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Effectiveness of Topical Antifungal Drugs in the Management of Fungal Keratitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

McDonald, Elissa M. MN(Hons)*; Ram, Felix S. F. PhD; Patel, Dipika V. PhD*; McGhee, Charles N. J. PhD*

The Asia-Pacific Journal of Ophthalmology: January/February 2014 - Volume 3 - Issue 1 - p 41–47
doi: 10.1097/APO.0b013e3182a618dd
Review Article
Editor's Choice

Fungal keratitis (FK) typically requires intensive therapy with topical antifungal agents. To date, evidence from clinical trials has been conflicting with respect to the most effective topical antifungal drug in the treatment of FK. Therefore, a systematic review and meta-analysis of randomized controlled trials (RCTS) using the Cochrane methodology was undertaken to evaluate the effectiveness of topical antifungals in management of FK. Outcomes included time to cure, treatment failure, complications of infection, visual acuity and adverse effects. A comprehensive search for studies was undertaken resulting in inclusion of 8 RCTs, predominantly from India, involving a total of 793 participants, the majority of whom were infected with filamentous fungi. Topical voriconazole was more likely to result in therapeutic keratoplasty compared with natamycin [relative risk (RR) 1.89 95% CI: 1.14, 3.12] with a number needed to treat of 13 (95% CI: 7, 50). Final visual acuity was significantly better with natamycin compared with voriconazole [weighted mean difference (WMD) 0.13, 95% CI 0.00, 0.27]. There was no difference in risk of treatment failure across all topical antifungal treatments studied (chlorhexidine gluconate, econazole, miconazole, natamycin, silver sulphadiazine and voriconazole). This study suggests treatment failure was comparable among antifungal treatments reviewed. However, natamycin resulted in better visual acuity following acute infection, compared with voriconazole. Voriconazole had a significantly greater risk of therapeutic keratoplasty compared with natamycin in the populations studied.

From the *Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland; and †School of Health Sciences, Massey University, Auckland, New Zealand.

Received for publication May 28, 2013; accepted July 21, 2013.

The corresponding author had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

The authors have no funding or conflicts of interest to declare.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Reprints: Elissa M. McDonald, MN(Hons), Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, Private Bag 92019, Auckland, 1142 New Zealand. E-mail:

© 2014 by Asia Pacific Academy of Ophthalmology
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