Modified Corneal Collagen Cross-linking (M-CXL) Combined With Intrastromal Injection Of Voriconazole For The Treatment Of Severe Fungal Keratitis With Ongoing Corneal Melting

The aim of this work is to evaluate the safety and efficacy of repeated sessions of modified corneal collagen cross linking (M-CXL) combined with intrastromal injection of voriconazole for the treatment of severe fungal keratitis with ongoing corneal melting and compare the outcome with intrastromal injection of voriconazole alone. This is a retrospective comparative clinical cohort study. Thirty eyes with clinically suspected and lab-confirmed severe fungal keratitis with ongoing corneal melting were included. These eyes were classified randomly into two groups each of 15 eyes. In group (A), all the eyes underwent repeated sessions of M-CXL with frequent instillations (FI) of topical voriconazole each week till the reversal of corneal melting, then intrastromal injections of voriconazole were added each week till complete corneal healing together with negative culture on lab examination. In group (B), all the eyes underwent repeated intrastromal injections of voriconazole each week together with frequent instillations (FI) of topical voriconazole till complete corneal healing with negative culture on lab examination. Identification of organisms was done by lab study before and after treatment. Corneal healing was evaluated by corneal examination and anterior segment OCT (AS-OCT). Successful treatment was reported in 13 eyes (86.7%) of group (A), while in group (B), successful treatment was reported in 9 eyes (60%), while failure of treatment with complications was reported in 2 eyes (13.3%) in group (A) , however, in group (B), failure of treatment with complications was reported in 6 eyes (40%), with statistically significant difference (p <0.05) between the two groups. Visual improvement was observed in group (A) more than group (B). M-CXL followed by intrastromal injection of voriconazole was found to be effective in treating severe fungal keratitis with ongoing corneal melting due to the known action of CXL for reversal of corneal melting and anti-infective properties. Our results revealed that combined M-CXL and intrastromal injection of voriconazole was safer than intrastromal injection of voriconazole alone for treating severe fungal keratitis with corneal melting with better visual outcomes.