Macrophomina phaseolina keratitis: treatment approach for poor response to topical natamycin.

A middle-aged woman presented with left eye redness and pain after trauma with a wooden stick. A greyish white anterior stromal infiltrate with overlying epithelial defect and surrounding pin-head like infiltrates was observed in the left cornea. Corneal scraping showed fungal hyphae on smears and was later identified as Macrophomina phaseolina Despite hourly topical natamycin 5% and oral ketoconazole, the infiltrates progressed in a migrating ring pattern. Voriconazole 1% eye drops were added, along with two intrastromal amphotericin B (5 µg/0.1 mL) injections a week apart, after which response was noted. Natamycin was stopped, and voriconazole monotherapy was continued for a month after its initiation. After 5 months, the infiltrate resolved without recurrence. This case highlights Macrophomina keratitis which mimicked Nocardia and Pythium infections and demonstrates successful treatment with topical voriconazole.