Postoperative Fungal Keratitis Managed by Anterior Chamber Washout and Intracameral Amphotericin-B: A Report of Two Cases

Abstract

Keratomycosis is a significant cause of mono-ocular blindness, especially in tropical regions. Fungal keratitis developing in corneal incisions is very rare. We report the experience of treating two patients diagnosed with recalcitrant candida keratitis post-phacoemulsification with anterior chamber washout and deep debridement. The first patient was a 68-year-old woman who underwent left eye phacoemulsification nine months ago with a postoperative best corrected visual acuity of 6/6. The second patient was a 73-yearold man who had uneventful right eye phacoemulsification six months prior with a postoperative best corrected visual acuity of 6/9. Both patients used topical steroids postoperatively for more than three months and noted a drop in vision. Both patients had deep stromal infiltration and endothelial plaque at the primary corneal wound. They were unresponsive to topical, intracameral, and systemic antifungal therapy. Both patients underwent anterior chamber evacuation of hypopyon and endothelial plaque removal. Evacuation of hypopyon and removal of endothelial plaque was done with a 23G vitrectomy cutter using a low-powered vacuum controlled at 200 mmHg. The fluid inside the tubing was sent for culture analysis. We used viscoelastic coating on the endothelium to minimize the damage during the operations. Intracameral amphotericin B 15 µg/0.1 ml was given at the end of the operation. Postoperatively, both patients had clear corneas. The first patient's visual acuity improved 6/18, and the second patient's visual acuity improved to 6/9. Both cultures isolated Candida parapsilosis sensitive to amphotericin. These patient cases highlight that evacuation of the anterior chamber infiltration in recalcitrant fungal keratitis and intracameral injection of amphotericin B can be an effective adjuvant therapy.

Case Series of Rare Fungal Keratitides: Experiences from a Quaternary Eye Hospital in Sydney, Australia

“…However, two thirds of our case series showed little response even to dual, topical and/or systemic antifungal therapy, further requiring antifungal injections or surgical intervention. In keeping with previous studies, when medical therapy failed in our cases, surgical interventions such as corneal debridement, therapeutic keratoplasty, anterior chamber washout and evisceration were then performed [5,55,56]. Corneal debridement has been demonstrated to provide a faster clinical resolution due to its facilitation of topical medical penetration with no reduction in visual potential and more accurate acquisition of pathogens than conventional scraping [57].…”

Fungal Keratitis: Diagnosis, Management, and Recent Advances

“…Many studies 80,82,[91][92][93][94][95][96][97][98][99][100][101] evaluated the use of intracameral antifungal drugs in deep keratomycosis (Table 2). Most of them reported a high success rate with few complications.…”

“… 55 Amphotericin B 5–10 µg in 0.1 mL of 5% dextrose 1–2 >80% responded with a reduction in size of the ulcer and infiltration, 18% required PKP – Endothelial toxicity, anterior subcapsular cataract, and mild AC reaction. Sharma et al 2016 97 (Randomized Controlled Trial) Evaluation of intracameral amphotericin B in the management of fungal keratitis 30 Amphotericin B 5 µg in 0.1 mL 5% dextrose 1–3 No differences in the treatment, success rates, time to healing, or mean final visual acuity Filamentous fungi, mostly Aspergillus flavus and Fusarium solani Increased incidence of cataract Maniam et al 2021 98 (Case report) Postoperative fungal keratitis managed by AC washout + intracameral amphotericin-B 2 Amphotericin B 15 µg in 0.1 mL 1 Evacuation of AC and intracameral amphotericin B can be an effective adjuvant therapy Candida parapsilosis Non Dong et al 2022 99 (Case report) Intracameral approach for recalcitrant fungal keratitis 2 Amphotericin B 10 µg in 0.1 mL 1 Both patients had remarkable results and BCVA of 20/20 Bipolaris spp. and Fusarium spp.…”