Focus on the standardization of diagnosis and treatment of fungal endophthalmitis / 中华实验眼科杂志

Fungal endophthalmitis is a kind of severe ocular infectious disease with poor prognosis.The damage degree of fungal endophthalmitis to ocular tissues is due to the fungi's destructivity,delayed diagnosis and non-standardized therapy.Early and proper intervention is crucial for saving visual function.There are different features of risk factors,pathogens and clinical presentations in exogenous infection and endogenous infection.Different key points of theraputic approaches should be identified to achieve early diagnosis and effective treatment,such as reasonably selecting the right type of antifungal drugs,different ways of administration,appropriate drug dose or surgical method.In the treatment of fungal endophthalmitis,the application of glucocorticoid is controversial,and the use of local or systemic glucocorticoid should be avoided as far as possible.

Intravitreal injection of drugs combined with vitrectomy on fungal endophthalmitis / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To study the intravitreal injection of voriconazole and liposomal amphotericin B combined with vitrectomy on treatment of fungal endophthalmitis. <p>METHODS: Selection of 27 cases(54 eyes)with fungal endophthalmitis caused by Aspergillus fumigatus infection from September 2014 to September 2016 in our hospital to accept the treatment were as the research objects. The 27 patients were randomly divided into control group and study group 1, study groups 2, each group of 9 patients. After vitrectomy, drug sensitivity test of three groups, drug testing for liposomal amphotericin B and voriconazole, were taken. After the application of oral voriconazole for three groups of patients with atropine ointment, and daily dressing, patients in study group 1 and 2 received intravitreal injected of voriconazole and liposomal amphotericin B respectively. The degree of corneal opacity, vitreous opacity and visual acuity were observed after operation. <p>RESULTS: Aspergillus fumigatus were sensitive to amphotericin B and voriconazole. Comparison of corneal opacity: at 1d after operation, the differences between control group with study group 1 and 2 were not significant(<i>P></i>0.05); the differences on the other time points were significant(<i>P</i><0.05); the differences between group 1 and 2 at different time were not significant(<i>P></i>0.05). Comparison of aqueous flare: at 1d after operation, the differences between control group with study group 1 and 2 were not significant(<i>P></i>0.05); the differences on the other time points were significant(<i>P</i><0.05); the differences between group 1 and 2 at 1 and 15d after operation were significant(<i>P</i><0.05), the differences at other time points were not significant(<i>P></i>0.05). Comparison of vitreous body opacity: except for at 1d after operation, the difference between control group and study group 1 were significant(<i>P</i><0.05); except for at 1, 4 and 6d after operation, the difference between control group and study group 2 were significant(<i>P</i><0.05); the differences between study group 1 and 2 were not significant(<i>P></i>0.05), except for at 6d after operation.<p>CONCLUSION: Intravitreal injection of voriconazole and liposomal amphotericin B combined with vitrectomy can be an effective treatment for fungal endophthalmitis. Compared with liposomal amphotericin B, voriconazole is better for early and middle stage of fungal endophthalmitis.

Recent Clinical Manifestation and Prognosis of Fungal Endophthalmitis: A 7-Year Experience at a Tertiary Referral Center in Korea

This study analyzed the recent causes, prognosis, and treatment strategies for fungal endophthalmitis. A retrospective review of patients who were diagnosed with fungal endophthalmitis at our center was conducted. The fungal organisms isolated from each patient and the visual prognosis according to the route of infection and treatment method were analyzed. A total of 40 eyes from 30 patients with fungal endophthalmitis were included in this study. Candida species were the most common causative organisms in 35 of 40 eyes. Endogenous and exogenous endophthalmitis were observed in 33 and 7 eyes, respectively. Pre- and post-treatment best-corrected visual acuity (BCVA) was not significantly different between endogenous endophthalmitis and exogenous endophthalmitis. The 40 eyes were treated using the following modalities: intravitreal antifungal agent injection with intravenous antifungal agent (16 eyes), vitrectomy with intravenous antifungal agent (14 eyes), intravenous antifungal agent alone (9 eyes), and evisceration (1 eye). Post-treatment BCVA only significantly improved after treatment in the vitrectomy group. Candida species were the most common cause of fungal endophthalmitis, irrespective of the route of infection. The visual prognosis of fungal endophthalmitis was generally poor. In conclusion, if the general condition of the patient tolerates a surgical procedure, prompt vitrectomy and intravitreal injection of antifungal agents can improve visual acuity.

Chorioretinal biopsy in an immunocompromised patient with subretinal mass.

A 59-year-old woman with autoimmune diseases presented with rapidly decreased vision in the left eye. Clinical examination and investigations were inconclusive. Pars plana vitrectomy and chorioretinal biopsy were performed. The histopathologic examination revealed acute branching, septate hyphae morphologically consistent with Aspergillus spp. The infection responded to systemic and intravitreous voriconazole. The subretinal mass gradually subsided but eventually the eye became blind. Chorioretinal biopsy is a valuable diagnostic procedure which, in some cases, may be the only way to provide a definite diagnosis and specific treatment of patients with progressive chorioretinal lesions of unknown etiology. In the presented case, although the vision cannot be recovered, we can avoid unnecessary enucleation and prevent the spread of infection that may threaten patient’s life.

Successful management of presumed Candida endogenous endophthalmitis with oral voriconazole.

Endogenous fungal endophthalmitis is most commonly caused by Candida species and usually occurs in patients with chronic diseases such as diabetes mellitus and renal insufficiency. Voriconazole, a broad-spectrum triazole antifungal agent, attains therapeutically significant concentrations in the vitreous cavity after systemic administration. We report, the successful management of presumed endogenous Candida endophthalmitis in a patient with multiple diseases and unstable systemic status with oral voriconazole. Though fungal endophthalmitis has been successfully treated with a combination of intravenous and intravitreal voriconazole, to the best of our knowledge this is the first report in ophthalmic literature (Medline Search) on the treatment of fungal endophthalmitis with only the oral route of administration of voriconazole.

Management of Fungal Ocular Infection with Topical and Intracameral Voriconazole

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.

A Case of Fungal Endophthalmitis Developed Early After Penetrating Keratoplasty

PURPOSE: To report a case of fungal endophthalmitis developed early after penetrating keratoplasty (PKP). CASE SUMMARY: A 67-year-old man was diagnosed with cataract, bullous keratopathy, and Fuchs' dystrophy. He underwent phacoemulsification, posterior chamber intraocular lens implantation, and PKP. The preoperative visual acuity was counting fingers. One day after surgery, his visual acuity was 20/200, and there was no abnormal finding. In the afternoon, a slit lamp examination showed endothelial plaque and white materials in the anterior chamber, and ultrasonography revealed vitritis. A Gram stain and a KOH smear of donor corneoscleral rim, which was conducted during the operation, revealed yeast-like organisms. An intravitreal amphotericin B injection was performed, and topical and systemic amphotericin B were administered. The donor corneoscleral rim scraping grew Candida albicans on culture. Amphotericin B injection into the anterior chamber and anterior chamber irrigation were performed. The patient's vitritis worsened, so we performed pars plana total vitrectomy. Two months after treatment, the cornea showed complete clearing, and the endothelial cell density was 1779 cells/mm2 on noncontact specular microscopy. Five months after treatment, the final best corrected visual acuity was 20/20. CONCLUSIONS: If a diagnosis of fungal endophthalmitis, which develops soon after PKP, is delayed, treatment could be very difficult. Culture of a donor corneoscleral rim may provide a guide to early diagnosis and successful treatment in cases of fungal endophthalmitis following PKP.

A Case of Intravitreal Voriconazole for the Treatment of Drug-resistant Penicillium Endophthalmitis

PURPOSE: To report a case of a drug-resistant Penicillium endophthalmitis that was treated with intravitreal voriconazole injection. CASE SUMMARY: A 73-year-old male who developed endophthalmitis after cataract surgery was treated with intravitreal vancomycin and ceftazidime injection after aqueous and vitreous cultures were done. The condition were not improve after intravitreal injection, and the culture showed Penicillium species. Fungal endophthalmitis was diagnosed and pars plana vitrectomy, intraocular lens removal, and intravitreal amphotericin B injection were performed. However, a progressive worsening of the ocular condition was observed, and the patient was transferred to our hospital. At initial visit, the best corrected visual activity was hand movement. The hypopyon and thick exudative membrane filled the anterior chamber. Pars plana vitrectomy and intravitreal voriconazole injection were performed under the diagnosis of drug-resistant Penicillium endophthalmitis. The condition improved after the operation, and there was no recurrence of endophthalmitis until four months after vitrectomy. CONCLUSIONS: Voriconazole is useful in the treatment of drug-resistant fungal endophthalmitis.

Candida Albicans Endophthalmitis after Phacoemulsification and Intraocular Lens Implantation

A case of fungal infection after uncomplicated phacoemulsification with posterior chamber intraocular lens implantation is reported. Initially, aqueous tap showed no organism. Despite capsular bag wash and intravitreal vancomycin treatment, the inflanmation persisted. Pars plana vitrectomy sample showed yeast cells on smear examination. Intravitreal Amphotericin B alongwith IOL explanation was performed. Candidla albicans growth was seen 011 inoculated culture plates and over the explanted IOL. The patient postoperatively developed secondary glaucoma that required surgical management. At two years follow-up. the vision is 6/18 with RGP contact lenses and no complications is observed.