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Worldwide corneal infections are a major cause of unilateral blindness.1 In some parts of the world, fungal infections are commoner than bacterial infections.2 3 The challenge lies not only in the diagnosis but also in appropriate therapy, once diagnosis is established. It becomes more difficult when laboratory tests are inconclusive or do not support the clinical diagnosis and the challenge is greater when the infection is mixed with bacterial or acanthamoeba co-infections.4
One major reason is the restricted availability of commercially available anti-fungal agents for use in the eye. Although the need is great, it is predominantly in the poorer countries of the world where affordability may not recompense the investment required in developing and licensing a drug. Treatment of fungal keratitis is therefore largely dependent on the use of unlicensed or off-label drugs.
Susceptibility of common filamentous and yeast species of pathogenic fungi differs and there is no broad spectrum anti-fungal agent available, even among the off-label and unlicensed preparations, that covers most of this range. Treatment therefore has to be commenced on clinical suspicion supported by preliminary diagnostic examination of smears of corneal samples. The PCR test5 can provide a reliable diagnosis in a few hours but is expensive. Culture can take up to 3 weeks and treatment cannot be deferred that long. A reasonable approach would be to use a combination of Econazole 1% (which is more effective against filamentous fungi such as Aspergillus and Fusarium spp.,) and …