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Filamentous fungal endophthalmitis: results of combination therapy with intravitreal amphotericin B and voriconazole.

Mithal K, Pathengay A, Bawdekar A, Jindal A, Vira D, Relhan N, Choudhury H, Gupta N, Gupta V, Koday NK, Flynn HW - Clin Ophthalmol (2015)

Bottom Line: Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed.Globe salvage was achieved in all cases.Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

View Article: PubMed Central - PubMed

Affiliation: Retina and Uveitis Services, LV Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, India.

ABSTRACT

Purpose: To report outcomes of exogenous fungal endophthalmitis treated with combination of intravitreal antifungal agents.

Design: Retrospective, non-randomized, interventional, consecutive case series.

Methods: Twelve eyes of twelve consecutive cases of filamentous fungal endophthalmitis were treated with a combination of intravitreal amphotericin-B and intravitreal voriconazole (AmB-Vo Regime) along with pars plana vitrectomy at a single center. Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed.

Results: Ten cases out of the twelve were postoperative endophthalmitis of which nine were part of a post cataract surgery cluster. The remaining included endophthalmitis following keratitis post pterygium excision (1) and following open globe injury (2). The most common fungus was Aspergillus terreus, which was isolated in 8/12, followed by A. flavus in 2/12 and Fusarium solani in 1/12. The presenting visual acuity ranged from light perception (LP) to counting fingers. The visual acuity at final follow-up was 20/400 or better in 7/12 eyes (58.33%) and 20/60 in 2/12 eyes (range 20/60 to LP). All eyes with corneal involvement had final visual acuity 20/400 or worse. Globe salvage was achieved in all cases.

Conclusion: Combining intravitreal amphotericin-B and voriconazole could be a novel treatment strategy in the management of endophthalmitis caused by filamentous fungus. Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

No MeSH data available.


Related in: MedlinePlus

(A–D) Postoperative clinical photographs after resolution of endophthalmitis following vitrectomy, intravitreal antifungal combination therapy (amp-Vo regimen), and adjuvant procedures.
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f3-opth-9-649: (A–D) Postoperative clinical photographs after resolution of endophthalmitis following vitrectomy, intravitreal antifungal combination therapy (amp-Vo regimen), and adjuvant procedures.

Mentions: In the current study, we treated filamentous fungal endophthalmitis with pars plana vitrectomy and a combination of intravitreal antifungal agents. This antifungal combination regimen was based on our clinical experience with case 1 (Table 1). This patient had undergone an open globe injury repair followed by pars plana lensectomy and vitrectomy for traumatic cataract and vitreous hemorrhage. Two months later, a condensed round mass of anterior vitreous exudates was seen clinically on slit-lamp examination through the pupil behind the iris in the inferotemporal quadrant. Fungal hyphae were demonstrated in the vitreous aspirate on microscopy and were later identified as A. flavus from growth on culture. Subsequently, the patient received daily intravitreal voriconazole for 7 days. Based on initial resolution but re-emergence of exudates during this course, we clinically suspected the isolate to be refractory to voriconazole alone and combined it subsequently with intravitreal amphotericin B given every 48 hours. Rapid and complete resolution of vitreous exudates was observed at the end of one week (Figure 3). We formulated a regimen comprising a combination of intravitreal voriconazole daily and amphotericin B every 48 hours (the AmB-Vo regimen). The frequency of injections was based on the half-life of amphotericin B and voriconazole in aphakic vitrectomized eyes being 1.8 days and 2.5 hours, respectively.8,9


Filamentous fungal endophthalmitis: results of combination therapy with intravitreal amphotericin B and voriconazole.

Mithal K, Pathengay A, Bawdekar A, Jindal A, Vira D, Relhan N, Choudhury H, Gupta N, Gupta V, Koday NK, Flynn HW - Clin Ophthalmol (2015)

(A–D) Postoperative clinical photographs after resolution of endophthalmitis following vitrectomy, intravitreal antifungal combination therapy (amp-Vo regimen), and adjuvant procedures.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4403700&req=5

f3-opth-9-649: (A–D) Postoperative clinical photographs after resolution of endophthalmitis following vitrectomy, intravitreal antifungal combination therapy (amp-Vo regimen), and adjuvant procedures.
Mentions: In the current study, we treated filamentous fungal endophthalmitis with pars plana vitrectomy and a combination of intravitreal antifungal agents. This antifungal combination regimen was based on our clinical experience with case 1 (Table 1). This patient had undergone an open globe injury repair followed by pars plana lensectomy and vitrectomy for traumatic cataract and vitreous hemorrhage. Two months later, a condensed round mass of anterior vitreous exudates was seen clinically on slit-lamp examination through the pupil behind the iris in the inferotemporal quadrant. Fungal hyphae were demonstrated in the vitreous aspirate on microscopy and were later identified as A. flavus from growth on culture. Subsequently, the patient received daily intravitreal voriconazole for 7 days. Based on initial resolution but re-emergence of exudates during this course, we clinically suspected the isolate to be refractory to voriconazole alone and combined it subsequently with intravitreal amphotericin B given every 48 hours. Rapid and complete resolution of vitreous exudates was observed at the end of one week (Figure 3). We formulated a regimen comprising a combination of intravitreal voriconazole daily and amphotericin B every 48 hours (the AmB-Vo regimen). The frequency of injections was based on the half-life of amphotericin B and voriconazole in aphakic vitrectomized eyes being 1.8 days and 2.5 hours, respectively.8,9

Bottom Line: Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed.Globe salvage was achieved in all cases.Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

View Article: PubMed Central - PubMed

Affiliation: Retina and Uveitis Services, LV Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, India.

ABSTRACT

Purpose: To report outcomes of exogenous fungal endophthalmitis treated with combination of intravitreal antifungal agents.

Design: Retrospective, non-randomized, interventional, consecutive case series.

Methods: Twelve eyes of twelve consecutive cases of filamentous fungal endophthalmitis were treated with a combination of intravitreal amphotericin-B and intravitreal voriconazole (AmB-Vo Regime) along with pars plana vitrectomy at a single center. Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed.

Results: Ten cases out of the twelve were postoperative endophthalmitis of which nine were part of a post cataract surgery cluster. The remaining included endophthalmitis following keratitis post pterygium excision (1) and following open globe injury (2). The most common fungus was Aspergillus terreus, which was isolated in 8/12, followed by A. flavus in 2/12 and Fusarium solani in 1/12. The presenting visual acuity ranged from light perception (LP) to counting fingers. The visual acuity at final follow-up was 20/400 or better in 7/12 eyes (58.33%) and 20/60 in 2/12 eyes (range 20/60 to LP). All eyes with corneal involvement had final visual acuity 20/400 or worse. Globe salvage was achieved in all cases.

Conclusion: Combining intravitreal amphotericin-B and voriconazole could be a novel treatment strategy in the management of endophthalmitis caused by filamentous fungus. Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

No MeSH data available.


Related in: MedlinePlus