This randomised double-blinded trial examined clinical outcomes of 50 patients with severe fungal keratitis treated with either adjuvant oral voriconazole or oral ketoconazole. Inclusion criteria were culture or smear proven fungal ulcers >5mm in maximum diameter, involving >4mm of the corneal centre and extending >50% of the stromal depth. Aspergillus species were the most common isolates, followed by Fusarium species. All patients were treated with the same regime of topical natamycin 5%, equal half received adjuvant oral voriconazole (VCZ) 200mg twice a day, and the other half – oral ketoconazole (KCZ) 200mg twice a day. The final best-corrected visual acuity was significantly better in the VCZ group compared to KCZ group by 0.26 LogMAR units. Resultant corneal scar was also significantly smaller in the VCZ group compared to KCZ group. There were no differences in the incidence of cataract, duration of healing of the epithelial defect, or the incidence of corneal perforations. The ratio of the tear film to serum concentration of the drugs for oral VCZ was significantly better than that for oral KCZ. Patients treated with VCZ reported less systemic side-effects compared to KCZ. The results of this study favour addition of adjuvant oral VCZ over oral KCZ in cases of severe fungal keratitis. VCZ can be especially useful in cases of Aspergillus proven infections, as this species is highly sensitive to VCZ. 

Comparison of oral voriconazole versus oral ketoconazole as an adjunct to topical natamycin in severe fungal keratitis: a randomized controlled trial.
Sharma N, Singhal D, Maharana P, et al.
2017; 36(12):1521-7.
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Magdalena Popiela

Royal Gwent Hospital, Cardiff, UK.

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