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    Natamycin still the best bet for fungal keratitis


    Oral voriconazole trial

    Topical natamycin, however, is not as effective as might be desired. The major limitation of the drug is its shallow penetration into the cornea.

    This shortcoming prodded the investigators to take a look at treatment with oral voriconazole for fungal ulcers because of its ability to penetrate the eye and the possibility that it might be more beneficial for deeper infections, Dr. Rose-Nussbaumer explained.

    However, the results of the Mycotic Ulcer Treatment Trial II, released in the last quarter of 2016 and published in JAMA Ophthalmol (2016; online), were mixed.

    This study was a randomized, double-masked, placebo-controlled study that looked at 240 smear-positive, severe fungal corneal ulcers in eyes with a visual acuity of 20/400 that were randomized to treatment with oral voriconazole or placebo. All patients received a topical anti-fungal treatment.

    The primary outcomes were the rates of perforation and the need for therapeutic PK at 3 months after the start of treatment. The baseline median BCVA was counting fingers, and the median infiltrate/scar size was 5.4 mm2.

    The Fusarium species was the most occurring pathogen, followed by the Aspergillus species (30% and 26.3%, respectively) in this patient population.

    The results indicated that a significantly (P = 0.003) higher rate of adverse events was associated with the use of oral voriconazole that included elevated liver function tests and visual disturbances, among others.

    No marked improvement

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