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Voriconazole-refractory fungal infection of phacoemulsification tunnel.

Mittal V, Mittal R, Sharma PC - Indian J Ophthalmol (2010 Sep-Oct)

Bottom Line: Full-thickness patch graft was done to arrest progressive necrosis.There was no recurrence in one-year follow-up.Present case illustrates the therapeutic challenge in fungal tunnel infections and possibility of voriconazole-resistant Aspergillus species.

View Article: PubMed Central - PubMed

Affiliation: Sanjivni Eye Care, Model Town, Ambala, Haryana, India.

ABSTRACT
A 44-year-old man presented 28 days after cataract surgery (phacoemulsification) in right eye with multiple pinpoint infiltrates in posterior stroma at cataract surgery wound site. Visual acuity was 20/60. Corneal scraping from the floor of the corneal tunnel revealed fungus which was later identified to be Aspergillus flavus. The patient was started on oral voriconazole 200 mg twice daily and topical voriconazole 1% every hour. Two intracameral injections of voriconazole (50 micrograms/ 0.1 ml) were given 72 h apart, five days after starting initial therapy. Infiltrates increased in size and density in spite of 20 days of voriconazole therapy. Full-thickness patch graft was done to arrest progressive necrosis. Four months after surgery, patient had 20/60 best-corrected visual acuity. There was no recurrence in one-year follow-up. Present case illustrates the therapeutic challenge in fungal tunnel infections and possibility of voriconazole-resistant Aspergillus species.

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First presentation (28 days post phacoemulsification). Infiltrate: 2 mm × 3.4 mm; posterior stromal
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Figure 0001: First presentation (28 days post phacoemulsification). Infiltrate: 2 mm × 3.4 mm; posterior stromal

Mentions: He was seen in our clinic on the 28th postoperative day (three days after the symptoms). BCVA was 20/60. Slit-lamp examination showed multiple pinpoint infiltrates in corneal tunnel area (2 mm × 3.4 mm) in posterior stroma [Fig. 1]. Siedel’s test was negative. Anterior chamber was quiet and fundus was within normal limits. Nasolacrimal duct was patent. Since infiltrates were in the posterior stroma only, corneal scrapings were taken from the floor of the tunnel and sent for Gram staining, 10% potassium hydroxide (KOH) mount and culture for fungus and bacteria. Gram stain and KOH mount didn’t show any organism. Since patient had developed these infiltrates 28 days after surgery, clinically it was decided to treat it like a fungal infection or slow-growing bacteria. Treatment given was topical voriconazole 1% one-hourly, moxifloxacin 5 mg/ml one-hourly and cycloplegics (1% atropine three times/day). A 1% solution of voriconazole was prepared by diluting 200 mg of the lyophilized intravenous preparation of voriconazole (Voritrop, INTAS Biopharmaceuticals) with 20 mL of normal saline. Once prepared, it was stored at 4 degrees and used for 48 h. Fungus (Aspergillus flavus) was grown on Sabouraud’s Dextrose Agar on the sixth day. Systemic voriconazole 200 mg twice daily was added to the treatment.


Voriconazole-refractory fungal infection of phacoemulsification tunnel.

Mittal V, Mittal R, Sharma PC - Indian J Ophthalmol (2010 Sep-Oct)

First presentation (28 days post phacoemulsification). Infiltrate: 2 mm × 3.4 mm; posterior stromal
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2992924&req=5

Figure 0001: First presentation (28 days post phacoemulsification). Infiltrate: 2 mm × 3.4 mm; posterior stromal
Mentions: He was seen in our clinic on the 28th postoperative day (three days after the symptoms). BCVA was 20/60. Slit-lamp examination showed multiple pinpoint infiltrates in corneal tunnel area (2 mm × 3.4 mm) in posterior stroma [Fig. 1]. Siedel’s test was negative. Anterior chamber was quiet and fundus was within normal limits. Nasolacrimal duct was patent. Since infiltrates were in the posterior stroma only, corneal scrapings were taken from the floor of the tunnel and sent for Gram staining, 10% potassium hydroxide (KOH) mount and culture for fungus and bacteria. Gram stain and KOH mount didn’t show any organism. Since patient had developed these infiltrates 28 days after surgery, clinically it was decided to treat it like a fungal infection or slow-growing bacteria. Treatment given was topical voriconazole 1% one-hourly, moxifloxacin 5 mg/ml one-hourly and cycloplegics (1% atropine three times/day). A 1% solution of voriconazole was prepared by diluting 200 mg of the lyophilized intravenous preparation of voriconazole (Voritrop, INTAS Biopharmaceuticals) with 20 mL of normal saline. Once prepared, it was stored at 4 degrees and used for 48 h. Fungus (Aspergillus flavus) was grown on Sabouraud’s Dextrose Agar on the sixth day. Systemic voriconazole 200 mg twice daily was added to the treatment.

Bottom Line: Full-thickness patch graft was done to arrest progressive necrosis.There was no recurrence in one-year follow-up.Present case illustrates the therapeutic challenge in fungal tunnel infections and possibility of voriconazole-resistant Aspergillus species.

View Article: PubMed Central - PubMed

Affiliation: Sanjivni Eye Care, Model Town, Ambala, Haryana, India.

ABSTRACT
A 44-year-old man presented 28 days after cataract surgery (phacoemulsification) in right eye with multiple pinpoint infiltrates in posterior stroma at cataract surgery wound site. Visual acuity was 20/60. Corneal scraping from the floor of the corneal tunnel revealed fungus which was later identified to be Aspergillus flavus. The patient was started on oral voriconazole 200 mg twice daily and topical voriconazole 1% every hour. Two intracameral injections of voriconazole (50 micrograms/ 0.1 ml) were given 72 h apart, five days after starting initial therapy. Infiltrates increased in size and density in spite of 20 days of voriconazole therapy. Full-thickness patch graft was done to arrest progressive necrosis. Four months after surgery, patient had 20/60 best-corrected visual acuity. There was no recurrence in one-year follow-up. Present case illustrates the therapeutic challenge in fungal tunnel infections and possibility of voriconazole-resistant Aspergillus species.

Show MeSH
Related in: MedlinePlus