What The Fluff: Fungal Keratitis In A 9 Year-Old Treated With Intrastromal Voriconazole

To report a case of fungal keratitis in a pediatric patient treated with intrastromal injection of Voriconazole.

A 9yo female was brought to our Eye Center due to a 3-week history of right eye redness. The patient was grazed by a sharp leaf on her eye causing redness and the appearance of a whitish fluffy opacity on the right cornea. In the interim, the whitish fluff increased in size with ensuing blurring of vision prompting consult. On examination, there was mild corneal edema without epithelial defects or stromal infliltrates. The presumed fungal ball was found adherent to the paracentral endothelium.

Anterior segment OCT was done which showed a hyperreflective mass with fuzzy borders adherent to the endothelium and hyperreflective dots scattered in the AC. Patient was started on topical Natamycin, Atropine, and Levofloxacin with serial keratectomy providing little improvement in redness and blurring. The whitish fluffy corneal infiltrate continued to increase in size. Hence, management was shifted surgically. Irrigation and aspiration of the fungal ball followed by intrastromal injection of voriconazole (50 μg/0.1 ml) using a G30 thin walled large bore needle and intracameral injection of low-dose voriconazole was done under general anesthesia. Initial regimen was shifted to topical Levofloxacin and Voriconazole after day 18 post-op.

There was no apparent post-procedure endothelial cell loss. There was gradual improvement in the patient’s visual acuity (20/250 pre-op, 20/100 day 1 post-op, and 20/20 day 25 post-op), with disappearance of redness and the corneal infiltrate. An endothelial opacity persisted, and the appearance of an anterior subcapsular cataract was noted at day 18 post-op. 

This is the first documented case of a fungal keratitis treated with intrastromal voriconazole in a pediatric patient. Intrastromal injection of voriconazole is an off-label use, but this case proved the procedure was safe on a pediatric patient. The treatment proved to be more effective compared to topicals alone. Clinical trials for the safety and efficacy of voriconazole as intrastromal injection is highly suggested.