Comparative efficacy and safety of topical caspofungin 0.5% and voriconazole 1% for fungal keratitis: a pilot clinical trial

To compare the efficacy of topical caspofungin 0.5% with topical voriconazole 1% in patients with fungal keratitis. In this pilot clinical trial, thirty-four eyes from 34 patients diagnosed with fungal keratitis, confirmed by positive smear or culture results or in vivo confocal microscopy (IVCM), were included in the study. Patients were randomized to receive either topical caspofungin 0.5% or voriconazole 1%. The primary outcome measure was best spectacle-corrected visual acuity (BSCVA) at 3 months of follow-up. Secondary outcomes were the percentage of healed ulcers, time to healing, and scar size. After 3 months of treatment, the mean BSCVA was1.17 ± 0.85 logarithm of minimum angle of resolution (LogMAR) units in the caspofungin group and 0.49 ± 0.56 LogMAR units in the voriconazole group and the difference between two groups was 0.18 LogMAR (95% CI, -0.14 to 0.51 P = 0.276). The final mean scar size was similar between the caspofungin group (2.47 ± 2.1) and the voriconazole group (3.09 ± 1.11) (P = 0.254, 95% CI, -1.88 to 0.50 mm). The percentage of cases healed was 70.6% (12/17) in the caspofungin group and 100% (17/17) in the voriconazole group (P = 0.060, Hazard ratio ,2.06 95% CI,0.97 to 4.37). Fusarium species were the most common species (9/34; 26.5% cases). Complete stromal healing occurred in all 5 patients infected with Fusarium species who were treated with voriconazole 1%. one out of 4 patients in the caspofungin group showed complete healing (P = 0.048). The patients in caspofungin group had large mean infiltration size 4.81± 1.60 mm, (P = 0.255) than 2.90± 1.60 mm in voriconazole group and deeper infiltration depth 25 ±13% than 15± 9%voriconazole group (P = 0.120). This study indicates that topical caspofungin 0.5% may be effective as topical voriconazole 1%, making caspofungin 0.5% a viable primary treatment option for patients with fungal keratitis.