Purpureocillium lilacinum keratitis: a case series and review of the literature.

ObjectiveTo describe the clinical features and risk factors of and optimal antifungal therapy for Purpureocillium lilacinum keratitis.DesignRetrospective case series in a quaternary referral hospital setting.MethodsComprehensive chart review of patients diagnosed with P. lilacinum keratitis in the past 10 years.ParticipantsFour patients were identified. All were aged 60 years or greater, with none having prior ocular trauma. Two had significant potential environmental exposure risks, and 3 were using systemic immunosuppressants for scleritis.ResultsAll cases received empirical treatment that included topical corticosteroids. Three were treated with combined oral, topical, and intracameral voriconazole, but developed endophthalmitis necessitating surgery with poor outcomes, including enucleation in 2. One case received combined oral and topical voriconazole with terbinafine, and maintained visual acuity without the need for surgery. All P. lilacinum isolates were susceptible to voriconazole.ConclusionsP. lilacinum keratitis is rare, with the major risk factor being immunosuppression. There may be no history of ocular trauma. Microbiological diagnosis and antifungal susceptibility testing is essential. Combination synergistic antifungal therapy with topical voriconazole and oral terbinafine, with addition of systemic voriconazole if needed, results in the best outcome.