Comparison of Natamycin and Voriconazole for the Treatment of Fungal Keratitis

Abstract

Objective-To conduct a therapeutic exploratory clinical trial comparing clinical outcomes of treatment with topical natamycin vs topical voriconazole for fungal keratitis.Methods-The multicenter, double-masked, clinical trial included 120 patients with fungal keratitis at Aravind Eye Hospital in India who were randomized to receive either topical natamycin or topical voriconazole and either had repeated scraping of the epithelium or not.Main Outcome Measures-The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 3 months. Other outcomes included scar size, perforations, and a sub-analysis of BSCVA at 3 months in patients with an enrollment visual acuity of 20/40 to 20/400.Results-Compared with those who received natamycin, voriconazole-treated patients had an approximately 1-line improvement in BSCVA at 3 months after adjusting for scraping in a multivariate regression model but the difference was not statistically significant (P=.29). Scar size at 3 months was slightly greater with voriconazole after adjusting for scraping (P=.48). Corneal perforations in the voriconazole group (10 of 60 patients) were not significantly different than in the natamycin-treated group (9 of 60 patients) (P>.99). Scraping was associated with worse BSCVA at 3 months after adjusting for drug (P=.06). Patients with baseline BSCVA of 20/40 to 20/400 showed a trend toward a 2-line improvement in visual acuity with voriconazole (P=.07).Conclusions-Overall, there were no significant differences in visual acuity, scar size, and perforations between voriconazole-and natamycin-treated patients. There was a trend toward scraping being associated with worse outcomes.

Predictors of outcome in fungal keratitis

“…Specific methods for the trial have been described previously. 9 In brief, 120 patients were randomized to receive either topical natamycin 5% (Alcon, Fort Worth, TX, USA) or topical voriconazole 1% (Pfizer, Inc., reconstituted by AuroLab, Madurai, India) at the Aravind Eye Care System in Madurai and Pondicherry, India, and independently (in a factorial design) to receive re-scraping of the corneal epithelium at 1 week and 2 weeks after enrolment or not. The primary outcome of the trial was best spectacle-corrected logMAR visual acuity (BSCVA) at 3 months after enrolment.…”

“…The primary outcome of the trial was best spectacle-corrected logMAR visual acuity (BSCVA) at 3 months after enrolment. 9 Institutional Review Board approval was obtained at the University of California, San Francisco, Dartmouth Medical School, and Aravind Eye Hospital.…”

“…9 Here, we report the results of a secondary analysis of the following variables (obtained at presentation) for their effects on the ultimate clinical outcome: age (years), gender, visual acuity (logMAR), estimated depth of the infiltrate, infiltrate/ scar size, epithelial defect size, feathery edges, endothelial plaque, hypopyon, location (central/ peripheral), multiple lesions, pigmented, epithelial defect size, history of recent ocular trauma, object of corneal injury (vegetative/non-vegetative), occupation (agriculture/non-agriculture), adnexal infection, corneal or lid abnormality, on topical antifungal at presentation, on topical antibiotic at presentation, on steroids at presentation, and duration of symptoms. Both infiltrate/ scar size and epithelial defect size were taken as the geometric mean of the longest diameter and the maximum distance perpendicular to this diameter.…”

“…The trial found no significant difference in outcomes between patients randomized to receive voriconazole or natamycin, and a non-significant trend towards worse visual acuity in patients randomized to receive re-scraping. 9 This analysis was a secondary analysis of the trial, and therefore the study was not specifically designed for these analyses. Exclusion or inclusion criteria may have biased these results.…”

Efeito terapêutico do crosslinking corneal na ceratite infecciosa

“…Most cases are bacterial, but the condition can also be caused by fungi, protozoa, and viruses (5)(6)(7)(8)(9) . The current standard therapy for bacterial and fungal keratitis is based on antibiotics and antifungals (10,11) . Although this is effective in most cases, some classes of microorganisms have been shown to be resistant to available antimicrobial agents (12,13) .…”