Suppurative Fungal Keratitis with Hyphae on Smear: When Topical Antifungal Therapy Has Not Led to Improvement
This protocol addresses the patient with suppurative keratitis in whom corneal smear has demonstrated fungal hyphae, and whose ulcer has not shown expected improvement on initial topical antifungal treatment. The clinical picture warrants a next-line approach.
Clinical scenario
Suppurative keratitis (corneal ulcer) with fungal hyphae confirmed on corneal smear. The presence of hyphae defines the causative organism and shapes all treatment decisions.
Why this line is needed — prior treatment failure
The preceding step used topical antifungal eye drops (Natamycin 5% or Amphotericin 0.15%) applied hourly, with adjunctive cycloplegics, analgesics, and anti-glaucoma medication as indicated — strictly avoiding any steroid-containing preparation. The expected goal was demonstrable improvement on examination every two days; if no improvement is observed after seven days of treatment, escalation is indicated. This protocol represents that next step.
Next-line approach (partial)
When a fungal corneal ulcer meets certain severity criteria, the structured protocol involves adding a systemic antifungal in combination with continued topical therapy. The specific criteria, agents, and complete regimen are set out in the full protocol.
References
Fungal hyphae seen on smear.
Systemic antifungals are recommended in fungal ulcers, which are:
large and deep, or
perforating, or
have scleral involvement.
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