Early Versus Delayed Intervention with Intracameral Liposomal Amphotericin B in Recalcitrant Keratomycosis: Experience of a Large Case Series NC05-NC09
Dr. Amit Gupta,
Professor, Department of Ophthalmology, Advanced Eye Centre, PGIMER, Chandigarh-160012, India.
Introduction: Fungal keratitis has been reported to cause up to 50% of all corneal ulcers in the Indian subcontinent. Fungal keratitis is also associated with a very poor outcome with conventional treatment modalities. A few limited case reports/series have demonstrated the usefulness of Intracameral injection of liposomal Amphotericin B in severe fungal keratitis. However, several questions regarding intracameral therapy using antifungal agents are, as yet, unanswered, including when to intervene with this treatment modality.
Aim: To evaluate whether an ‘early’ versus ‘delayed’ intervention using Intracameral Injection of Liposomal Amphotericin B (ICAMB) influences the efficacy, outcomes and complications in severe recalcitrant Keratomycosis.
Materials and Methods: This prospective interventional study enrolled 50 eyes of proven fungal keratitis, not responding to conventional antifungal therapy administered over two weeks. They were randomly allocated to Group A (25 eyes) and Group B (25 eyes). Intervention with Intracameral injection of liposomal Amphotericin B, 10 micrograms/0.1 mL was done at either two weeks (Group A) or at four weeks (Group B). The clinical profile, visual acuity, time to epithelial defect closure, time to heal, final anatomical outcome, surgical interventions and complications were compared between the groups. Spearman correlation between healing time and other clinical characteristics was also done. The primary outcome measures were healing time, functional (final visual acuity) and anatomical outcomes (type of corneal opacity).
Results: The mean healing time in Group A was 17.5±3.64 days and 32.2±8.89 days in Group B (p<0.001). The anatomical outcome in the form of a maculo-leucomatous corneal opacity was observed in 12 (48%) eyes in Group A versus 4 (16%) eyes in Group B (p=0.03), leucomatous corneal opacity in 13 (52%) eyes in Group A versus 16 (64%) eyes in Group B (p=0.56), and adherent leucoma in none of the eyes in Group A versus 5 (20%) eyes in Group B (p=0.05). None of the eyes in Group A required additional surgical intervention while 10 eyes in Group B developed corneal perforation, thus requiring surgical intervention (p=0.006).
Conclusion: The present data has shown that eyes with severe non-responding keratomycosis may have a satisfactory outcome if Intracameral liposomal Amphotericin B therapy is initiated early rather than delaying this adjunctive treatment. In the authors’ experience, ICAMB significantly hastened the resolution and reduced the incidence of corneal perforation and ocular morbidity in resistant keratomycosis.