Background  

To evaluate antifungal chemotherapy in patients with fungal keratitis guided by in vivo confocal microscopy.

Methods  

A total of 121 patients (121 eyes) with fungal keratitis were enrolled in this study. Confocal microscopy was performed in real time after topical and/or oral antifungal chemotherapy. Hyphal density and morphology, composition of inflammatory cells, and appearance of corneal stromal cells at the central and peripheral corneal lesions were recorded. Antifungal therapy discontinued at 1 week after hyphae and inflammatory cells could not be detected, and affected corneal stromal cells became visible.

Results  

Successful outcomes were achieved in 110 patients (90.9%). By confocal microscopy, we observed the gradual decrease of hyphae-positive sites and hyphal density during the chemotherapy. The inflammatory cells reduced in number and heterogeneity, while corneal stromal cells recovered. The antifungal drugs were tapered according to the changes in hyphae, inflammatory cells, and corneal stromal cells. There was no fungal recurrence during the 2-month follow-up period. The other 11 patients (9.1%) had deteriorated infection within 1 week of antifungal therapy, and therefore were subjected to corneal transplantation.

Conclusions  

In vivo confocal microscopy appears to be an effective approach to guide antifungal chemotherapy. It allows comprehensive evaluation of hyphae, inflammatory cells, and corneal stromal cells in real time, and provides valuable and objective information required in selecting and adjusting therapeutic regimens for the treatment of fungal keratitis.