Intracameral Amphotericin Research Articles

Partial DMEK Donor Removal as a Successful Treatment of Donor-Related Fungal Keratitis

Abstract: An 84-year-old woman with Fuchs dystrophy underwent uncomplicated Descemet membrane endothelial keratoplasty in her right eye (OD). Donor rim culture returned positive for Candida albicans with no signs of clinical infection until postoperative week (POW) 14 when the patient noted new eye pain and photosensitivity in the OD. Examination revealed 3+ cells without hypopyon and 2 infiltrates localized to a small peripheral area of previously noted clinically insignificant inferior donor graft scrolling. Anterior chamber tap of the OD was performed, which showed no fungal growth. The patient was administered topical fortified voriconazole 1% 6 times a day and oral voriconazole 200 mg twice a day. On day 3, the infiltrate enlarged, and intracameral amphotericin (0.15 mg/mL, 0.1 cc) was injected. On day 6 with progression of the infiltrate, a partial donor descemetorhexis to remove the infiltrate and intracameral injection of voriconazole (0.25 mg/mL, 0.1 cc) were performed. Culture from the partially removed graft was positive for C. albicans. Vision improved to logMAR 0.18 (Snellen 20/30) with no evidence of recurrence to postoperative month 10. To the best of our knowledge, this is the first case of late-onset Candida interface keratitis successfully treated with a partial descemetorhexis.

Combined topical and intracameral injection of Amphotericin B versus topical Amphotericin B in management of fungal keratitis in MOC, Egypt

Fungal keratitis is a sight threatening condition which is widespread in tropical and subtropical countries. This study aimed to evaluate the efficacy of a combination of topical and intracameral injections of amphotericin B in the treatment of severe fungal keratitis. Patients and methods. This prospective, comparative study included 40 patients of culture proved fungal keratitis recruited from outpatient clinic of Mansoura ophthalmic center, faculty of medicine Mansoura University, Egypt, in the period from January 2017 to December 2018. Pregnant and lactating women, Children < 12 years of age, One-eyed patients, Patients with concurrent sclera involvement and Patients with impending perforations, elevated intraocular pressure were excluded from the study. The patients were randomly divided into 2 groups: Group A: underwent only topical amphotericin B. Group B: underwent combined topical & intracameral injection of antimicrobials. Patients were followed up at 1 day, 1 week, weekly till the end of the first month after injection then every 2 weeks for another month after then monthly till the 6th month. Results. Both groups were sex and age matched. Trauma was the most common risk factor recorded. Aspergillus was the commonest causative agent (85%) in group A, the size of corneal ulcer improved from 32.44 ± 19.37 to 29.71 ± 17.16 at 1st week to 18.81 ± 10.04 in the 1st month, in group B the ulcer size decreased from 30.24 ± 16.09 to 21.81 ± 11.04 (p<0.001) in the 1st week the ulcer achieved complete healing within 3 months. In group A the hypopyon level was 2.46 ± 1.23 mm which was fixed at the same value at 2nd day then decreased to 1.36 ± 0.43 ml at 1st month then to 0.90 ± 0.31 mm and 0.37 ± 0.17 mm at 2nd and 3rd months. In group B, the base line of hypopyon level was 3.22 ± 2.09 mm decreased to 1.45 ± 0.62 mm (at 1st week) decreased from 1.02 ± 0.61 mm at 2nd weeks to 0.33 ± 0.19 mm at 6th weeks. In group A, the reported complications were staphyloma (2 cases), thinning (6 cases), hyphema (2 cases) and Atrophia Bulbi (1 case). In group B the complications showed mild variations in distribution as follows; staphyloma (1 case), thinning (3 cases), hyphema (3 cases) and Atrophia Bulbi (1 case). The mean duration for the complete healing in group A, was 48.82 ± 5.31 days while the mean duration in group B, that was 29.59 ± 3.24 days (p< 0.001). Conclusions. Intracameral Amphotericin B injection is safe and effective technique in treatment of fungal keratitis.

Evaluation of Intracameral Amphotericin B in the Management of Fungal Keratitis: Randomized Controlled Trial

Purpose: To evaluate the efficacy and safety of intracameral amphotericin B (ICAMB) in the management of fungal keratitis.Methods: In total, 45 eyes with smear-confirmed fungal keratitis with hypopyon were randomized into three treatment groups: Group I (topical antifungal treatment + oral antifungal); Group II (topical antifungal treatment + ICAMB + oral antifungal); and Group III (topical antifungal treatment + drainage of hypopyon + ICAMB + oral antifungal). The main outcome measures were treatment success rate, time to heal, visual acuity gain, and presence of complications.Results: There were no differences in the treatment success rates (p = 0.66), time to healing (p = 0.18), or mean final visual acuity (logMAR) (p = 0.8) between the three groups. The major complication observed was increased incidence of cataract in group III (40%), though it was statistically insignificant.Conclusions: ICAMB does not offer any benefit over topical antifungal therapy when performed alone or associated with drainage of hypopyon.

Efficacy Profile of Intracameral Amphotericin B. The Often Forgotten Step.

The objectives of this study were to assess visual and structural outcomes in mycotic keratitis after conventional treatment (topical and systemic antifungals) and intracameral amphotericin B (ICAMB), and to evaluate any complications. This was a prospective, nonrandomized, nonblinded interventional study. This study was conducted on 104 eyes of 104 patients with fungal corneal ulcers. Patients were categorized into 2 groups: group A, who received conventional topical and systemic antifungal medications, and group B, who received ICAMB in the dose of 5 to 10 μg in 1 mL of 5% dextrose. Response to treatment was evaluated. Results of the 2 groups were compared with appropriate statistical indices. The mean final visual acuity in patients in group B receiving ICAMB was 1.22 ± 0.31 logMAR units. The improvement in mean visual acuity was 1.40 ± 0.2 logMAR units. In group A, mean visual outcome was 1.25 ± 0.73 logMAR units. There was an improvement by 0.55 ± 0.30 logMAR units. Healing with varying degrees of opacification occurred in a significant number of patients (81.48%) treated with ICAMB as compared with conventional treatment (Z = 2.24, P < 0.05). Complications, such as sloughing, occurred in significantly fewer patients treated with ICAMB as compared with conventional treatment (Z = 2.29, P < 0.05). In cases of keratomycosis where response to local and systemic antifungal treatment is not evident after 7 days, ICAMB can be safely administered to prevent the progression of ulcers and the development of complications.

Candida pelliculosa endophthalmitis after cataract surgery: a case report

BackgroundHere we report the first case of postoperative endophthalmitis due to Candida pelliculosa after cataract surgery. We describe the clinical management of this type of candida infection in the eye.Case presentationA 57-year-old Turk man was seen at our clinic at the end of the first postoperative month after cataract surgery. He presented with eye redness, pain and decreased visual acuity. His ophthalmologic examination revealed moderate tyndall and a mild flare in the anterior chamber. Hypopyon in the capsular bag posterior to the intraocular lens was seen in the second postoperative month. Despite topical and subconjunctival bacterial endophthalmitis treatment, there was no improvement in the clinical situation. Candida pelliculosa was isolated from a sample culture obtained from the anterior chamber. Oral fluconazole could not be administered because of increased liver enzyme levels and intravenous amphotericin B could not be administered because of an allergic reaction. Intraocular lens explantation, pars plana vitrectomy and anterior chamber lavage by rupturing the posterior wall of the microabscesses were performed. Intravitreal and intracameral amphotericin B injections were given four times in addition to surgical interventions. The patient has been followed for 2 years and his best-corrected visual acuity was 0.4 at the last visit.ConclusionNearly 1 month after cataract surgery, a patient presented with eye redness and blurred vision, with corneal endothelial deposits, hypopyon in the capsular bag and microabscesses on the incision sites and corneal endothelium. Candida pelliculosa should be considered in patients showing these symptoms. Multiple intraocular amphotericin B (5 μg) administrations can be used safely even in cases with high sensitivity to systemic use. Rupturing the posterior wall of the abscesses on the corneal endothelium surgically with intraocular lens explantation and pars plana vitrectomy are recommended.

Management of Fusarium keratitis and its associated fungal iris nodule with intracameral voriconazole and amphotericin B

A retrospective case report on the management of a 56‐year‐old man who was diagnosed with Fusarium keratitis with an associated iris fungal nodule. He presented with persistent right ocular pain, redness, photophobia and reduced vision following an injury six weeks earlier. Conservative management with topical antibiotics and intracameral injections was successfully used to treat a rare case of Fusarium keratitis with an associated fungal iris nodule. The patient had complete resolution of his vision. Therefore, conservative management of the fungal nodule is a successful therapy without the risk of anterior chamber dissemination, which may occur with surgical resection.

Candida Fermentati

The aim of this study was to report a rare case of fungal keratitis from Eastern India. This is a case report. A 52-year-old man with a history of minor trauma presented with a total corneal ulcer and hypopyon in the left eye. Microbiologic examination of corneal scrapings showed yeast cells in direct smear and typical yeast colonies on multiple solid agar media. Identification of the organism isolated in the culture was performed using the D1/D2 region of the large subunit (LSU 28S rDNA)-based molecular technique. Polymerase chain reaction amplified a band with a sequence that was 100% homologous with that of Candida fermentati. The organism was susceptible to amphotericin B and anidulafungin and demonstrated resistance to voriconazole, itraconazole, and fluconazole. Therapeutic keratoplasty was performed, followed by the recurrence of the infection in the graft, which was controlled with topical and intracameral amphotericin B. At the end of 3 months, the affected eye had developed phthisis bulbi. This is the first report of isolation of C. fermentati, a species closely related to Candida guilliermondii, from keratitis. Molecular diagnostic techniques are helpful in the accurate identification of this organism, which is clinically important in view of an antifungal susceptibility pattern that differs from that of other yeasts and for selection of appropriate therapy.

Schizophyllum commune: A New Organism in Eye Infection

We report a case of mycotic keratitis caused by a rare fungus Schizophyllum commune. Clinical examination, slit-lamp examination, and microbiological evaluation of the corneal ulcer were done, and its treatment outcome was studied. The fungal etiology was established by conventional microbiological techniques, polymerase chain reaction and speciation by DNA sequencing. Corneal scraping showed the presence of fungal filaments. The fungus was identified as S. commune based on DNA sequence analysis of the internal transcribed spacer region. The organism was susceptible to amphotericin B and voriconazole and demonstrated resistance to anidulafungin, itraconazole, and fluconazole. Therapeutic keratoplasty was performed but there was recurrence of the infection in the graft, which was controlled with topical voriconazole and intracameral amphotericin B. At the end of 3 months, the affected eye had developed phthisis bulbi. The best of our knowledge, this is the first reported case of keratitis caused by the rare fungus S. commune. Management of these cases is difficult, and surgical procedures may be needed.

Lasiodiplodia theobromae keratitis: a rare fungi from eastern India

We report here a case of a 32-year old female with a history of minor trauma presented with total corneal ulcer and hypopyon in the left eye. Microbiological examination of corneal scraping showed refractile hyphae with asepted branching filaments and black pigmented colonies in multiple solid agar medium. Identification of the organism was made from culture using D1/D2 region of Large Sub Unit (28S rDNA) based molecular technique. Polymerase chain reaction amplified a band with a sequence that was 100% homologous with Lasiodiplodia theobromae. The organism was sensitive to amphotericin B and voriconazole, and demonstrated resistance to itraconazole and fluconazole. Therapeutic keratoplasty was performed followed by recurrence in graft controlled with topical voriconazole and intracameral amphotericin B. Graft failure was reported after three months.

Lasiodiplodia theobromae Keratitis: A Case Report and Review of Literature

A case report and review of literature is reported of a rare case of fungal keratitis from eastern India. A 32-year-old woman with a history of vegetative trauma presented with keratitis in left eye. Microbiological examination of corneal scraping showed refractile hyphae with aseptate branching filaments and black pigmented colonies on multiple solid agar medium. Organism was identified from culture using D1/D2 region of LSU (Large Sub Unit: 28S rDNA)-based molecular technique. PCR amplified a band with a sequence that was 100% homologous with Lasiodiplodia theobromae. The organism was susceptible to amphotericin B and voriconazole and demonstrated resistance to itraconazole and fluconazole. A therapeutic keratoplasty was performed following non-responsiveness to initial topical voriconazole (2%) therapy. Recurrence in graft was controlled with topical voriconazole and intracameral amphotericin B. However, the graft failed at the end of 3months. L. theobromae is a rare cause of fungal keratitis. Management of these cases is difficult, often involving surgical procedures.

Therapeutic efficacy of intracameral amphotericin B injection for 60 patients with keratomycosis.

To evaluate the therapeutic efficacy of intracameral amphotericin B (ICAMB) injection in the treatment of keratomycosis. The study design was a prospective controlled clinical trial. A total of 60 eyes of 60 patients were divided into two groups, 30 in the ICAMB injection group (group A) and 30 in the control group-topical application amphotericin B (group B). Serial measurements of the size of the keratomycosis-namely, two maximum linear dimensions perpendicular to each other, and the area and perimeter was done at start of therapy and follow up on day 3, 7, and 21. Rate of healing of the keratomycosis were measured as percentage decrease from the baseline parameter at each subsequent follow up. The data were analyzed by the non-parametric Wilcoxon rank sum test. The mean time to disappearance of hypopyon was 9.6±9.2 (range:1-26) days in group A and 26.8±20.8 (range:14-62) days in group B (P=0.03). The median percentage decrease in the size of the keratomycosis was significantly greater than that in the cord serum group at day 21(P<0.05) when measured in terms of the area and perimeter. A greater number of patients showed complete re-epithelialization in group A (n=27) than in group B (n=14) (P<0.05). None of the patients reported any side effects or discomfort with either treatment. ICAMB injection leads to faster healing of the keratomycosis refractory to all medical management and reducing time to disapperence of hypopyon compared to topical application amphotericin B.

Intracameral amphotericin B in the management of Candida glabrata anterior uveitis after penetrating keratoplasty

Abstract Purpose To report management of Candida glabrata anterior uveitis after penetrating keratoplasty with intracameral amphotericin B. Methods Case report and literature review Results We report a case of a 79‐year‐old woman that presented with anterior uveitis and a dense endothelial plaque at the graft‐host junction in her only eye six weeks after repeated penetrating keratoplasty with donor tissue that was culture‐positive for Candida glabrata. Anterior chamber tap was performed and 5 µg of amphotericin B was injected in the anterior chamber. Cultures of the anterior chamber were positive for the same pathogen as the corneosleral donor rim. She was also treated with topical 0,5% amphotericin B for the next month and topical corticosteroids. At the end of follow up after 16 months her SCVA was 0,6. There was no evidence of recurrent fungal intraocular infection and the graft remained clear with the endothelial cell density of 2286 cells/mm. Conclusion In our opinion intracameral amphotericin B is effective and safe in the therapy of Candida glabrata anterior uveitis after penetrating keratoplasty.

Therapeutic Effect of Intracameral Amphotericin B Injection in the Treatment of Fungal Keratitis

To study the therapeutic efficacy of intracameral amphotericin B (ICAMB) injection in the treatment of fungal keratitis. Fourteen patients with fungal keratitis received ICAMB, 10 microg/0.1 mL (group A), and 17 patients received conventional treatment only (group B). Visual acuity, time to hypopyon disappearance, time to epithelial defect closure, time to final improvement, and final outcome were analyzed and compared between the 2 groups. The concentration of amphotericin B in the aqueous humor after injection was measured using high-performance liquid chromatography. The mean final visual acuity (log MAR) was 1.6 +/- 1.1 in group A and 1.3 +/- 1.4 in group B (P = 0.24). The mean time to disappearance of hypopyon, epithelial defect closure, and final improvement was 9.4 +/- 9.4, 19.8 +/- 10.4, and 26.6 +/- 9.2 days in group A and 26.7 +/- 21.3 (P = 0.03), 32.6 +/- 22.8 (P = 0.08), and 52.8 +/- 38.2 days (P = 0.04) in group B, respectively. At the last follow-up, treatment success was achieved in 92.9% of group A and 82.4% of group B (P = 0.38). The mean concentration of intracameral amphotericin B was 601.6 +/- 51.3 ng/mL at 6 hours, 98.8 +/- 43.1 ng/mL at 1 day, 57.0 +/- 11.6 ng/mL at 3 days, and 52.3 +/- 8.3 ng/mL at 7 days after injection. ICAMB seems to be effective in reducing time to disappearance of hypopyon and final improvement in the treatment of fungal keratitis.

Efficacy of Intracameral Amphotericin B Injection in the Management of Refractory Keratomycosis and Endophthalmitis

To evaluate the efficacy of intracameral amphotericin B injection in the adjunctive management of keratomycosis with probable intraocular extension not responding to conventional antifungal therapy. Fourteen eyes of 12 patients with fungal keratitis that did not respond to initial treatment with topical and intravenous fluconazole and oral itraconazole were treated with up to 5 intracameral injections of 5 microg of amphotericin B. Six eyes received one injection, and 8 required subsequent injections. Twelve eyes responded to amphotericin B therapy, including 5 that healed with a central corneal scar and 8 that healed with a peripheral opacity. Two eyes progressed to evisceration. Four eyes developed anterior subcapsular cataract after intracameral amphotericin B. Intracameral amphotericin B may be an effective adjunctive treatment of fungal keratitis unresponsive to conventional antifungal therapy, although cataract may occur.

Management of tunnel fungal infection with voriconazole

A 59-year-old woman presented 1 month after cataract surgery in the right eye with a stromal infiltrate at the site of the cataract surgery wound. The visual acuity was perception of light with accurate projection. Corneal scraping of the infiltrate revealed septate hyphae. There was no response to 6 weeks of therapy with topical fortified antibiotic agents and topical antifungal therapy in the form of natamycin 5%, amphotericin B 0.15%, and intracameral amphotericin B. The patient was started on oral voriconazole 200 mg twice daily and topical voriconazole 1% every hour, and resolution of the ulcer was noted within 3 days. At the 4-month follow-up, a visual acuity of 20/60 was achieved, with the formation of a vascularized corneal opacity superiorly. This case illustrates that topical and oral voriconazole may be used in the treatment of recalcitrant cases of fungal tunnel infections not responding to conventional antifungal therapy.

Risk Factors Affecting Efficacy of Intracameral Amphotericin Injection in Deep Keratomycosis

Purpose: To investigate the clinical efficacy of intracameral amphotericin injection and to evaluate risk factors affecting primary treatment success in fungal infection invading the anterior segment of the eye. Methods: Twenty-six eyes of 26 patients diagnosed with fungal infection in the anterior segment were studied. The initial treatment regimen was a topical 0.15% amphotericin application and itraconazole oral administration after culture. Amphotericin (5 ug/0.1 ml, 0.1 cc) was repeatedly injected intracamerally when the infection intensified. Penetrating keratoplasty was conducted for eyes unresponsive to intracameral amphotericin injection. The relative risk ratios of ulcer size, infiltration depth, culture positivity, and hypopyon were compared in each treatment group to evaluate the treatment response. Results: Of patients with fungal infection, 30.7% were cured with intracameral amphotericin injection, while 30.7% needed penetrating keratoplasty. Intracameral amphotericin injection was needed in the presence of large corneal ulcers (>14 mm2), hypopyon, positive fungal culture, use of steroid eye drops, and deep infiltration at initial examination. Large ulcer size (>14 mm2) was the main risk factor for needing penetrating keratoplasty. Of the eyes Candida infection, 66.5% needed evisceration. Conclusions: Large ulcer size and the isolation of Candida were poor prognostic factors related to the efficacy of intracameral amphotericin injection.

Late-Onset Donor-to-Host Transmission of Candida glabrata Following Corneal Transplantation

To demonstrate the potential value of obtaining routine fungal cultures of donor rims at the time of corneal transplantation and instituting prophylactic therapy in culture-positive cases, even in the absence of clinical evidence of established microbial keratitis or endophthalmitis. Interventional case report and literature review. A 69-year-old Saudi man underwent penetrating keratoplasty with donor tissue that was culture-positive for Candida glabrata. The postoperative course was complicated by slight override of the graft associated with an associated epithelial defect, but there was no evidence of microbial keratitis or significant anterior chamber inflammation. Following repair of the graft override on postoperative day 42, the epithelial defect healed. The subsequent clinical course was unremarkable until postoperative day 146, when a deep stromal infiltrate was present at the graft-host junction, associated with a dense endothelial plaque. Cultures of the anterior chamber were positive for Candida glabrata. Treatment with topical and intracameral amphotericin B and systemic fluconazole, along with topical corticosteroids and intracameral t-PA, was successful in eradicating the corneal infiltrate and resolving intraocular inflammation. Four months after treatment was initiated, there was no evidence of recurrent fungal keratitis or endophthalmitis. This case provides support for the practice of obtaining routine fungal cultures of donor rims at the time of corneal transplantation and for the implementation of prophylactic antifungal therapy in culture-positive cases.

Colletotrichum graminicola

We report the first case of an ocular infection with the fungus Colletotrichum graminicola causing keratitis in a 27-year-old man. Twenty-four months after a postoperative course complicated by recurrent fungal keratitis requiring two penetrating keratoplasties, two anterior chamber washouts, a conjunctival flap, and medical treatment with topical natamycin, intracameral amphotericin B, and oral fluconazole. The patient has shown no signs of fungal recurrence despite a failed corneal graft. C. graminicola is a new corneal pathogen and should be included in the differential diagnosis of mycotic keratitis.

Successful Treatment of Postoperative Candida Endophthalmitis in an Eye with an Intraocular Lens Implant

Candida endophthalmitis developed in the left eye of a 71-year-old man two months after he underwent extracapsular cataract extraction and intraocular lens implantation. The symptoms included decreased vision and redness but no pain. The discovery of the cause of the endophthalmitis was delayed because it was initially treated as a sterile postoperative inflammation. Vitrectomy with intracameral amphotericin B and treatment with topical and systemic amphotericin B and flucytosine led to resolution of the infection and a final visual acuity of 20/80. It was not necessary to remove the intraocular lens.