Treatment of Alternaria Keratitis with Intrastromal and Topical Caspofungin in Combination with Intrastromal, Topical, and Oral Voriconazole

Abstract

To report a case of refractory atypical Alternaria keratitis that was treated with intrastromal and topical caspofungin 0.5% in combination with topical, oral, and intrastromal voriconazole. A 67-year-old female with a history of bilateral intraocular lens exchange and left pseudophakic bullous keratopathy was referred to the emergency department of the Royal Victorian Eye and Ear Hospital, Melbourne, Australia. Visual acuity of her left eye was limited to counting fingers. A fine branching pattern was noted throughout the anterior stroma of her left corneal graft. The anterior chamber was deep and quiet. Hourly topical voriconazole 1% was initiated, with limited response. One week later, Alternaria spp. was cultured from the corneal scraping. Subsequently, topical caspofungin 0.5% was added, with concomitant use of topical, oral, and intrastromal voriconazole. Despite gradual symptomatic improvement, topical voriconazole was increased to 2% and intrastromal caspofungin was added. The patient was discharged after almost 5 weeks of treatment. Topical voriconazole 2% and topical caspofungin 0.5% were continued for an additional 3 weeks and 1 week, respectively, in the outpatient setting. The patient underwent left penetrating keratoplasty 3 weeks postdischarge. Visual acuity was stable at 20/150, with no reported adverse event 15 months postoperative. Treatment for Alternaria keratitis remains challenging, as it is refractory to existing antifungal agents. To our knowledge, this is the first reported instance of the use of intrastromal caspofungin to treat Alternaria keratitis in a case in which clinical resolution was not fully achieved despite the use of topical caspofungin in addition to extensive use of topical, intrastromal, and oral voriconazole. This case highlights the importance of intensive pharmacologic management and therapeutic penetrating keratoplasty in preventing evisceration of the patient's eye, especially when Alternaria keratitis is involved. Intrastromal and topical caspofungin were employed in combination with voriconazole for the management of refractory Alternaria keratitis, with no observed adverse effects.