Management of tunnel fungal infection with voriconazole

Abstract

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.

Factors Affecting Treatment Outcomes With Voriconazole in Cases With Fungal Keratitis

“…The pathophysiology of fungal keratitis after ocular surgery may be attributed to introduction of the organisms directly via surgery, or a delayed breach of the ocular surface via sutures or abnormal epithelium that overlies incisions. 17 Miedziak et al 18 also identified a history of ocular surgery and long-term topical steroid use as pertinent risk factors correlating with a need for penetrating keratoplasty in the management of microbial keratitis.…”

Recalcitrant fungal tunnel infection treated with intrastromal injection of voriconazole

“…In a prior report by Jhanji et al [3], topical and oral voriconazole was successfully used in the treatment of a fungal tunnel infection not responding to conventional antifungal therapy. Prakash et al [4] reported a series of three cases in which intrastromal voriconazole was used in conjunction with topical treatment for the successful treatment of deep-seated, recalcitrant, fungal keratitis.…”

Aqueous humor concentration of voriconazole after topical administration in rabbits

“…Additionally, there are some single case studies reporting successful topical voriconazole treatment in fungal keratitis in different clinical circumstances [13,14]. Despite the importance of clinical outcome in cases of fungal keratitis, as demonstrated in several infectious animal models, to our knowledge only one systematic investigation of AH concentrations after different oral voriconazole dosing regimes has been performed [15].…”