From the Research
Topical natamycin 5% is the recommended first-line treatment for filamentous fungal keratitis, especially for Fusarium infections, due to its superior efficacy and safety profile compared to other antifungal agents, as demonstrated in the most recent and highest quality studies, including the Mycotic Ulcer Treatment Trial (MUTT) 1 and 2 studies 1, 2.
Key Findings
- The MUTT-1 study compared topical natamycin 5% versus voriconazole 1% for filamentous fungal keratitis and found that natamycin was superior to voriconazole, particularly for Fusarium infections 1.
- The MUTT-2 study evaluated whether adding oral voriconazole to topical antifungal therapy would improve outcomes in severe fungal keratitis and found that it did not improve visual outcomes and was associated with increased adverse events 1.
- A recent study published in 2024 compared the efficacy of monotherapy (natamycin 5% or Natasol 1%) versus combination therapy (natamycin 5% and voriconazole 1%) in the treatment of mild-moderate fungal keratitis and found that topical Natasol 1% tended to shorten the time to complete epithelization compared to topical natamycin 5% and combination therapy 2.
Treatment Recommendations
- Topical natamycin 5% should be applied hourly while awake for the first 3-4 days, then gradually tapered, as it is considered first-line therapy for filamentous fungal keratitis, especially Fusarium infections 1, 2.
- Alternative topical therapies, such as voriconazole, chlorhexidine, amphotericin B, and econazole, may be considered in cases where natamycin is not available or effective 1.
- Surgical therapy, typically in the form of therapeutic penetrating keratoplasty, may be required for severe cases or following corneal perforation 1.