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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
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SDC

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: namrata.sharma@gmail.com).

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

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 (www.corneajrnl.com).

Received July 07, 2018

Accepted August 14, 2018

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