Treatment of Endogenous Fungal Endophthalmitis: Focus on New Antifungal Agents

Abstract

Endogenous fungal endophthalmitis, involving only the chorioretinal structures or extending to involve the vitreous (vitritis), is a sight-threatening infection requiring early appropriate therapy. Endophthalmitis is a relatively frequent complication of candidemia and less commonly occurs in patients who have invasive aspergillosis. Because the eye is a protected compartment, penetration of systemically administered antifungal agents is highly variable. In the posterior segment of the eye, amphotericin B (AmB) achieves very poor concentrations, but fluconazole concentrations are high. Among newer antifungal agents, voriconazole shows the most promise, because therapeutic concentrations for most Candida and Aspergillus species are achieved in the vitreous, and its antifungal activity is broad. In contrast, neither posaconazole nor the 3 echinocandins achieve adequate therapeutic concentrations in the vitreous. For sight-threatening macular involvement and vitritis, intravitreal injection of either AmB or voriconazole is helpful to achieve high local antifungal activity as quickly as possible. We review the available evidence regarding the most appropriate use of antifungal agents for endogenous fungal endophthalmitis, with the emphasis on treatment of infections due to Candida species.

Successful salvage treatment of Lecythophora mutabilis keratitis with topical voriconazole

“…The greatest clinical experience has been occurred with topical and systemic amphotericin B. 1,6 Amphotericin B has poor ocular penetration after intravenous (IV) administration and, hence, the administration of higher doses may be required to ensure adequate concentration of amphotericin B in the eye; however, IV administration of high-dose amphotericin B is known to cause severe renal toxicity, which can occur in up to 80% of patients. photericin B lipid complex in the treatment of fungal endophthalmitis have been published.…”

“…[1][2][3][4][5] The most common antifungal treatments are intravenous and/or topical amphotericin B. Voriconazole is a new triazole antifungal agent with the broad spectrum of antifungal activity. 6 The purpose of this case is to report that voriconazole has worked effectively in a patient with Lecythophora mutabilis keratitis, who did not respond to standard amphotericin B therapy. into blood agar and Mc Conkey agar but bacterial growth could not detect.…”

“…This result may be due to penetration of amphotericin B lipid complex through the cornea is poor. 1,6 The reported clinical experience of intravitreal injection of AmB-d in humans is limited to case reports and small case series. 6 Recently, there has been increasing interest in the use of voriconazole for keratitis.…”

“…1,6 The reported clinical experience of intravitreal injection of AmB-d in humans is limited to case reports and small case series. 6 Recently, there has been increasing interest in the use of voriconazole for keratitis. Voriconazole has an excellent broad spectrum of antifungal activity and is active against species that are known to be resistant to the other antifungal agents commonly used in fungal keratitis.…”

Management of Fungal Keratitis in Pediatric Patients

“…Capsofungin is more expensive and its use is limited. Posaconazole concentrations in the vitreous are not high and not recommended for the treatment (51). In severe cases, to improve the quality and reduce treatment period, subconjunctival fluconazole and intravitreal or intra cameral amphotericin B injection seem to be effective (52).…”