Intrastromal voriconazole: the next effective adjunctive treatment for recalcitrant keratomycosis.

Introduction: Fungal keratitis is a commonly encountered infection of the cornea which may lead to moderate to severe visual loss. Aim: To report the result of intra-stromal voriconazole in refractory keratomycosis. Method: Fungal keratitis is a commonly encountered infection of the cornea which may lead to moderate to severe visual loss. It may be caused by several species of fungi and accounts for nearly 50% of all cases of infectious keratitis in developing countries. The penetration of antifungal drugs into the deeper layers of cornea is sub-optimal, thus making it difficult to treat cases of deep fungal keratitis. We report two cases of refractory fungal keratitis; one caused by aspergillus fumigates and other by fusarium as seen on lactophenol cotton blue mount from scrapings. Both the cases were resistant to topical 5% natamycin and 1 % voriconazole and therefore, intra-stromal voriconazole reconstituted to 50 microns / 0.1 ml was injected circumferentially into the mid-stroma in close proximity to the ulcer margins in both the cases. Result: A marked reduction in the size of ulcer (both epithelial defect and infiltrates) was noted at 72 hours after intra-stromal voriconazole. A repeat injection was given in both the cases four days after the first injection. No complications were seen in any of the cases. Conclusion: Intra-stromal voriconazole offers an effective adjunctive in treating refractory keratomycosis as the direct deposition of drug into deeper stroma results into higher therapeutic concentrations into ulcer; thus obviating the need for therapeutic penetrating keratoplasty in such patients.