The Use Of Combination Of Intrastromal Voriconazole Injection And Cornea Debridement In Recalcitrant Fungal Keratitis

Background: Keratomycosis also was known as fungal keratitis remains a significant challenge to ophthalmologists,because it is a major cause of corneal blindness in the developing countries where incidence and prevalence are high.Fungal keratitis has doubled during last decade.The management of fungal keratitis is still unsatisfactory because antifungal drugs have poor penetration to the cornea and limited spectrum against yeast and filamentous fungi which cause most of the clinical cases.Recently voriconazole has emerged as a promising therapy,because of its broad spectrum against filamentous fungi;it also achieves a higher concentration in the cornea,once combined with deep debridement.In this study,we investigated whether intrastromal voriconazole injection combined with deep debridement has resulted in good outcome.We are also using In vivo confocal microscopy because it is emerging as a tool for rapid diagnoses in recalcitrant fungal keratitis with high sensitivity.In vivo confocal microscopy is used to monitor drug response and drug toxicity.AS-OCT was performed to record the depth of lesion pretreatment and followed after treatment.Objective The primary objective of this study is to assess the effectiveness of intrastromal voriconazole injection combined with deep debridement in the management of recalcitrant fungal keratitis.Design The study is retrospective,non-comparative study of 31 cases with fungal keratitis.Patient and methods 31 patients were admitted at the first Hospital Jilin University and analyzed retrospectively.The patients were collected between October 2017 to January 2018 at the First Hospital of Jilin University,and their ages were between 35 to 74 years,samples of 6 cases with details are presented.All the cases were diagnosed with fungal keratitis,based on combination clinical history,laboratory,and IVCM and AS-OCT findings.Most of these patients were transferred to the first Hospital of Jilin University department of ophthalmology from the secondary hospitals or come to the outpatient department all with a history of treatment failure and as such qualified as recalcitrant fungal keratitis.These patients were deemed to be candidates for a combination of intrastromal voriconazole injection combined with cornea debridement.Results There were 17(54.8%)males and 14(45.2%)females.The range of ages was from 35 to 74 years,and the mean age was 57.2±10.6 years.The age ranges of the patients were divided into 5 groups: younger than 40 years,40 to 50 years,50 to 60 years,60 to 70 years and older than 70 years.27 patients(87.1%)had improved visual acuity,and visual acuity of 3 patients(9.7%)worsened.The diseased eye was left in 11 patients(35.5%)and right in 20 patients(64.5%).Treatment was successful in 28 patients(90.3%)and failed in 3 patients(9.7%).Epithelial healing times were between 4-5 weeks,and the numbers of voriconazole reinjections were on average between four to five times.Seven patients(23.3%)were farmers,which is a strong risk factor for fungal keratitis.Treatment was the only independent influence factor of visual acuity outcome,the visual acuity improved after treatment;the P value was significant(P < 0.05).Conclusion: Intrastromal voriconazole injection combined with cornea debridement is an efficient,safe and fast method for treatment of recalcitrant fungal keratitis.