Management of Fungal Ocular Infection with Topical and Intracameral Voriconazole

Hoon Kim Kyung; Joon Kim Myoung; Hungwon Tchah

doi:10.3341/jkos.2008.49.7.1054

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Kyung, Myoung, and Tchah: Management of Fungal Ocular Infection with Topical and Intracameral Voriconazole

Original Article

J Korean Ophthalmol Soc 2008;49(7):1054-1060.

Published online: 7 September 2008

DOI: https://doi.org/10.3341/jkos.2008.49.7.1054

Management of Fungal Ocular Infection with Topical and Intracameral Voriconazole

Hoon Kim Kyung, M.D., Joon Kim Myoung, M.D., Hungwon Tchah, M.D.

Department of Ophthalmology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

Address reprint requests to Myoung Joon Kim, M.D. Department of Ophthalmology, University of Ulsan College of Medicine, Asan Medical Center #388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, Korea Tel: 82-2-3010-3680, Fax: 82-2-470-6440, E-mail: joon@amc.seoul.kr

Received 2 April 2008 Accepted 30 August 2007

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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 µg/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.

Keywords: Fungal endophthalmitis, Fungal keratitis, Voriconazole

References

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Figure 1.

(A), (B) : Post-treatment photographs of fungal keratitis with 5% topical voriconazole (A : Case 1, B : Case 2). (C), (D) : Pretreatment (C) and post-treatment (D) photographs of case 4. (D) shows controlled fungal keratitis with therapeutic penetrating keratoplasty and topical voriconazole. (E), (F) : Pretreatment (E) and post-treatment (F) photographs of case 6 with fungal endophthalmitis.

Table 1.

Patients who were treated with topical and/or intracameral voriconazole for fungal ocular infection

Case	Gender	Age	Diagnosis	Isolates	Concomitant medication	VAinitial* (logMAR)	VAlast^† (logMAR)	Outcome	Risk factor for infection	Duration of topical voriconazole treatment	Time to remission	Intracameral voriconazole injection	Complication or Side effect
Case 1	Male	34	Fungal keratitis	Septated hyphae (smear)	Moxifloxacin (topical)	F.C^‡ (2.2)	0.03 (1.5)	Cured	Stevens-Johnson syndrome	6 wk	4 wk	-	-
Case 2	Male	42	Fungal keratitis	Negative	Fortified antibiotics (5% ceftazidime, 2% tobramycin)	F.C^‡ (2.2)	0.1 (1.0)	Cured	Injury from foreign body	4 wk	4 wk	-	-
Case 3	Female	59	Fungal keratitis	Negative	Fortified antibiotics (5% ceftazidime, 2% tobramycin)	0.63 (0.2)	0.4 (0.4)	Cured	Injury from wood branch	4 wk	3 wk	-	-
Case 4	Male	65	Fungal keratitis	Beauveria bassiana	Fortified antibiotics (5% cefazolin, 2% tobramycin) / timolol+dorzolamide, brimonidine / Voriconazole (oral, 200 mg qd, 7 wk)	0.03 (1.5)	0.2 (0.7)	Therapeutic penetrating keratoplasty	Farmer	4 wk	4 wk	-	Increased intraocular pressure Cataract progression
Case 5 (Right)	Female	48	Fungal endophthalmitis	Trichosporon	inkin Levofloxacin (topical)	F.C^‡ (2.2)	0.03 (1.5)	Cured	Corneal patch graft infection	8 wk	8 wk	Twice	Cataract progression
Case 6 (Left)	Female	48	Fungal endophthalmitis	Candida albicans	Moxifloxacin (topical) / Voriconazole (oral, 200 mg qd, 4 wk)	0.05 (1.3)	(0.8) 0.16	Cured	Infection of donor cornea	12 wk	10 wk	Once	Photophobia (related to oral medication)

^* Visual acuity at initial visit;

^† Visual acuity at last visit;

^‡ Finger count; wk=weeks; logMAR=logarithm of minimum angle of resolution.

Table 2.

Comparison of groups with or without isolated organism

	Organism isolated	Organism not isolated
Number	4	2
Time to remission (mean)	6.5 wk	3.5 wk
Outcome (fail/success)	1/3	0/2
VA improvement (logMAR)	0.68	0.50

wk=weeks; logMAR=logarithm of minimum angle of resolution; VA=visual acuity.

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