J Korean Ophthalmol Soc.  2008 Jul;49(7):1054-1060. 10.3341/jkos.2008.49.7.1054.

Management of Fungal Ocular Infection with Topical and Intracameral Voriconazole

• Kim KH
• Kim MJ
• Tchah H

• KMID: 1476958
• DOI: http://doi.org/10.3341/jkos.2008.49.7.1054

Abstract

PURPOSE
To describe the successful treatment of a series of fungal ocular infections with voriconazole.
METHODS
A retrospective chart review was conducted for six eyes of five patients: four eyes of four patients with fungal keratitis, and two eyes of one patient with fungal endophthalmitis who were treated with topical and intracameral voriconazole. A battery of analyses on corneal isolates, clinical outcomes, duration of treatment, time to remission, complications, concomitant medication, and visual acuity at the initial and last visits was performed.
RESULTS
Six eyes of five patients were treated in total. Three eyes with fungal keratitis were treated with 5% topical voriconazole, and infection was controlled. Therapeutic penetrating keratoplasty was performed on one eye with fungal keratitis due to impending corneal perforation; this eye was treated successfully with topical voriconazole without recurrent inflammation. Both eyes of one patient with fungal endophthalmitis were given an intracameral voriconazole (100 microgram/0.1 cc) injection twice in the right eye and once in the left eye, and infection was controlled with continued topical voriconazole therapy. There was no clinically remarkable corneal epithelial toxicity from topical application. No corneal endothelial toxicity was observed after an intracameral injection of voriconazole.
CONCLUSIONS
Voriconazole is known to penetrate efficiently into ocular tissues. As shown in our case series, voriconazole is a new, promising therapy for intractable fungal ocular infection.

Keyword

Fungal endophthalmitis; Fungal keratitis; Voriconazole

MeSH Terms

Endophthalmitis
Eye
Eye Infections, Fungal
Humans
Inflammation
Keratitis
Keratoplasty, Penetrating
Pyrimidines
Retrospective Studies
Time-to-Treatment
Triazoles
Visual Acuity
Pyrimidines
Triazoles

Figure

• 

  Figure 1. (A), (B) : Post-treatment photographs of fungal keratitis with 5% topical voriconazole (A : Case 1, B : Case 2). (C), (D) : Pretreatment (C) and post-treatment (D) photographs of case 4. (D) shows controlled fungal keratitis with therapeutic penetrating keratoplasty and topical voriconazole. (E), (F) : Pretreatment (E) and post-treatment (F) photographs of case 6 with fungal endophthalmitis.

Reference

References

1. Bunya VY, Hammersmith KM, Rapuano CJ. . Topical and oral voriconazole in the treatment of fungal keratitis. Am J Ophthalmol. 2007; 143:151–3.

2. Anderson KL, Mitra S, Salouti R. . Fungal keratitis caused by Paecilomyces lilacinus associated with a retained intracorneal hair. Cornea. 2004; 23:516–21.

3. Shah KB, Wu TG, Wilhelmus KR, Jones DB. Activity of voriconazole against corneal isolates of Scedosporium apiospermum. Cornea. 2003; 22:33–6.

4. Ozbek Z, Kang S, Sivalingam J. . Voriconazole in the management of Alternaria keratitis. Cornea. 2006; 25:242–4.

5. Jurkunas UV, Langston DP, Colby K. Use of voriconazole in the treatment of fungal keratitis. Int Ophthalmol Clin. 2007; 47:47–59.

6. Johnson L, Kauffman C. Voriconazole: a new triazole antifungal agent. Clin Infect Dis. 2003; 36:630–7.

7. Hariprasad SM, Mieler WF, Holz ER. . Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans. Arch Ophthalmol. 2004; 122:42–7.

8. Gao H, Pennesi ME, Shah K. . Intravitreal voriconazole. An electographic and histopathologic study. Arch Ophthalmol. 2004; 122:1687–92.

9. Sen P, Gopal L, Sen PR. Intravitreal voriconazole for drug-resistant fungal endophthalmitis: case series. Retina. 2006; 26:935–9.

10. Kramer M, Kramer MR, Blau H. . Intravitreal voriconazole for the treatment of endogenous Aspergillus endophthalmitis. Ophthalmology. 2006; 113:1184–6.

11. Breit SM, Hariprasad SM, Mieler WF. . Management of endogenous fungal endophthalmitis with voriconazole and caspofungin. Am J Ophthalmol. 2005; 139:135–40.

12. Srinivasan M. Fungal keratitis. Curr Opin Ophthalmol. 2004; 15:321–7.

13. Thomas PA. Current perspectives on ophthalmic mycoses. Clin Microbiol Rev. 2003; 16:730–97.

14. Sohn SW, Hahn YH. The minimal inhibitory concentrations of antifungal agents for clinical isolates in fungal keratitis. J Korean Ophthalmol Soc. 2000; 41:1054–61.

15. O’Day DM, Head WS, Robinson RD, Clanton JA. Corneal penetration of topical amphotericin B and natamycin. Curr Eye Res. 1986; 5:877–82.

16. O’Day DM. Selection of appropriate antifungal therapy. Cornea. 1987; 6:238–45.

17. Thomas PA. Fungal infections of the cornea. Eye. 2003; 17:852–62.

18. Ozbek Z, Kang S, Sivalingam J. . Voriconazole in the management of Alternaria keratitis. Cornea. 2006; 25:242–4.

19. Park SH, Kim MS. A case report of intracameral amphotericin B injection in the management of deep keratomycosis. J Korean Ophthalmol Soc. 2004; 45:681–5.

20. Kaushik S, Ram J, Brar GS. . Intracameral amphotericin B: Initial experience in severe keratomycosis. Cornea. 2001; 20:715–9.

21. Kuriakose T, Kothari M, Paul P. . Intracameral amphotericin B injection in the management of deep keratomycosis. Cornea. 2002; 21:653–6.