reduction: A Randomized Clinical Trial Evaluating the Effect of Adjuvant Cross-Linking on Outcomes in Fungal Keratitis. Ophthalmology. 2020 Feb;127(2):159-166.}