High-Dose Oral Posaconazole for the Treatment of Recalcitrant Fungal Keratitis

Ferguson, Tanner J.; Downes, Rachel A.; Isada, Carlos M.; Goshe, Jeffrey M.

doi:10.1097/ico.0000000000002832

Cited by 6 publications

(4 citation statements)

References 18 publications

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“…There have been four other reports of refractive Purpureocillium lilacinus treated successfully with posaconazole [38][39][40][41]. Additional case reports further highlight the clinical efficacy of posaconazole in cases of recalcitrant fungal keratitides not responding to conventional therapies [40,42]. This is also the first case of Lomentospora prolificans (formerly Scedosporium prolificans) [43] keratitis successfully treated with solely medical management using topical natamycin.…”

Section: Discussionmentioning

confidence: 85%

“…Posaconazole is a newer triazole antifungal that is usually well tolerated and has the added benefit of extended side chains that provide additional points of contact with the azole target, CYP51, compared to voriconazole [36,37]. There have been four other reports of refractive Purpureocillium lilacinus treated successfully with posaconazole [38][39][40][41]. Additional case reports further highlight the clinical efficacy of posaconazole in cases of recalcitrant fungal keratitides not responding to conventional therapies [40,42].…”

Section: Discussionmentioning

confidence: 99%

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Case Series of Rare Fungal Keratitides: Experiences from a Quaternary Eye Hospital in Sydney, Australia

Xuan

Hong

Trinh

et al. 2023

JoF

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The present article reports on the management of six different and rare cases of fungal keratitides, two of which have never been documented in previous literature. This is a case series of six patients with rare fungal keratitides managed at a quaternary eye referral unit, Sydney Eye Hospital, Australia over a period of 7 months (May to December, 2022). The order of occurrence of fungi isolated was Scedosporium apiospermum, Lomenstospora prolificans, Cladosporium spp., Paecilomyces, Syncephalastrum racemosum and Quambalaria spp. A combination of medical and surgical interventions was employed, including topical and systemic anti-fungal therapy, with one requiring therapeutic penetrating keratoplasty and another eventuating in evisceration. Two patients were successfully treated with corneal debridement and two others required pars plana vitrectomy with anterior chamber washout. It is important to remain vigilant with monitoring patient symptoms and correlating with clinical signs to guide antifungal therapy even in the context of confirmed culture and sensitivity results.

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Section: Discussionmentioning

confidence: 85%

Section: Discussionmentioning

confidence: 99%

Case Series of Rare Fungal Keratitides: Experiences from a Quaternary Eye Hospital in Sydney, Australia

Xuan

Hong

Trinh

et al. 2023

JoF

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“…Patients on oral voriconazole need periodic liver function tests to monitor for liver toxicity. High-dose oral posaconazole has been successful in a small case series of recalcitrant contact lens-associated fungal keratitis [63].…”

Section: Therapy For Fungal Keratitismentioning

confidence: 99%

Therapy for contact lens-related ulcers

Jeang

Tuli

2022

Current Opinion in Ophthalmology

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Purpose of reviewThe current review covers the current literature and practice patterns of antimicrobial therapy for contact lens-related microbial keratitis (CLMK). Although the majority of corneal ulcers are bacterial, fungus and acanthamoeba are substantial contributors in CLMK and are harder to treat due to the lack of commercially available topical medications and low efficacy of available topical therapy.Recent findingsTopical antimicrobials remain the mainstay of therapy for corneal ulcers. Fluoroquinolones may be used as monotherapy for small, peripheral bacterial ulcers. Antibiotic resistance is a persistent problem. Fungal ulcers are less responsive to topical medications and adjunct oral or intrastromal antifungal medications may be helpful. Acanthamoeba keratitis continues to remain a therapeutic challenge but newer antifungal and antiparasitic agents may be helpful adjuncts. Other novel and innovative therapies are being studied currently and show promise.SummaryContact lens-associated microbial keratitis is a significant health issue that can cause vision loss. Treatment remains a challenge but many promising diagnostics and procedures are in the pipeline and offer hope.

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“…[130]. A recent case series by Ferguson et al [132] showed that high-dose oral posaconazole (500-600 mg once daily) provides rapid response to fungal keratitis (two cases of Fusarium and one case of Paecilomyces) not responding to conventional agents. No significant systemic side effects were found in this series with high-dose posaconazole therapy.…”

Section: Posaconazolementioning

confidence: 99%

Recent Perspectives in the Management of Fungal Keratitis

Raj

Vanathi

Ahmed

et al. 2021

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Mycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic examination and culture isolation have been the gold standard in the laboratory diagnosis of fungal keratitis. A culture isolate of the aetiological fungus is essential to perform antifungal susceptibility testing. As the culture isolation of fungi is time-consuming, causing delays in the initiation of treatment, newer investigative modalities such as in vivo confocal microscopy and molecular diagnostic methods have recently gained popularity. Molecular diagnostic techniques now help to obtain a rapid diagnosis of fungal keratitis. Genomic approaches are based on detecting amplicons of ribosomal RNA genes, with internal transcribed spacers being increasingly adopted. Metagenomic deep sequencing allows for rapid and accurate diagnosis without the need to wait for the fungus to grow. This is also helpful in identifying new emerging strains of fungi causing mycotic keratitis. A custom-tear proteomic approach will probably play an important diagnostic role in future in the management of mycotic keratitis. Positive repeat cultures are being suggested as an important gauge indicative of a poor prognosis. Positive repeat fungal cultures help to modify a treatment regimen by increasing its frequency, providing the addition of another topical and oral antifungal agent along with close follow-up for perforation and identifying need for early therapeutic keratoplasty. The role of collagen crosslinking in the treatment of fungal keratitis is not convincingly established. Rapid detection by multiplex PCR and antifungal susceptibility testing of the pathogenic fungi, adopted into a routine management protocol of fungal keratitis, will help to improve treatment outcome. Early therapy is essential in minimizing damage to the corneal tissue, thereby providing a better outcome. The role of conventional therapy with polyenes, systemic and targeted therapy of antifungal agents, newer azoles and echinocandins in fungal keratitis has been widely studied in recent times. Combination therapy can be more efficacious in comparison to monotherapy. Given the diversity of fungal aetiology, the emergence of new corneal pathogenic fungi with varying drug susceptibilities, increasing the drug resistance to antifungal agents in some genera and species, it is perhaps time to adopt recent molecular methods for precise identification and incorporate antifungal susceptibility testing as a routine.

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High-Dose Oral Posaconazole for the Treatment of Recalcitrant Fungal Keratitis

Cited by 6 publications

References 18 publications

Case Series of Rare Fungal Keratitides: Experiences from a Quaternary Eye Hospital in Sydney, Australia

Case Series of Rare Fungal Keratitides: Experiences from a Quaternary Eye Hospital in Sydney, Australia

Therapy for contact lens-related ulcers

Recent Perspectives in the Management of Fungal Keratitis

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