To describe a technique for intracorneal application of voriconazole into the supradescemetic space in a case of deep recalcitrant Candida parapsilosis keratitis of a penetrating cornea graft.
A deep intracorneal incision reaching the center of the corneal infiltrate was created with a 20-gauge MVR blade. Then, a 27-gauge hydrodissection cannula was inserted deep into the corneal pocket, and 0.1 ml of voriconazole 0.5 mg/ml was injected until a bullous detachment of Descemet membrane (DM) covered 1/3 of the graft's area. DM detachment was documented by anterior segment optical coherence tomography (AS-OCT).
AS-OCT confirmed the creation of a drug depot in the supradescemetic space, which partially regressed during the following hours; 24 h after the injection, a complete reattachment of DM was documented. After 4 weeks, the stromal infiltrate has cleared completely and no signs of recurrence were observed 3 months after injection.
In the present case, the supradescemetic voriconazole injection led to resolution of a deep recalcitrant fungal infiltrate. The herein described technique could be tried in similar cases, where an intrastromal injection is indicated, as it may offer a larger intracorneal drug depot.