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

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.

Keywords: Aspergillus; amphotericin B; endophthalmitis; fungal; intravitreal; voriconazole.

Figure 1

Clinical photographs of case 1. Notes: (A), ball of fungal exudates visible through pupil 2 months following open globe injury repair and vitrectomy. (B) partial response and reappearance of exudates following treatment with intravitreal voriconazole. (C), rapid and complete resolution of exudates with combined antifungal treatment observed at one week. (D), fundus photograph 3 months after resolution of endophthalmitis.

Figure 2

Preoperative clinical photographs of a few exogenous filamentous fungal endophthalmitis cases. Notes: (A), post cataract surgery endophthalmitis with corneal and scleral tunnel fungal infiltrate. (B), cobweb-like exudates in pupillary area and on intraocular lens. (C), organized coagulum in the anterior chamber. (D), post-pterygium excision keratitis and endophthalmitis.

Figure 3

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