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Management Algorithm for Fungal Keratitis

The TST (Topical, Systemic, and Targeted Therapy) Protocol

Sharma, Namrata, MD; Sahay, Pranita, MD; Maharana, Prafulla K., MD; Singhal, Deepali, MD; Saluja, Gunjan, MD; Bandivadekar, Pooja, MD; Chako, Jacob, MD; Agarwal, Tushar, MD; Sinha, Rajesh, MD; Titiyal, Jeewan S., MD; Satpathy, Gita, MD; Velpandian, Thirumurthy, MD

doi: 10.1097/ICO.0000000000001781
Clinical Science

Purpose: To evaluate the efficacy of the topical, systemic and targeted therapy (TST) protocol in management of fungal keratitis.

Method: All cases of treatment-naive smear- or culture-proven fungal keratitis presenting between June 2013 and May 2017 were recruited. The TST protocol included initial treatment with topical natamycin 5% with addition of oral ketoconazole or voriconazole in ulcers with size >5 mm, depth >50%, or impending perforation. Topical voriconazole 1% was included in case of poor response at 7 to 10 days. Intrastromal or intracameral antifungal injections were administered in case of poor response to combination therapy. Penetrating keratoplasty was performed in case of poor response to any of the regimen.

Results: The study included 223 cases of fungal keratitis with a mean age of 43.6 ± 15.3 years and a male-to-female ratio of 1.8:1. The mean area of the ulcer and infiltrate at presentation was 25.52 ± 19 and 25.7 ± 14.4 mm2, respectively. Corrected distance visual acuity at presentation was 2.05 ± 0.43 logMAR that improved to 1.6 ± 0.4 logMAR at 3 months. Fusarium (42.2%) was the most common microorganism isolated, followed by Aspergillus (32.8%). The mean healing time was 41.5 ± 22.2 days, with a final scar size of 14.6 ± 8.2 mm2. The treatment success rate with the TST protocol was 79.8%. Corneal perforation developed in 7% of cases (n = 15), and keratoplasty was performed for 20.2% of cases (n = 45).

Conclusions: The TST protocol provides a stepwise treatment algorithm for management of cases of fungal keratitis with varying severity.

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Correspondence: Namrata Sharma, MD, Department of Ophthalmology, Room-482, 4th floor, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India (e-mail:

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

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Received July 07, 2018

Accepted August 14, 2018

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