Alternaria Keratitis: Clinical Presentation and Resolution With Topical Fluconazole or Intrastromal Voriconazole and Topical Caspofungin

PURPOSE: The purpose of this study was to describe the clinical presentation of 3 cases of Alternaria keratitis and their response to medical therapy. METHODS: All cases of Alternaria keratitis diagnosed and treated at the University of Illinois Eye and Ear Infirmary from 1999 to 2007 were reviewed for clinical presentation, antifungal therapy, and final visual acuity. RESULTS: Three cases of Alternaria keratitis were identified. All patients presented with an indolent steroid-treated keratitis and a history of recent cataract surgery, agricultural trauma, or contact lens wear. None of the patients responded to natamycin, and 1 also failed to respond to topical and systemic voriconazole. Patients responded rapidly to either topical fluconazole 0.02% or a combination of intrastromal voriconazole and topical caspofungin 0.5%. Final visual acuity ranged between 20/15 and 20/25. CONCLUSIONS: Alternaria keratitis has a varied clinical presentation and may present without macroscopic pigmentation. In vitro sensitivity testing may be helpful in directing therapy for Alternaria keratitis, but clinical response should be monitored as the primary endpoint. Response to natamycin was poor, but successful resolution with topical fluconazole or intrastromal voriconazole and topical caspofungin with preservation of good visual acuity was possible.