{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T01:43:10Z","timestamp":1791855790257,"version":"4.3.4"},"reference-count":31,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2024,4,30]],"date-time":"2024-04-30T00:00:00Z","timestamp":1714435200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Microorganisms"],"abstract":"<jats:p>This study aims to report the efficacy of a combined intrastromal injection in optimizing the outcome of severe mycotic keratitis. Herein, we report a case series of 20 consecutive patients with positive fungal cultures not responding to topical antifungal treatment. Patients received cycles of intrastromal injections of voriconazole (50 \u00b5g\/0.1 mL) and amphotericin B (2.5 \u00b5g\/0.1 mL); all patients continued their topical antifungal therapy. The organisms isolated were Fusarium (n = 5), Aspergillus (n = 4), Candida (n = 4), Rhodotorula (n = 2), Penicillium (n = 2), Alternaria (n = 1), Bipolaris (n = 1), and Curvularia (n = 1). The size of the infiltrate varied from 6.5 to 1.5 mm. At presentation, the best corrected visual acuity (BCVA, namely, the best visual acuity achieved with glasses, if needed) was less than 20\/400 in all patients, improving to better than 20\/400 in eleven patients. Seven patients required surgical intervention; four of them underwent penetrating keratoplasty (PK) \u00e0 chaud one month after the first intrastromal injection. Patients who underwent surgery achieved a BCVA of 20\/40 or better. Combined intrastromal injections before therapeutic penetrating keratoplasty (TPK) effectively reduced ulcer size and graft diameter, preventing infection recurrence. Our results highlight the efficacy of combined intrastromal injections in optimizing outcomes for severe mycotic keratitis undergoing TPK.<\/jats:p>","DOI":"10.3390\/microorganisms12050922","type":"journal-article","created":{"date-parts":[[2024,5,2]],"date-time":"2024-05-02T11:39:42Z","timestamp":1714649982000},"page":"922","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Efficacy of the Combined Intrastromal Injection of Voriconazole and Amphotericin B in Recalcitrant Fungal Keratitis"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2847-1691","authenticated-orcid":false,"given":"Antonio","family":"Moramarco","sequence":"first","affiliation":[{"name":"Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy"},{"name":"IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arianna","family":"Grendele","sequence":"additional","affiliation":[{"name":"Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy"},{"name":"IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danilo","family":"Iannetta","sequence":"additional","affiliation":[{"name":"Department of Organs of Sense, University of Rome La Sapienza, 00185 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simone","family":"Ottoboni","sequence":"additional","affiliation":[{"name":"Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy"},{"name":"IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giulia","family":"Gregori","sequence":"additional","affiliation":[{"name":"Eye Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, 60131 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natalie","family":"di Geronimo","sequence":"additional","affiliation":[{"name":"Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy"},{"name":"IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5447-8817","authenticated-orcid":false,"given":"Margherita","family":"Ortalli","sequence":"additional","affiliation":[{"name":"Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy"},{"name":"Microbiology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3093-363X","authenticated-orcid":false,"given":"Tiziana","family":"Lazzarotto","sequence":"additional","affiliation":[{"name":"Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy"},{"name":"Microbiology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3877-0417","authenticated-orcid":false,"given":"Luigi","family":"Fontana","sequence":"additional","affiliation":[{"name":"Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy"},{"name":"IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,4,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1136\/bjo.2009.169607","article-title":"Geographic Variations in Microbial Keratitis: An Analysis of the Peer-Reviewed Literature","volume":"95","author":"Shah","year":"2011","journal-title":"Br. J. Ophthalmol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e49","DOI":"10.1016\/S1473-3099(20)30448-5","article-title":"The Global Incidence and Diagnosis of Fungal Keratitis","volume":"21","author":"Brown","year":"2021","journal-title":"Lancet Infect. Dis."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"324","DOI":"10.4274\/tjo.galenos.2020.35305","article-title":"Prognostic Factors Affecting Graft Survival in Patients Undergoing Penetrating Keratoplasty for Infectious Keratitis","volume":"50","year":"2020","journal-title":"Turk. J. Ophthalmol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1111\/1469-0691.12126","article-title":"Mycotic Keratitis: Epidemiology, Diagnosis and Management","volume":"19","author":"Thomas","year":"2013","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Hoffman, J.J., Arunga, S., Mohamed Ahmed, A.H.A., Hu, V.H., and Burton, M.J. (2022). Management of Filamentous Fungal Keratitis: A Pragmatic Approach. J. Fungi, 8.","DOI":"10.3390\/jof8101067"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"877","DOI":"10.3109\/02713688609029240","article-title":"Corneal Penetration of Topical Amphotericin B and Natamycin","volume":"5","author":"Head","year":"1986","journal-title":"Curr. Eye Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1136\/bjophthalmol-2014-305412","article-title":"Intrastromal Voriconazole for Deep Recalcitrant Fungal Keratitis: A Case Series","volume":"99","author":"Kalaiselvi","year":"2015","journal-title":"Br. J. Ophthalmol."},{"key":"ref_8","first-page":"111","article-title":"Therapeutic Keratoplasty for Infectious Keratitis: A Review of the Literature","volume":"28","author":"Sony","year":"2002","journal-title":"Eye Contact Lens"},{"key":"ref_9","first-page":"373","article-title":"Critical Evaluation of Therapeutic Keratoplasty in Cases of Keratomycosis","volume":"23","author":"Panda","year":"1991","journal-title":"Ann. Ophthalmol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1721","DOI":"10.1001\/archopht.123.12.1721","article-title":"Intracorneal Injection of Amphothericin B for Recurrent Fungal Keratitis and Endophthalmitis","volume":"123","author":"Song","year":"2005","journal-title":"Arch. Ophthalmol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1016\/j.ajo.2008.02.023","article-title":"Evaluation of Intrastromal Injection of Voriconazole as a Therapeutic Adjunctive for the Management of Deep Recalcitrant Fungal Keratitis","volume":"146","author":"Prakash","year":"2008","journal-title":"Am. J. Ophthalmol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1097\/ICO.0000000000002044","article-title":"Recurrence of Infection in Corneal Grafts After Therapeutic Penetrating Keratoplasty for Microbial Keratitis","volume":"39","author":"Chatterjee","year":"2020","journal-title":"Cornea"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1097\/ICO.0000000000000181","article-title":"Toxicity of Intrastromal Voriconazole Injection on Corneal Endothelium in Rabbits","volume":"33","author":"Park","year":"2014","journal-title":"Cornea"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1097\/ICO.0000000000001781","article-title":"Management Algorithm for Fungal Keratitis: The TST (Topical, Systemic, and Targeted Therapy) Protocol","volume":"38","author":"Sharma","year":"2019","journal-title":"Cornea"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Zemba, M., Radu, M., Istrate, S., Dumitrescu, O.-M., Ionescu, M.A., Vatafu, A., and Barac, I.R. (2023). Intrastromal Injections in the Management of Infectious Keratitis. Pharmaceutics, 15.","DOI":"10.3390\/pharmaceutics15041091"},{"key":"ref_16","first-page":"631","article-title":"Recent studies on corneal epithelial barrier function","volume":"52","author":"Liu","year":"2016","journal-title":"Zhonghua Yan Ke Za Zhi Chin. J. Ophthalmol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"4205","DOI":"10.1111\/bph.14024","article-title":"Principles of Pharmacology in the Eye","volume":"174","author":"Awwad","year":"2017","journal-title":"Br. J. Pharmacol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"269","DOI":"10.2165\/00003495-200767020-00009","article-title":"Voriconazole: A Review of Its Use in the Management of Invasive Fungal Infections","volume":"67","author":"Scott","year":"2007","journal-title":"Drugs"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"871","DOI":"10.1136\/bjo.2007.136515","article-title":"Voriconazole in the Treatment of Fungal Eye Infections: A Review of Current Literature","volume":"92","author":"Hariprasad","year":"2008","journal-title":"Br. J. Ophthalmol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"5597003","DOI":"10.1155\/2021\/5597003","article-title":"Efficacy of Voriconazole Corneal Intrastromal Injection for the Treatment of Fungal Keratitis","volume":"2021","author":"Li","year":"2021","journal-title":"J. Ophthalmol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1097\/ICO.0b013e31818225f8","article-title":"Alternaria Keratitis: Clinical Presentation and Resolution with Topical Fluconazole or Intrastromal Voriconazole and Topical Caspofungin","volume":"28","author":"Tu","year":"2009","journal-title":"Cornea"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1007\/s10792-010-9354-3","article-title":"Recalcitrant Fungal Tunnel Infection Treated with Intrastromal Injection of Voriconazole","volume":"30","author":"Jain","year":"2010","journal-title":"Int. Ophthalmol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1007\/s10792-020-01576-1","article-title":"Excisional Penetrating Keratoplasty for Fungal Interface Keratitis after Endothelial Keratoplasty: Surgical Timing and Visual Outcome","volume":"41","author":"Fontana","year":"2021","journal-title":"Int. Ophthalmol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1735","DOI":"10.1136\/bjo.2010.192815","article-title":"Evaluation of Intrastromal Voriconazole Injection in Recalcitrant Deep Fungal Keratitis: Case Series","volume":"95","author":"Sharma","year":"2011","journal-title":"Br. J. Ophthalmol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"35","DOI":"10.4103\/ijo.IJO_378_19","article-title":"Intrastromal Voriconazole: An Adjuvant Approach for Recalcitrant Mycotic Keratitis","volume":"68","author":"Konar","year":"2020","journal-title":"Indian J. Ophthalmol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"340","DOI":"10.3109\/02713683.2013.847961","article-title":"Toxicity and Pharmacokinetics of Intrastromal Injection of Amphotericin B in a Rabbit Model","volume":"39","author":"Qu","year":"2014","journal-title":"Curr. Eye Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"526","DOI":"10.1016\/j.ophtha.2005.10.063","article-title":"Risk Factors for Treatment Outcome in Fungal Keratitis","volume":"113","author":"Lalitha","year":"2006","journal-title":"Ophthalmology"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1085","DOI":"10.1007\/s10792-016-0372-7","article-title":"Results of Therapeutic Penetrating Keratoplasty for Bacterial and Fungal Keratitis","volume":"37","author":"Sukgen","year":"2017","journal-title":"Int. Ophthalmol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1097\/01.ico.0000248381.24519.0d","article-title":"Penetrating Keratoplasty for Corneal Perforations in Fungal Keratitis","volume":"26","author":"Xie","year":"2007","journal-title":"Cornea"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1097\/ICO.0000000000001432","article-title":"Outcome of Therapeutic Keratoplasty in Hopeless Microbial Keratitis Cases Otherwise Advised Evisceration","volume":"37","author":"Jain","year":"2018","journal-title":"Cornea"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2245","DOI":"10.2147\/OPTH.S358709","article-title":"Outcomes of Severe Fungal Keratitis Using in Vivo Confocal Microscopy and Early Therapeutic Penetrating Keratoplasty","volume":"16","author":"Sourlis","year":"2022","journal-title":"Clin. Ophthalmol."}],"container-title":["Microorganisms"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-2607\/12\/5\/922\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T14:37:40Z","timestamp":1760107060000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-2607\/12\/5\/922"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,30]]},"references-count":31,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2024,5]]}},"alternative-id":["microorganisms12050922"],"URL":"https:\/\/doi.org\/10.3390\/microorganisms12050922","relation":{},"ISSN":["2076-2607"],"issn-type":[{"value":"2076-2607","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,4,30]]}}}