CLINICAL SCIENCE
Management Algorithm for Fungal Keratitis: The TST
(Topical, Systemic, and Targeted Therapy) Protocol
Namrata Sharma, MD, Pranita Sahay, MD, Prafulla K. Maharana, MD, Deepali Singhal, MD,
Gunjan Saluja, MD, Pooja Bandivadekar, MD, Jacob Chako, MD, Tushar Agarwal, MD,
Rajesh Sinha, MD, Jeewan S. Titiyal, MD, Gita Satpathy, MD, and Thirumurthy Velpandian, MD
Purpose: To evaluate the efficacy of the topical, systemic and
targeted therapy (TST) protocol in management of fungal keratitis.
Method: All cases of treatment-naive smear- or culture-proven fungal
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keratitis presenting between June 2013 and May 2017 were recruited.
The TST protocol included initial treatment with topical natamycin 5%
with addition of oral ketoconazole or voriconazole in ulcers with size
.5 mm, depth .50%, or impending perforation. Topical voriconazole
1% was included in case of poor response at 7 to 10 days. Intrastromal
or intracameral antifungal injections were administered in case of poor
response to combination therapy. Penetrating keratoplasty was per-
formed in case of poor response to any of the regimen.
Results: The study included 223 cases of fungal keratitis with
a mean age of 43.6 6 15.3 years and a male-to-female ratio of 1.8:1.
The mean area of the ulcer and infiltrate at presentation was 25.52 6
19 and 25.7 6 14.4 mm2, respectively. Corrected distance visual
acuity at presentation was 2.05 6 0.43 logMAR that improved to 1.6
6 0.4 logMAR at 3 months. Fusarium (42.2%) was the most common
microorganism isolated, followed by Aspergillus (32.8%). The mean
healing time was 41.5 6 22.2 days, with a final scar size of 14.6 6
8.2 mm2. The treatment success rate with the TST protocol was
79.8%. Corneal perforation developed in 7% of cases (n = 15), and
keratoplasty was performed for 20.2% of cases (n = 45).
Conclusions: The TST protocol provides a stepwise treatment
algorithm for management of cases of fungal keratitis with varying
severity.
Key Words: fungal keratitis, mycotic ulcer, intrastromal injection,
natamycin, voriconazole, ketoconazole
(Cornea 2019;38:141–145)
F ungal keratitis, more commonly seen in tropical and
subtropical countries, is a major cause of corneal blind-
Received for publication July 7, 2018; accepted August 14, 2018. Published
online ahead of print October 16, 2018.
From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India
Institute of Medical Sciences, New Delhi, India.
The authors have no funding or conflicts of interest to disclose.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.corneajrnl.com).
Correspondence: Namrata Sharma, MD, Department of Ophthalmology,
Room-482, 4th floor, Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences, New Delhi 110029,
India (e-mail: namrata.sharma@gmail.com).
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Cornea  Volume 38, Number 2, February 2019
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ness.1 The prognosis in cases of fungal keratitis is poor
largely because of nonavailability of antifungal drugs with
good ocular penetration.2,3 There have been multiple reports
describing the treatment outcomes in cases of fungal ulcers;
however, these studies have evaluated only a specific subset
of fungal corneal ulcers using specific drugs.4–12 None of the
published reports have evaluated a comprehensive treatment
regimen covering all stages and grades of fungal corneal
ulcers. The lack of any specific comprehensive treatment
protocol has led to variability in the practice pattern of cornea
specialists across the world. This often confuses the general
ophthalmologist (first contact person) in initiating the appro-
priate treatment in cases of fungal keratitis.4–10,13,14
We herein present the outcomes with the topical,
systemic and targeted therapy (TST) protocol in management
of fungal keratitis at our center.
MATERIALS AND METHODS
In this prospective interventional study, all cases of
fungal keratitis that presented to the cornea clinic of Dr.
Rajendra Prasad Centre for Ophthalmic Sciences, a tertiary
eye care center, between June 2013 and May 2017 were
recruited. Written informed consent was obtained from all
participants. Institutional ethics committee approval was
obtained from the Institutional Review Board/Ethics Com-
mittee, AIIMS, New Delhi. The research was conducted
adhering to the tenets of the Declaration of Helsinki.
The inclusion criteria were smear- and/or culture-
proven fungal keratitis and patients willing to participate in
the study. No clinical criteria were used to start antifungal
therapy in the absence of either KOH or fungal culture report
to avoid bias in the study. The exclusion criteria were cases of
mixed microbial keratitis (on smear or culture analysis),
evidence of herpetic keratitis on history or examination,
perforation or impending perforation, endophthalmitis, scler-
itis, patients on previous antifungal therapy, and patients not
willing to follow up (Table 1).
The details regarding the history, including age, sex,
onset, progression, and predisposing factors such as trauma,
steroid use, or recent ocular surgery were elicited. The
baseline parameters including corrected distance visual acuity
(CDVA), location, size, and depth of the ulcer were recorded.
The size of the epithelial defect and stromal infiltrate was
measured using a slit lamp in the greatest dimension and
along an axis perpendicular to it. The depth of the infiltrate
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Sharma et al
TABLE 1. Eligibility Criteria of the Study
Inclusion criteria, all must be met
Fungal keratitis at the initial visit
Smear-positive and/or culture-positive fungal keratitis
Willing for follow-up visits
Provides consent to be a part of the study
Exclusion criteria, any exclude
Impending perforation
Perforated corneal ulcer
Associated scleritis or endophthalmitis
Evidence of bacteria on Gram staining or bacterial culture at the time of
enrollment
Evidence of herpetic keratitis by history or examination
Previously on antifungal treatment
Known allergy to study medications
Not willing to participate
was assessed on slit-lamp examination by comparing it with
corneal thickness. Ultrasonography to rule out coexisting
endophthalmitis was performed in cases in which the
posterior segment could not be visualized. CDVA was
recorded using the Snellen and logarithm of minimum angle
of resolution (logMAR) scales.
Corneal scraping was performed for all cases, and the
samples were subjected to Gram staining, potassium hydrox-
ide wet-mount preparation, and bacterial (blood agar and
chocolate agar) and fungal culture (Sabouraud dextrose agar)
with antibiotic sensitivity examination.
Treatment was based on the TST protocol, which we
have been following for the last 4 years (Fig. 1). All cases
were followed up on days 3, 7, 14, 21, and every week until
complete healing of the corneal ulcer was noted.
FIGURE 1. TST protocol for man-
agement of fungal keratitis.
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Cornea  Volume 38, Number 2, February 2019
At 3-month follow-up, the time to healing, CDVA, and
scar size were noted. All cases that developed corneal
perforation while on treatment or exhibited poor response to
treatment (,20% resolution in infiltrate/ulcer size at 3 weeks)
were considered treatment failures and were planned for
therapeutic keratoplasty.
Treatment Protocol
All cases were initially treated with topical natamycin
5% (NTM) every hour for the first 48 hours, every 2 hours
during waking hours until complete epithelial healing was
observed, and then every 4 hours for 3 weeks. In addition,
cycloplegic was prescribed in the form of topical homatropine
2% 4 times a day. In case of poor response to treatment at the
7th to 10th day of follow-up, topical Voriconazole 1% (VCZ)
was added every hour for first 48 hours, and then every 2
hours during waking hours until complete epithelial healing
occurred. In case of poor response noted after 7 to 10 days of
starting VCZ, intrastromal/intracameral/combined injection of
the antifungal agent was given. The same was repeated until
a maximum of 4 injections at an interval of 72 hours.
Systemic antifungal agents were given to all cases with
ulcers having a maximum linear diameter of .5 mm and/or
an ulcer depth of .50% and continued until complete healing
of the corneal infiltrate was noted. Oral ketoconazole (KCZ)
200 mg twice daily with meal or oral VCZ 200 mg twice daily
2 hours after meals was the medication used for systemic
treatment. Serial monitoring of liver function tests was done
in these cases. Therapeutic keratoplasty was performed for
cases not responding to intrastromal injection, corneal ulcers
associated with thinning wherein intrastromal injection carries
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Cornea  Volume 38, Number 2, February 2019 TST Protocol for Fungal Keratitis

high risk of corneal perforation, and cases that developed

TABLE 2. Baseline Parameters of Patients With Fungal Keratitis
corneal perforation on follow-up with medical treatment.
The technique of intrastromal injection was similar to Parameter Cases (n = 223)
that described by us in one of our earlier studies.15 Briefly, the Age (yrs) 43.6 6 15.3
technique involved multiple injections of 50 mg/0.1 mL of Male (%) 64.6 (n = 144)
reconstituted VCZ solution loaded in a 1-mL tuberculin Female (%) 35.4 (n = 79)
syringe with a 30-gauge needle. The needle is inserted Mean duration of symptoms (d) 29.7 6 21.2
obliquely into the cornea from the uninvolved clear area to BSCVA (logMAR) 2.05 6 0.43
reach just flush to the ulcer at the mid stromal level. Multiple Mean ulcer area (mm2) 25.52 6 19
injections are given around the ulcer to form a barrage around Infiltrate area (mm2) 25.7 6 14.4
the lesion. History of trauma (%) 50.6 (n = 113)
History of steroid use (%) 5.3 (n = 12)
Culture positive (%) 66.8 (n = 149)
Main Outcome Measures KOH positive (%) 80.2 (n = 179)
The outcome measures included CDVA at 3 months, BSCVA, best spectacle-corrected visual acuity; KOH, potassium hydroxide.
percentage of healed cases in each group, rate of corneal
perforation, requirement for therapeutic keratoplasty, and
scar size.
ganism isolated (42%, n = 63/149). This was followed by
Aspergillus spp. (49/149; 32.8%), Alternaria spp. (9/149;
Statistical Analysis 6%), Cladosporium spp. (5/149; 3.3%), Acremonium (5/149;
Statistical analysis was performed with Stata-11.1 pro- 3.3%), Curvularia (5/149; 3.3%), Candida (2/149; 1.3%),
gram for Windows (Microsoft Inc, Redmond, WA). Data Penicillium (2/149; 1.3%), and others (9/149; 6.1%) (Table 3).
were presented as mean 6 SD/median (minimum 6 maxi- The most common microorganism isolated from the host
mum) and frequency percentage as applicable. cornea culture in cases undergoing therapeutic keratoplasty
(36/223; 16.1%) was Aspergillus spp. (17/36; 47.2%),
followed by Alternaria (7/36; 19.4%), Fusarium spp. (6/36;
RESULTS 16.6%), and Candida (1/36; 2.7%). Reinfection was noted in
During the 4-year study period, 3014 cases of corneal 4 eyes after therapeutic keratoplasty, and the microorganisms
ulcer presented to our cornea clinic, of which 1125 were smear- positive in these cases were Alternaria spp. in 2 eyes and
and/or culture-proven fungal keratitis. However, only 223 cases Fusarium spp and Aspergillus spp. in 1 eye each.
met the inclusion criteria and were recruited for the purpose of
the study. The number of cases excluded was significantly
more than those enrolled. This is because ours is a referral Treatment Outcome
center, and the cases that present to us have had already been The overall treatment success rate with the TST
exposed to some antifungal agents that could have diluted our protocol was 79.8%. In the intrastromal group (n = 82), the
primary purpose. Hence, we excluded these patients to replicate success rate was 89%, and in the medical management (n =
the situation faced by a general ophthalmologist. 141) group, it was 74.5%. Corneal perforation developed in
15 cases (6.7%) while on treatment, and therapeutic pene-
trating keratoplasty was performed in 45 cases (20.2%) because
Baseline Parameters of treatment failure (perforation/nonhealing corneal ulcer;
Mean age of cases was 43.6 6 15.3 years (range 8 medical management group: 36 cases; intrastromal group: 9
months—85 years), with a male-to-female ratio of 1.8:1. The cases). Overall, the mean healing time in our study was 41.5 6
mean time to presentation at our cornea clinic was 29.7 6 22.2 days. For cases in which intrastromal antifungal injections
21.2 days (range 3–120 days), with a CDVA of 2.05 6 0.43 were given, the healing time was 36.2 6 10.7 days. The healing
logMAR (range 0.18–3). The most common risk factor
associated with occurrence of fungal keratitis was trauma
(113/223; 50.6%), others being steroid use (12/223; 5.3%), TABLE 3. Microorganism Cultured in Cases of Fungal Keratitis
post-keratoplasty (13/223; 5.8%), post-cataract surgery (2/ Microorganism N (%)
223; 0.89%), and post-corneal collagen cross-linking (2/223;
Fusarium species 63 (42.2%)
0.89%). Although most of the ulcers were central or para-
Aspergillus species 49 (32.8%)
central in location, 7.6% of cases (17/223) had peripheral
Alternaria species 9 (6%)
corneal ulcers. The mean areas of the ulcer and infiltrate were
Acremonium species 5 (3.3%)
25.52 6 19 and 25.7 6 14.4 mm2, respectively (Table 2).
Curvularia specie 5 (3.3%)
Cladosporium 5 (3.3%)
Microbiological Results Candida species 2 (1.3%)
Penicillium 2 (1.3%)
Fungal culture was positive in 66.8% (n = 149/223) of
Others 9 (6.1%)
the cases, with Fusarium being the most common microor-

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Sharma et al
TABLE 4. Treatment Outcome at 3-Month Follow-Up
Parameters
Treatment success rate (%) 72.6%
Mean healing time (d) 41.5 6 22.2
BSCVA (logMAR) 1.6 6 0.4
Mean scar size (mm2) 14.6 6 8.2
Corneal perforation while on treatment (%) 6.7% (n = 15)
Therapeutic keratoplasty for treatment failure 20.2% (n = 45)
time for cases treated with only topical and systemic antifungal
agents was 45.8 6 27.6 days. Mean CDVA at 3 months was
1.6 6 0.4 logMAR (range 0–2.7 logMAR), with a final scar size
of 14.6 6 8.2 mm2 (Table 4).
DISCUSSION
Fungal keratitis is a common corneal pathology, which if
treated well and quickly, can severely reduce the ocular
morbidity. In the past few decades, several new antifungal
agents have been developed with improved efficacy. A lot of
research work has been done on the treatment outcome of these
individual drugs and combination therapy. However, there are
no well-defined standard management guidelines for cases of
fungal keratitis.
In our study, we followed the TST protocol for
management of cases with culture- and/or smear-positive
fungal keratitis. The overall success rate with the TST
protocol was 79.8%. This is comparable to the success rate
reported by most of the large treatment trials in the field of
fungal keratitis. Parchand et al,16 in a randomized control
trial (RCT), reported a success rate of 66.7% to 73.7%
among the different study groups in case of severe fungal
keratitis (see Supplemental Table 1, Supplemental Digital
Content 1, http://links.lww.com/ICO/A719). Sharma et al,9
in an RCT comparing the effect of oral KCZ and VCZ in
addition to topical therapy, reported a success rate of 72%
to 80% among the different treatment groups.
In our study, the success rate in cases requiring
intrastromal antifungal agents was 89%. This is higher than
the success rate in previous studies. Kalaiselvi et al,17 in
a case series of 25 patients receiving intrastromal VCZ,
reported healing in 72% cases. Sharma et al,8 in an RCT
comparing topical VCZ to intrastromal VCZ in addition to
topical NTM, reported an 80% healing rate in the intrastromal
group. Nada et al,10 in a retrospective case series comparing
intrastromal amphotericin B with topical fluconazole to
topical amphotericin B, reported resolution in 82.9% of cases
in the intrastromal group. This is possibly because a multi-
pronged treatment strategy was used.
The overall healing time noted in our study was 41.5 6
22.2 days, which is comparable to other studies. Parchand
et al16 reported a mean healing time of 37.4 6 9.7 days in his
study. The healing time noted in the intrastromal group in our
study was 36.2 6 10.7 days. This is comparable to our
previous study with a mean healing time of 36.1 6 20.2 days.8
In this study, a lower rate of corneal perforation (6.7%)
and need for therapeutic keratoplasty (20.2%) for treatment
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Cornea  Volume 38, Number 2, February 2019
failure were observed. Prajna et al,4 in the MUTT 1 study that
compared topical VCZ with NTM, observed an overall 16%
rate of corneal perforation and/or need for undergoing
therapeutic keratoplasty. In MUTT 2, Prajna et al5 reported
a higher rate of corneal perforation (27%) in cases under
treatment and requirement for therapeutic keratoplasty
(43.8% cases).
The overall complications seen in our study were less
compared with other major studies. The reason for this can be
many. First, there was early use of combination topical therapy
(NTM and VCZ) in our study. In vitro studies conducted by the
authors report a synergistic effect of NTM and VCZ against
fungal isolates. Sradhanjali et al,18 in an in vitro study, found
a synergistic effect between the 2 drugs in 24.4% of the test
organisms. An additive effect was observed in 53.7%, whereas
indifference was noted in 22%. No cases of antagonism were
observed in this study. In a similar study by Al-Hatmi et al,19
a 3.5- to 10-fold decrease in the minimum inhibitory
concentration of NTM and VCZ was observed when used in
combination compared with isolated use. Second, we tried
intracameral and intrastromal injections wherever possible
before resorting to therapeutic keratoplasty. This may have
led to healing in many cases, which would have otherwise
required therapeutic keratoplasty for treatment failure.
The limitation of our study is that it does not have
a control arm because of ethical issues, so it is difficult to
comment whether following this protocol leads to better
outcomes. However, because the success rate observed in our
study is comparable to that of most of the major studies
conducted in the field of fungal keratitis, one can rely on its
results. However, the real-life situation for an ophthalmolo-
gist is similar, where one faces all varieties of fungal keratitis
and one adopts the use of more than 1 therapeutic modality,
which complement each other, especially in severe and
recalcitrant cases.
The MUTT 1 trial evaluated the role of topical NTM
versus topical VCZ and concluded that topical NTM is
superior. The MUTT 2 trial evaluated the role of systemic
VCZ versus placebo therapy and concluded that systemic
VCZ is not useful. This leads to a dilemma, especially when
dealing with cases of severe fungal keratitis that are not
responding to topical NTM therapy. Therefore, we formulated
the TST protocol to evaluate the cumulative effect of using
more than 1 antifungal drug (topical or systemic) along with
multiple routes for targeting the focus of infection. The results
suggest that the TST protocol may be safely used in daily
clinical practice even by a general ophthalmologist for
management of all grades of fungal corneal ulcer.
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