|Year : 1983 | Volume
| Issue : 7 | Page : 1019-1021
Treatment of fungal corneal ulcers with econazole
Indu Arora, OP Kulshrestha, Sandhya Upadhaya
S.M.S Medical College and Hospital, Jaipur, Rajasthan, India
Lecturer in Ophthalmology, S.M.S. Medical College and Hospital. Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Arora I, Kulshrestha O P, Upadhaya S. Treatment of fungal corneal ulcers with econazole. Indian J Ophthalmol 1983;31, Suppl S1:1019-21
|How to cite this URL:|
Arora I, Kulshrestha O P, Upadhaya S. Treatment of fungal corneal ulcers with econazole. Indian J Ophthalmol [serial online] 1983 [cited 2020 May 26];31, Suppl S1:1019-21. Available from: http://www.ijo.in/text.asp?1983/31/7/1019/29734
The therapy of fungal keratitis remains extraordinarily problematic despite substantial clinical awareness. Ophthalmic antifungal agents are not yet available through commercial outlets. The Ophthalmologist must either concoct his, own topical preparations from the available systemic compounds or attempt to use a dermatologic ointment in the conjunctiva.
In the present study, selected cases of fungal ulcers were studied for the therapeutic effect of Econazole eye ointment 1% on fungal corneal ulcers.
| Material and methods|| |
Corneal ulcer patients attending the S.M.S. Hospital Eye O.P.D. were interrogated and examined for clinical signs of fungal ulcer i.e. ulcers resulting from injury especially with organic matter, ulcers developing after prolonged use of topical steroids, ulcers not responding to antibiotics, ulcers with a dry raised yellowish white slough, or with satellite lesions or a ring abscess with or without a hypopyon and minimal vascularisation.
Patients with clinical suspicion of fungal ulcers were admitted, examined and investigated especially for diabetes. Under aseptic conditions, scrap ings from the base and advancing edge of the ulcer were taken and subjected to PAS staining and culture on Sabouraud's medium.
Only those patients with either of the above tests positive were included in the present study. All cases included in the study were carefully examined on the slit lamp and the ulcers were graded as follows.
0 indicates - no effect on cornea
1 + indicates - upto 33% of cornea
2 + indicates - 34 to 66% of cornea
3 + indicates 67 to 100% of cornea
These scores were modified according to the density of the corneal opacification :
If nebular - Nothing was added
If macular - add I point If leukomatous - add 2 points
Thus the final score ranges for 0 to 5+ The therapeutic regimen in all cases was:
Econazole 1% - 2 hourly for the first 4
eye ointment days applied
- 4 hourly from 5th to 20th day
- 6 hourly subsequently, upto 3 weeks after complete healing.
Supportive therapy in the form of tablet Septran 2 tablets BD for seven days, Sulphacetamide 30% eye drops QID, Atropine 1% Eye Ointment, oral B complex and Vitamin C.
Progress of the patients was recorded on the 4th day and at weekly intervals subsequently.
| Observations|| |
Among the 16 cases selected for the study
1. The following causative or predisposing factor were found for the fungal ulcers:
a) Injuries or foreign bodies of organic nature 7
b) Metallic foreign bodies 1
c) Prolonged (one and a half months) use of topical antibiotics 1
d) Prolonged (Four weeks) use of steroids 1
e) Predisposed due to diabetes 1
f) Old & debilitated (80 yrs.) with a lacrimal fistula on the same side 1 No causative or predisposing factor was discernible in some cases 4
2. a) PAS staining was positive in 10 patients
b) Fungal culture on Sabouraud's medium was positive in 7 patients.
3. Severity of the ulcers :
a) Grade 4 + in 1
b) Grade 3 + in 8
c) Grade 2 + in 7
4. Clinical Course
a) 12 patients had uneventful recovery between 2 to 6 weeks
(I) 5 by 4 weeks
(II) 3 by 3 weeks
(III) 2 by 5 weeks
(IV) 1 by 2 weeks
(V) I by 6 weeks
b) One patient was having satisfactory recovery but had persistent congestion, irritation and itching which reduced markedly on withdrawal of the drug for one day. The Econazole therapy was, however, continued and the ulcer healed completely by the 35 day, and Econazole was promptly withdrawn. The child came one month later with recurrence, and this time he was treated with Amphotericin B drops in view of the side effects observed due to Econazole. He however did not respond well to Amphotericin B and was advised penetrating keratoplasty following which the patient was lost to follow up.
c) In 3 patients the ulcer progressed to grade 5+ and perforation became imminent. Therapeutic keratoplasty was advised. It was performed in 2 patients, followed by 6 weeks of Econazole therapy
and integrity of the eye, with finger count ing, was retained. The 3rd patient did not agree for the operation and left against medical advice.
4. We observed that a maximum number (3) of fungal ulcers healed in 28 days and no relationship between the original severity of the ulcer and speed of recovery was found.
| Discussion|| |
Because of the disastrous outcome of untreated fungal keratitis or treatment with an ineffective agent - before commencing a full fledged clinical trial with Econazole we had to be reasonably sure of the clinical efficacy of this relatively untried drug. Thus, in 3 cases, before commencing the clinical trials, we started therapy with Econazole alongwith a supportive antifungal agent, Amphotericin B drops. Since good recovery was observed in the 1st two weeks with combined thereapy Amphotericin B drops were withdrawn after 2 weeks and equally good recovery was observed with Econazole alone.
Though Jones et a1 does not recommend therapy of Imidazoles (Econazole) & Polyene antibiotics (Amphotericin B), because of antagonistic drug action, Hogl & Raab in their in vitro experiments, have found no such antagonism.
Our clinical experience in the above three cases (though a very small number to be statistically significant) also points to the same.
Jones et al recommended that all antifungal therapy should, if possible, commence intensively and be continued at reduced levels for a long time. We followed this regimen in all cases except in one where Econazole had to be withdrawn due to side effects on complete healing of the ulcer. This case came back to us with recurrence after one month, thereby indicating that the Econazole therapy should be continued for a few weeks after the ulcer has completely healed.
The clinical evidence of 13 cases directly responding to Econazole 1% and two cases responding after penetrating keratoplasty indicates high efficay of Econazole in'treating fungal ulcers. Side effects were observed in only one patient.
| Summary|| |
From our clinical trials of Econazole, in 16 cases of keratomycosis, complete clinical recovery in 15 of these with side effects only in 1 case, we conclude that Econazole 1% is a safe and effective antifungal agent with broad ranges. It may particularly be of use in India and other developing countries, where, in the rural areas fungal keratitis is more frequent and laboratory. facilities for identification and sensitivity testing of the infecting fungus are generally lacking.
| Acknowledgments|| |
We are grateful to M/s Sarabhai Chemicals, Baroda for making available Econazole 1% eye ointment for this study.
| References|| |
Lacatcher-Kherazo, D. and Seegal, B.E., 1972. Microbiology of the eye. The C.V. Mosby Company, St. Louis. pg. 232.
Smolin, G. Okumoto, M. and Wilson, F.M., 1974, Armer. J. Ophthalmol. 77, 583-588.
Rysselaere, m. 1981, Mykosen 24/4,238-240.
Jones, B.R., Clayton, Y.M. and Oji, E.O. : 1979, Recognition and chemotherapy of oculomycosis, 55, 625-623.
Hogl, F. and Rabb, W. : 1981, Mykosen. 24/5; 261274.