Fungal Keratitis Medication

  • Author: Daljit Singh, MBBS, MS, DSc; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Oct 27, 2011
 

Medication Summary

The antifungal agents used include polyenes (eg, natamycin, amphotericin B), azoles (eg, ketoconazole, miconazole, fluconazole, itraconazole), and fluorinated pyrimidines (eg, flucytosine). Amphotericin B is the drug of choice in fungal keratitis caused by yeasts. Natamycin has a broad-spectrum of activity against filamentous organisms. Oral fluconazole and ketoconazole should be considered in the management of deep fungal keratitis.

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Antifungal agents

Class Summary

Their mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

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Natamycin (Natacyn)

 

Initial drug of choice in Fusarium keratitis. Predominantly fungicidal tetraene polyene antibiotic, derived from Streptomyces natalensis that possesses in vitro activity against a variety of yeast and filamentous fungi, including Candida, Aspergillus, Cephalosporium, Fusarium, and Penicillium species. Binds fungal cell membrane forming a polyenesterol complex that alters membrane permeability, depleting essential cellular constituents. Activity against fungi is dose-related but not effective, in vitro, against gram-negative or gram-positive bacteria.

Generally, therapy should be continued for 14-21 d or until the fungal keratitis has resolved. In many cases, may help to reduce dosage gradually at 4- to 7-day intervals to ensure elimination of the organism.

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Amphotericin B 0.1-0.25% (Amphocin, Fungizone)

 

Polyene antibiotic produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols (eg, ergosterol) in the fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death. First agent of choice in corneal infections due to yeasts, such as Candida species.

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Ketoconazole (Nizoral)

 

Fungistatic activity. Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Often used systemically in the treatment of deep fungal infections. Studies have confirmed intraocular penetration in keratitis due to Fusarium, Aspergillus, Curvularia, and Candida species.

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Fluconazole (Diflucan)

 

Alternative drug to ketoconazole in the treatment of deep fungal keratitis caused by a variety of fungi. Fungistatic activity. Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol, thereby disrupting cellular membranes.

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Flucytosine 1% (Ancobon)

 

Converted to fluorouracil after penetrating fungal cells. Inhibits RNA and protein synthesis. Active against Candida and Cryptococcus and generally used in combination with amphotericin B. High incidence of acquired resistance has occurred; therefore, combined treatment with other agents is recommended.

In the treatment of fungal keratitis, polyenes and imidazoles have mostly replaced flucytosine.

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Contributor Information and Disclosures
Author

Daljit Singh, MBBS, MS, DSc  Professor Emeritis, Department of Ophthalmology, Guru Nanak Dev University, Amritsar, India; Director, Daljit Singh Eye Hospital

Daljit Singh, MBBS, MS, DSc is a member of the following medical societies: All India Ophthalmological Society, American Society of Cataract and Refractive Surgery, Indian Medical Association, International Intraocular Implant Club, and Intraocular Implant and Refractive Society, India

Disclosure: Nothing to disclose.

Coauthor(s)

Arun Verma, MD  Senior Consultant, Department of Ophthalmology, Dr Daljit Singh Eye Hospital, India

Disclosure: Nothing to disclose.

Specialty Editor Board

Anastasios J Kanellopoulos, MD  Assistant Program Director, Clinical Associate Professor, Department of Ophthalmology, Manhattan Eye, Ear, and Throat Hospital, New York University

Anastasios J Kanellopoulos, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Eye Bank Association of America, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, George Alexandrakis, MD, to the development and writing of this article.

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Fungal corneal ulcer.
Perforated fungal ulcer.
Fungal infection under treatment.
Perforated fungal corneal ulcer.
Fungal ulcer in an elderly woman.
Fungal ulcer.
Fungal corneal ulcer, with excessive vascularization.
Marginal ulcer, fungus positive.
Healed fungal ulcer.
Fungal keratitis.
Corneal perforation, blocked by a crystalline lens and being covered by epithelium.
Fungal keratitis, being controlled.
Fungal infection.
Fungal infection.
Fungal abscess.
Fungal corneal abscess/ulcer. A proven case of fungal infection, 5 days' duration. Intense infiltration around the abscess.
 
 
 
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