We read with great interest the paper by Agarwal et al, on successful use of systemic and topical itraconazole for mycotic keratitis. We published the first series on oral itraconazole therapy for mycotic keratitis. We used oral itraconazole capsules and topical 1% itraconazole cream, both obtained from Janssen Pharmaceutica, Belgium; Agarwal et al have neither stated the source of the itraconazole powder that they used nor the source of the artificial tears with which they prepared their topical suspension. As mentioned in their paper, 100 mg of itraconazole powder in 100 ml artificial tears does not constitute a 1% suspension but is only a 0.1% suspension. We have also reported (not cited by Agarwal et al) on oral and topical itraconazole therapy for fungal keratitis.
The definition of superficial and deep keratitis is not stated in the study. In Table 1, 72.2% (39 cases) have presented with deep stromal infiltration which does not correlate with the number of superficial keratitis, i.e., is 50% (27 cases). Again in Table 1, 10 of 54 eyes presented with endophthalmitis or panophthalmitis; management of these eyes in detail is not mentioned. The authors have also mentioned that there is a faster rate of healing in group I than in group II patients but the mean time of healing is not mentioned in either group.
As a large majority of patients (92.5%) presented with visual acuity of 3/60 or less, it is difficult to comprehend how favourable response to therapy was graded in terms of number of lines improvement in the Snellen’s chart. Instead of grading the ulcers after treatment, it might have been more useful to have graded the ulcers before treatment. Jones. suggested grading keratitis into “non-severe” or “severe” at presentation. We have used a similar grading system in studies with various antifungals, since we believe that the response of severe ulcers to therapy is a true gauge of the efficacy of an antifungal compound.
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Conflict of Interest:
1. Agarwal PK, Roy P, Das A, Banerjee A, Maity PK, Banerjee AR. Efficacy of topical and systemic itraconazole as a broad-spectrum antifungal agent in mycotic corneal ulcer. A preliminary study Indian J Ophthalmol. 2001;49:173–76
2. Thomas PA, Abraham DJ, Kalavathy CM, Rajasekaran J. Oral itraconazole therapy for mycotic keratitis Mycoses. 1988;31:271–79
3. Rajasekaran J, Thomas PA, Kalavathy CM, Joseph PC, Abraham DJ. Itraconazole therapy for fungal keratitis Indian J Ophthalmol. 1987;35:157–60
4. Jones DB. Decision making in the management of microbial keratitis Ophthalmology. 1981;88:814–20