Is there any extra advantage of prescribing oral anti-fungal agents in addition to topical anti-fungal drops in patients of fungal keratitis? If yes, then what is the indication, what is the best agent for this purpose and the correct dosing and duration?
From my Point of view, the role of oral antifungal agents in this context is low, as systemic sideeffects may occur and you get much higher corneal/intraocular concentrations when you apply the drugs topically
A meta-analysis of nine randomised, controlled trials (568 patients) concluded there is little evidence to suggest a particular oral antifungal over topical antifungals, and vice versa. (Florcurz & Peczon, 2012: Medical interventions for fungal
keratitis. Cochrane Database Syst Rev 2012)
If there are laboratories near you which perform antifungal susceptibility testing, this may be worthwhile in order to choose the best therapeutic regimen.
Thomas & Kaliamurthy (2013) suggest that the following agents are suitable for fungal keratitis:
Topical: natamycin (5%), econazole (1%), AmB (0.15-0.3%), 5FC (1%) clotrimazole (1%), miconazole (1%), ketoconazole (1-2%), itraconazole (1%), fluconazole (1%), voriconazole (1-2%), and caspofungin (0.5%).
IV: Amphotericin and miconazole (600-1200mg/day)
Oral: ketoconazole (beware side effects, check FDA info; 200-600mg/day), itraconazole (100-200mg/day), fluconazole (50-200mg/day) or voriconazole (400mg/day).
Other options include intrastromal injections of voriconazole and AmB, itracameral voriconazole, or intravitreal AmB, fluconazole and voriconazole.
All options are discussed in more detail in that review.
Article Mycotic keratitis: Epidemiology, diagnosis and management
In my opinion for Fungal keratitis the patient will receive topically clotrimazole (1%)- crem twice a day , fluconazole (1%) dros 3 times a day, besides Betadine 2.5% also has antifungal activity. The latest study revealed that fluconazol is better that voriconazole , which earlier was presentes as a very active topical antifungal.
Oral: fluconazole 150-mg/day only 7 days. Good luck !
In our experience oral Itraconazole 100-200 mgs/12 hs for two weeks, are good in aid of topical ocular droops of other triazole like voriconazole 1% for Aspergillus infection, not for Fusarium.
Itraconazole is a liposoluble compound and it stay in lacrimal oil layer.
One agent under study to prevent fungal infection in Boston K-Pro eyes is 0.01% hypochlorous acid, whose in vitro antifungal activity achieved a kill rate of 99.99% or better for all mold and yeast species tested after exposure to the agent for 1 minute, Odorcic said. The in vitro antifungal time-kill assays were undertaken at Massachusetts Eye and Ear Infirmary.
“When you look at our results, you can see that hypochlorous acid was extremely effective for all of the mold and all of the yeast species tested,” she said.
The agent, currently sold as Avenova (NovaBay Pharmaceuticals), is considered a broad-spectrum antimicrobial and is FDA cleared as an adjunctive treatment for blepharitis, Odorcic said. – by Patricia Nale, ELS