CLINICAL SCIENCE

The Effects of Intrastromal Voriconazole Injection and Topical Voriconazole in the Treatment of Recalcitrant Fusarium Keratitis
Heidar Siatiri, MD,* Farid Daneshgar, MD,* Nasim Siatiri, MD, and Alireza Khodabande, MD

Purpose: To describe the course and outcome in 3 patients with

recalcitrant fungal keratitis treated with intrastromal voriconazole injection and topical voriconazole application.

Methods: The present study was an interventional case series. A 50

mg/0.1 mL solution of voriconazole was injected into the corneal stromal tissue around the corneal ulcer, and 1% topical voriconazole was added to the therapeutic regimen if the ulcer failed to respond to 5% topical natamycin hourly and oral ketoconazole twice per day. The inltration and epithelial defect size were measured at each visit using a slit-lamp biomicroscope. Anatomical outcomes were assessed.

Results: A dramatic therapeutic response was observed in 2 patients. An amniotic membrane transplantation using cyanoacrylate glue was required to seal the microperforation in a patient with a chemical burn superinfected with Fusarium. Conclusions: Intrastromal injection of voriconazole together with topical voriconazole effectively reduced the inltration size and controlled the infection in patients with Fusarium keratitis. However, continued application of the topical medication is critical for a favorable outcome of treatment.
Key Words: voriconazole, Fusarium, fungal keratitis, corneal abscess (Cornea 2011;30:872875)

Most available antifungal agents are fungistatic.4 This limitation, together with the poor topical penetration of fungal agents, has prompted ophthalmologists to seek more potent antifungal agents and better routes of application. Voriconazole and other new triazoles are, at least theoretically, superior to the traditionally used antifungal agents.5 Several cases of the topical and systemic use of voriconazole to treat fungal keratitis have been reported.610 For example, Prakash et al11 used intrastromal voriconazole injection for the treatment of recalcitrant deep fungal keratitis. Despite this, studies addressing the therapeutic effects of voriconazole on fungal keratitis are insufcient. The current study presents data on 3 patients with intractable fungal keratitis treated with an intrastromal injection of voriconazole and topical application to further elucidate the effectiveness of voriconazole for the treatment of fungal keratitis.

PATIENTS AND METHODS

The 3 patients had fungal keratitis involving the deep stroma that was unresponsive to a 2-week regimen of conventional antifungal therapy. All the patients provided informed consent. The clinical diagnosis of fungal keratitis was conrmed by positive smears and culture results. Corneal scrapings were performed under topical anesthesia using 0.5% tetracaine and were sent for Gram staining and culturing on blood agar, chocolate agar, and Sabouraud agar. The patients were admitted to the hospital, and treatment was started when positive smear results for fungal elements were received. The 3 patients were initially treated with 5% topical natamycin hourly and 200 mg of oral ketoconazole twice per day. The corneal inltration size was measured every day, and the infection was considered to become worse if the corneal inltration size was increased compared with the previous measurements. When there was no improvement or the corneal ulcer further deteriorated after a 2-week regimen of this antifungal therapy, we added an intrastromal injection of voriconazole, 50 mg/0.1 mL, accompanied by 1% topical voriconazole hourly to the initial treatment. The injection solution was prepared by dissolving 200 mg of lyophilized voriconazole powder (Vfend; Pzer) in 19 mL of sterile distilled water to obtain 20 mL of a 1% (10 mg/mL) solution. Then, 1 mL of the 1% solution was added to 19 mL of sterile distilled water to obtain a 0.5 mg/mL (50 mg/0.1 mL) solution. The 0.5 mg/mL solution was used for the intrastromal injection, and the 1% solution was used for topical application. Local anesthesia was established with
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ungal keratitis is one of the most challenging forms of infectious keratitis to treat,1 and it may extend to adjacent tissues, inducing scleritis or endophthalmitis that could potentially result in loss of the eye.2 Penetrating keratoplasty may be necessary to treat fungal keratitis, which may have a poor prognosis.3

Received for publication February 10, 2010; revision received January 5, 2011; accepted January 11, 2011. From the *Cornea Department; Ophthalmic Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran 1336616351, Iran. The authors state that they have no proprietary or conicts of interest to disclose. Reprints: Farid Daneshgar, Anterior Segment Department, Farabi Eye Hospital, Qazwin Sq, Kargar St, Tehran, Iran (e-mail: daneshgar@razi. tums.ac.ir). Copyright 2011 by Lippincott Williams & Wilkins

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a retrobulbar injection of 2 mL of 2% lidocaine. Under aseptic conditions, the 50 mg/0.1 mL solution was injected into the corneal stroma using an insulin syringe with a 30-gauge needle that was inserted bevel-down into the midstroma. The injection was performed under high magnication using an operating microscope, and care was taken not to inadvertently enter the anterior chamber. Multiple drug injections were administered around the circumference of the lesion to hydrate the corneal stroma. A total of 0.1 mL was injected in all cases. The size of the inltration and epithelial defect were measured every morning using a slit-lamp biomicroscope. The topical antifungal medications were continued for at least 1 week after complete reepithelialization of the cornea.

Case 2
A 32-year-old man experienced an alkali chemical burn in his left eye 20 days before he was referred to us with a superinfection of Fusarium species. He had an extensive dense corneal inltration with satellite lesions and hypopyon. The inltration size was 9 mm; deep corneal stromal layers were inltrated and stromal tissue necrosis was present. The ulcer failed to respond to the initial antifungal therapy, and he was enrolled in the study on intrastromal voriconazole injection and 1% topical voriconazole. The inltration was signicantly reduced in size 48 hours after treatment (Fig. 2, Table 1), but we observed evidence of epithelial toxicity. Seven days later, a microperforation appeared at the center of the ulcer and a shallow anterior chamber was noted. Surgery was performed to seal the perforation using cyanoacrylate glue and an amniotic membrane overlay. Two months later, he had a vascularized scar in the center of the cornea with no inammation.

Case 3 CASE REPORTS Case 1

A 44-year-old man was referred to us for recalcitrant keratitis. He reported the development of red eye after a mosquito came in contact with the surface of his eye. He had a central abscess in his left eye that did not respond to the initial antifungal therapy. Smears were positive, and the culture was positive for Fusarium species. Initial antifungal therapy was started. The initial therapy included topical natamycin hourly and oral ketoconazole twice per day. The diameter of the inltration was 2 mm, and deep corneal stromal layers were involved. The ulcer failed to respond after 2 weeks; he was administered an intrastromal injection of voriconazole, and 1% voriconazole drops were added to his therapeutic regimen. Two days after the injection, the inltration size was reduced (Fig. 1, Table 1) and did not change again until 7 days after he received a second intrastromal injection. The inltration resolved 14 days after the second injection, and he was discharged from the hospital. One month after discharge, a circumscribed paracentral scar with no vascularization was present. A 29-year-old man with a history of trauma in the right eye caused by wood particles was admitted for fungal keratitis with positive smears for fungi. The culture was positive for Fusarium species. Antifungal therapy was initiated immediately after hospitalization. The paracentral dense abscess with vegetative borders failed to respond to the initial therapy. An intrastromal voriconazole injection and hourly voriconazole drops were started, and we noted a dramatic reduction in the size and density of the inltration 48 hours later (Fig. 3, Table 1). Seven days later, we observed no inltration and continued reepithelialization. A paracentral scar and thinning with no vascularization were present 1 month after admission.

DISCUSSION
Most antifungal drugs are fungistatic, and their poor penetration when applied as topical medications hampers the treatment of deep fungal keratitis. Several studies have investigated the effect of more potent drugs and delivery to the site of action in the posterior stroma using intrastromal or intracameral injections.12,13 Prakash et al11 recently reported

FIGURE 1. A, Central abscess unresponsive to conventional therapy. B, Reduction in inltrate size 48 hours after intervention. C, A second injection was administered because the therapeutic response to the rst injection was insufcient. D, One month after discharge, a faint nebulous scar with pigment deposition was present (case 1). q 2011 Lippincott Williams & Wilkins www.corneajrnl.com |

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TABLE 1. Size of Corneal Abscess and Epithelial Defect Before and 48 Hours After Intrastromal Voriconazole Injection and Application of Topical Voriconazole
Case 1 2 3 Size of Inltration Before Injection (mm) 2 9 5.5 Size of Inltration 48 h After Injection (mm) 1 5.5 1.5 Size of Epithelial Defect Before Injection (mm) 4 11 6.5 Size of Epithelial Defect 48 h After Injection (mm) 4 8 6.5

a favorable outcome using intrastromal voriconazole injection in 3 patients with deep recalcitrant fungal keratitis. They performed an intrastromal injection if 2 consecutive courses of topical antifungal therapy, including 14 days of 5% natamycin drops every 2 hours and 14 days of 1% voriconazole drops hourly, did not halt the infection. We administered intrastromal voriconazole (50 mg/0.1 mL) if a favorable response was not observed after a 2-week treatment period with 5% topical natamycin drops hourly and oral ketoconazole twice per day. We observed a reduction in inltration size after intrastromal voriconazole and topical application of voriconazole in addition to the initial treatment regimen in all 3 patients. This nding is consistent with those reported by Prakash et al.11 We also repeated the intrastromal injection in case 1, as was reported by Tu,14 in a case of Alternaria keratitis. In our series, Fusarium was isolated as the etiologic agent in all 3 patients. The Fusarium genus contains more than 100 species and more than 15 of them are capable of causing infections in humans. Fusarium species are resistant to many of the antifungal drugs that are currently used to treat fungal infections.15 Some Fusarium species, such as Fusarium verticillioides, are resistant to most antifungal drops (90% minimal inhibitory concentration of .16 mg/mL for amphotericin B, .8 mg/mL for itraconazole, and .8 mg/mL for voriconazole).16 Among these resistant fungi, Fusarium solani is the most resistant15 and, along with Fusarium oxysporum, is

the most common etiologic agent in fungal infections. We did not have appropriate facilities to identify the species of Fusarium in our patients. Identication of Fusarium to the species level is time-consuming and laborious and requires reference laboratories and the expertise of a trained mycologist.15 We observed a reduction in inltrate size in the early postoperative period in all patients. Case 2 had microperforation develop after a reduction in inltrate size. The obvious reduction of the corneal inltration size after intrastromal injection of voriconazole and topical voriconazole suggests the drug toxicity and sterile keratolysis as contributing factors, accompanied by the infectious process, leading to microperforation of the cornea that was induced by mandatory frequent use of epitheliotoxic antifungal drugs and the absence of reepithelialization in the cornea 29 days after the chemical burn.17 In such cases, early intervention with topical and intrastromal voriconazole may halt the development of keratolysis and prevent further surgical intervention. Cyanoacrylate compounds have antifungal activity18; however, this seems to have no signicant role in the clinical course of the fungal ulcer. Nevertheless, using cyanoacrylate compounds to seal corneal microperforations with an amniotic membrane transplantation could be useful in some cases. Case 2 responded favorably to an amniotic membrane overlay using cyanoacrylate glue.

FIGURE 2. A, Dense corneal abscess before intervention. B, At 48 hours after the addition of topical and intrastromal voriconazole, gray white epithelial edges and erosions are visible. C, Corneal microperforation sealed by cyanoacrylate glue and overlay amniotic membrane transplant. D, Two months after surgery, a quiescent vascularized corneal scar was present (case 2).

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FIGURE 3. A, Dense crescent-shaped paracentral corneal abscess unresponsive to conventional antifungal therapy. B, At 48 hours after intrastromal injection and topical voriconazole, the inltration was reduced to a minimal size. C, Seven days after intervention, the inltrate was resolved and the epithelial defect was reduced. D, A quiescent paracentral scar and thinning was apparent 1 month after the intrastromal voriconazole injection (case 3).

Fusarium is a signicant plant pathogen.15 It is a ubiquitous organism widely found in agricultural settings.19 The abundance of pathogenic organisms in the environment presents a signicant risk factor for fungal keratitis. In summary, the optimal treatment for Fusarium infection has not yet been established,15 and numerous cases of Fusarium keratitis worldwide end with the loss of the eye. Delivery of voriconazole directly to the site of action by an intrastromal injection increases the drug concentration above minimal inhibitory concentration of most of the Fusarium species and can change the course of the disease from serious to a favorable outcome. REFERENCES
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8. Verma S, Tuft SJ. Fusarium solani keratitis following LASIK for myopia. Br J Ophthalmol. 2002;86:11901191. 9. Klont RR, Eggrink C, Rijs AYMM, et al. Successful treatment of Fusarium keratitis with corneal transplantation and topical and systemic voriconazole. Clin Infect Dis. 2005;40:110112. 10. Nulens E, Eggink C, Rijs AYMM, et al. Keratitis caused by Scedosporium apiospermum successfully treated with a cornea transplant and voriconazole. J Clin Microbiol. 2003;41:22612264. 11. Prakash G, Sharma N, Goel M, et al. Evaluation of intrastromal injection of voriconazole as a therapeutic adjunctive for the management of deep recalcitrant fungal keratitis. Am J Ophthalmol. 2008;146:5659. 12. Garsia-Valenzuela E, Song CD. Intrastromal injection of amphotericin B for recurrent fungal keratitis and endophthalmitis. Arch Ophthalmol. 2005;123:17211723. 13. Yoon KC, Jeong IY, Im SK, et al. Therapeutic effect of intracameral amphotericin B injection in the treatment of fungal keratitis. Cornea. 2007;26:814818. 14. Tu EY. Alternaria keratitis: clinical presentation and resolution with topical uconazole or intrastromal voriconazole and topical caspofungin. Cornea. 2009;28:116119. 15. Alastruey-Izquierdo A, Cuenca-Estrella M, Monzon A, et al. Antifungal susceptibility prole of clinical Fusarium spp. isolates identied by molecular methods. J Antimicrob Chemother. 2008;61:805809. 16. Nucci M, Annaissie E. Fusarium infection in immunocompromised patients. Clin Microbial Rev. 2007;20:659704. 17. Wagoner MD. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Surv Ophthalmol. 1997;41:275312. 18. Lv YP, Wang XY, Song BA, et al. Synthesis, antiviral and antifungal bioactivity of 2-cyano-acrylate derivatives containing phosphonyl moieties. Molecules. 2007;12:965978. 19. Chang CW, Ho CK, Chen ZC, et al. Fungi genus and concentration in the air of onion elds and their opportunistic action related to mycotic keratitis. Arch Environ Health. 2002;57:349354.

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