Voriconazole-impregnated multilayered AMT and intracorneal plus intracameral injection in recalcitrant fungal corneal ulcer

We describe the management of a referred man in his 50s with corneal ulcer in the left eye. Slit-lamp biomicroscopy revealed an infiltrate (4.5×3.5 mm), involving full corneal thickness, corneal melt less than one-third corneal thickness and hypopyon (3.0 mm). Branched septate hypha on direct microscopy and Aspergillus flavus in Sabaraud's dextrose agar confirmed the clinical diagnosis of fungal corneal ulcer. We used natamycin 5% suspension 1 hourly, voriconazole 1% 1 hourly, gatifloxacin 0.5% three times and atropine 1% three times per day, for 2 weeks. However, there was no improvement and the corneal melt increased. We used intracameral plus intracorneal voriconazole injection with voriconazole-impregnated amniotic membrane transplant. We observed a significant decrease in conjunctival congestion, size/depth of infiltrate and hypopyon at the first week of antifungal therapy. Subsequently, at 6 weeks, corneal infiltrate had decreased and superficial corneal vascularisation appeared. Later, at 12 weeks, the patient developed corneal opacity.