Natamycin plus ISV injection confers no benefit in filamentous fungal ulcers
The addition of intrastromal voriconazole (ISV) to topical natamycin does not appear to provide any benefit in the primary treatment of moderate-to-severe filamentous fungal ulcers, a recent study in India has found.
“Studies consistently suggest that voriconazole has a limited role in the treatment of filamentous fungal ulcers,” according to the investigators.
This outcome-masked, randomized controlled clinical trial included 151 patients with moderate vision loss resulting from a smear-positive fungal ulcer. Study eyes were randomly assigned to either topical natamycin plus ISV injection or topical natamycin alone.
Microbiological cure on 3-day repeat culture analysis was the primary outcome, while secondary outcomes included microbiological cure on 7-day repeat culture analysis, 3-week and 3-month best spectacle-corrected visual acuity, infiltrate or scar size or both, perforation rate, therapeutic penetrating keratoplasty (TPK), and other adverse events.
Of the patients, 70 were enrolled at the Aravind Eye Hospital in Pondicherry, India. Baseline cultures grew Fusarium in 19 patients (27 percent), Aspergillus in 17 (24 percent) and other filamentous fungi in 19 (27 percent). Thirteen patients (19 percent) had negative results.
After controlling for baseline culture status, ISV injection was associated with a 1.82-fold risk of 3-day culture positivity (95 percent CI, 0.65–5.23; p=0.26) and a 1.98-fold risk of positive 7-day culture results (0.69–5.91; p=0.20).
Patients in the ISV injection arm had 0.5 logMAR lines (approximately 0.5 Snellen lines, –2.6 to 3.6 lines; p=0.75) of decreased visual acuity and 0.55 mm (–0.13 to 1.25; p=0.11) worse infiltrate or scar size or both at 3 months after controlling for baseline values.
Furthermore, ISV injection was associated with a 2.85-fold (0.76–10.75; p=0.12) increased risk of perforation after controlling for baseline infiltrate depth. However, there was no difference in the rate of TPK (hazard ratio, 0.95, 0.44–2.04; p=0.90).