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Fungal Endophthalmitis Medication

  • Author: Lihteh Wu, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Mar 11, 2016
 

Medication Summary

The best initial therapy for patients with endogenous fungal endophthalmitis has not been established. However, a broad-spectrum systemic antifungal agent, such as amphotericin B or fluconazole, is recommended as first-line therapy.

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Polyene antibiotics

Class Summary

They are classified based on the number of conjugated double bonds. Fungicidal agents bind to sterols in the cell membrane of susceptible fungi and change the permeability of the cell membrane, leading to leakage of cellular constituents and consequently cell death.

Amphotericin B (Amphocin, Fungizone)

 

Polyene antibiotic produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death. Particularly active against Candida, Cryptococcus, and Aspergillus species.

An infectious disease specialist should be consulted regarding the appropriate protocol and dosage.

Several studies have shown poor intravitreal penetration when given systemically.

Special attention is required when making the dilutions and injecting in gas-filled eyes because it has a narrow therapeutic range and can cause retinal toxicity.

Subconjunctival injections of amphotericin B have no role in fungal ocular infections.

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Imidazoles

Class Summary

Bind to the fungal cell membrane and induce permeability changes that alter intracellular electrolyte levels, leading to fungal cell damage. These agents are fungistatic.

Fluconazole (Diflucan)

 

Fungistatic activity. Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol, thereby disrupting cellular membranes. Effective against Candida, Cryptococcus, and Aspergillus species. Bioavailability following oral administration is comparable to parenteral administration. Good CSF and intravitreal penetration is achieved after systemic administration.

Ketoconazole (Nizoral)

 

Fungistatic activity. Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death. Active against Blastomyces dermatitidis, C immitis, and Candida and Fusarium species, and exhibits some activity against Aspergillus species.

Itraconazole (Sporanox)

 

Fungistatic activity. Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.

Miconazole (Absorbine, Femizol)

 

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, resulting in fungal cell death.

The lotion is preferred in intertriginous areas. If the cream is used, apply sparingly to avoid maceration effects.

Administered intravenously due to poor absorption from the gastrointestinal tract.

Used as a second-line drug in the treatment of Candida, Cryptococcus, and Aspergillus species and coccidioidomycosis.

Use in cases that are resistant to treatment with amphotericin B.

Voriconazole (Vfend)

 

Used for primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or Scedosporium apiospermum infections. A triazole antifungal agent that inhibits fungal cytochrome P-450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis.

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Corticosteroids

Class Summary

Some have advocated the use of intravitreal dexamethasone as an adjuvant. Inflammation is believed to play a role in the destructive nature of this disease.

Dexamethasone (Ocu-Dex)

 

For various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

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Chemotherapeutic agents

Class Summary

Inhibit cell growth and proliferation.

Flucytosine (Ancobon)

 

Converted to fluorouracil after penetrating fungal cells. Inhibits RNA and protein synthesis. Active against Candida and Cryptococcus species and generally used in combination with amphotericin B.

A fluorinated pyrimidine that becomes deaminated by susceptible fungi to fluorouracil, which blocks thymidine synthesis.

Effective against Candida and Cryptococcus species and certain strains of Aspergillus species.

Use in combination with another agent because acquired resistance develops frequently when flucytosine is administered alone.

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Echinocandins

Class Summary

Inhibit cell wall synthesis.

Caspofungin (Cancidas)

 

Used to treat refractory invasive aspergillosis. First of a new class of antifungal drugs (glucan synthesis inhibitors). Inhibits synthesis of beta-(1,3)-D-glucan, an essential component of fungal cell wall.

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Contributor Information and Disclosures
Author

Lihteh Wu, MD Asociados de Macula Vitreo y Retina de Costa Rica

Lihteh Wu, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Club Jules Gonin, Macula Society, Pan-American Association of Ophthalmology, Retina Society

Disclosure: Received income in an amount equal to or greater than $250 from: Bayer Health; Quantel Medical; Heidelberg Engineering.

Coauthor(s)

Dhariana Acón, MD Ophthalmologist, Caja Costarricense Seguro Social, Hospital de Guapiles, Costa Rica

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Retina Society, American College of Healthcare Executives, American Uveitis Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Acknowledgements

Teodoro Evans, MD Consulting Surgeon, Vitreo-Retinal Section, Clinica de Ojos, Costa Rica

Disclosure: Nothing to disclose.

Rafael Alberto García, MD Chief of Outpatient Services, Department of Ophthalmology, Hospital México of San José, Costa Rica

Disclosure: Nothing to disclose.

References
  1. Essman TF, Flynn HW Jr, Smiddy WE, Brod RD, Murray TG, Davis JL. Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis. Ophthalmic Surg Lasers. 1997 Mar. 28(3):185-94. [Medline].

  2. Klotz SA, Penn CC, Negvesky GJ, Butrus SI. Fungal and parasitic infections of the eye. Clin Microbiol Rev. 2000 Oct. 13(4):662-85. [Medline].

  3. Sridhar J, Flynn HW Jr, Kuriyan AE, Miller D, Albini T. Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections. J Ophthalmic Inflamm Infect. 2013. 3(1):60. [Medline].

  4. Sridhar J, Flynn HW Jr, Kuriyan AE, Miller D, Albini T. Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections. J Ophthalmic Inflamm Infect. 2013 Sep 20. 3 (1):60. [Medline].

  5. Smith TC, Benefield RJ, Kim JH. Risk of Fungal Endophthalmitis Associated with Cataract Surgery: A Mini-Review. Mycopathologia. 2015 Dec. 180 (5-6):291-7. [Medline].

  6. Mikosz CA, Smith RM, Kim M, Tyson C, Lee EH, Adams E. Fungal endophthalmitis associated with compounded products. Emerg Infect Dis. 2014 Feb. 20(2):248-56. [Medline].

  7. Schiedler V, Scott IU, Flynn HW, Davis JL, Benz MS, Miller D. Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. Am J Ophthalmol. 2004 Apr. 137(4):725-31. [Medline].

  8. Shah CP, McKey J, Spirn MJ, Maguire J. Ocular candidiasis: a review. Br J Ophthalmol. 2008 Apr. 92(4):466-8. [Medline].

  9. Rao NA, Hidayat A. A comparative clinicopathologic study of endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared to aspergillosis. Trans Am Ophthalmol Soc. 2000. 98:183-93; discussion 193-4. [Medline].

  10. Lundquist O, Osterlin S. Glucose concentration in the vitreous of nondiabetic and diabetic human eyes. Graefes Arch Clin Exp Ophthalmol. 1994 Feb. 232(2):71-4. [Medline].

  11. Paulus YM, Cheng S, Karth PA, Leng T. PROSPECTIVE TRIAL OF ENDOGENOUS FUNGAL ENDOPHTHALMITIS AND CHORIORETINITIS RATES, CLINICAL COURSE, AND OUTCOMES IN PATIENTS WITH FUNGEMIA. Retina. 2015 Dec 11. [Medline].

  12. Lalwani GA, Flynn HW Jr, Scott IU, Quinn CM, Berrocal AM, Davis JL, et al. Acute-onset endophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology. 2008 Mar. 115(3):473-6. [Medline].

  13. Anand A, Madhavan H, Neelam V, Lily T. Use of polymerase chain reaction in the diagnosis of fungal endophthalmitis. Ophthalmology. 2001 Feb. 108(2):326-30. [Medline].

  14. Sakai T, Kohzaki K, Watanabe A, Tsuneoka H, Shimadzu M. Use of DNA microarray analysis in diagnosis of bacterial and fungal endophthalmitis. Clin Ophthalmol. 2012. 6:321-6. [Medline].

  15. William A, Spitzer MS, Deuter C, Blumenstock G, Partsch M, Voykov B, et al. Outcomes of Primary Transconjunctival 23-Gauge Vitrectomy in the Diagnosis and Treatment of Presumed Endogenous Fungal Endophthalmitis. Ocul Immunol Inflamm. 2016 Jan 30. 1-7. [Medline].

  16. Khan FA, Slain D, Khakoo RA. Candida endophthalmitis: focus on current and future antifungal treatment options. Pharmacotherapy. 2007 Dec. 27(12):1711-21. [Medline].

  17. Mora-Duarte J, Betts R, Rotstein C, Colombo AL, Thompson-Moya L, Smietana J. Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med. 2002 Dec 19. 347(25):2020-9. [Medline].

  18. Gauthier GM, Nork TM, Prince R, Andes D. Subtherapeutic ocular penetration of caspofungin and associated treatment failure in Candida albicans endophthalmitis. Clin Infect Dis. 2005 Aug 1. 41(3):e27-8. [Medline].

  19. Mikosz CA, Smith RM, Kim M, Tyson C, Lee EH, Adams E, et al. Fungal endophthalmitis associated with compounded products. Emerg Infect Dis. 2014 Feb. 20 (2):248-56. [Medline].

  20. Sallam A, Taylor SR, Khan A, McCluskey P, Lynn WA, Manku K. FACTORS DETERMINING VISUAL OUTCOME IN ENDOGENOUS CANDIDA ENDOPHTHALMITIS. Retina. 2012 Jan 31. [Medline].

  21. Tanaka H, Ishida K, Yamada W, Nishida T, Mochizuki K, Kawakami H. Study of ocular candidiasis during nine-year period. J Infect Chemother. 2016 Mar. 22 (3):149-56. [Medline].

  22. Akler ME, Vellend H, McNeely DM, Walmsley SL, Gold WL. Use of fluconazole in the treatment of candidal endophthalmitis. Clin Infect Dis. 1995 Mar. 20(3):657-64. [Medline].

  23. Blumenkranz MS, Stevens DA. Therapy of endogenous fungal endophthalmitis: miconazole or amphotericin B for coccidioidal and candidal infection. Arch Ophthalmol. 1980 Jul. 98(7):1216-20. [Medline].

  24. Breit SM, Hariprasad SM, Mieler WF et al. Management of endogenous fungal endophthalmitis with voriconazole and caspofungin. Am J Ophthalmol. 2005 Jan. 139(1):135-40. [Medline].

  25. Brod RD, Flynn HW, Clarkson JG, Pflugfelder SC, Culbertson WW, Miller D. Endogenous Candida endophthalmitis. Management without intravenous amphotericin B. Ophthalmology. 1990 May. 97(5):666-72; disc: 672-4. [Medline].

  26. Brooks RG. Prospective study of Candida endophthalmitis in hospitalized patients with candidemia. Arch Intern Med. 1989 Oct. 149(10):2226-8. [Medline].

  27. Christmas NJ, Smiddy WE. Vitrectomy and systemic fluconazole for treatment of endogenous fungal endophthalmitis. Ophthalmic Surg Lasers. 1996 Dec. 27(12):1012-8. [Medline].

  28. Cornely OA, Schmitz K, Aisenbrey S. The first echinocandin: caspofungin. Mycoses. 2002. 45 Suppl 3:56-60. [Medline].

  29. Crump JR, Elner SG, Elner VM, Kauffman CA. Cryptococcal endophthalmitis: case report and review. Clin Infect Dis. 1992 May. 14(5):1069-73. [Medline].

  30. Donahue SP, Greven CM, Zuravleff JJ, Eller AW, Nguyen MH, Peacock JE Jr, et al. Intraocular candidiasis in patients with candidemia. Clinical implications derived from a prospective multicenter study. Ophthalmology. 1994 Jul. 101(7):1302-9. [Medline].

  31. Edwards JE Jr, Foos RY, Montgomerie JZ, Guze LB. Ocular manifestations of Candida septicemia: review of seventy-six cases of hematogenous Candida endophthalmitis. Medicine (Baltimore). 1974 Jan. 53(1):47-75. [Medline].

  32. Gao H, Pennesi ME, Shah K, Qiao X, Hariprasad SM, Mieler WF, et al. Intravitreal voriconazole: an electroretinographic and histopathologic study. Arch Ophthalmol. 2004 Nov. 122(11):1687-92. [Medline].

  33. Griffin JR, Pettit TH, Fishman LS, Foos RY. Blood-borne Candida endophthalmitis. A clinical and pathologic study of 21 cases. Arch Ophthalmol. 1973 Jun. 89(6):450-6. [Medline].

  34. Gross JG. Endogenous Aspergillus-induced endophthalmitis. Successful treatment without systemic antifungal medication. Retina. 1992. 12(4):341-5. [Medline].

  35. Henderson DK, Edwards JE Jr, Montgomerie JZ. Hematogenous candida endophthalmitis in patients receiving parenteral hyperalimentation fluids. J Infect Dis. 1981 May. 143(5):655-61. [Medline].

  36. Hunt KE, Glasgow BJ. Aspergillus endophthalmitis. An unrecognized endemic disease in orthotopic liver transplantation. Ophthalmology. 1996 May. 103(5):757-67. [Medline].

  37. Luttrull JK, Wan WL, Kubak BM, Smith MD, Oster HA. Treatment of ocular fungal infections with oral fluconazole. Am J Ophthalmol. 1995 Apr. 119(4):477-81. [Medline].

  38. Martinez-Vazquez C, Fernandez-Ulloa J, Bordón J, Sopena B, de la Fuente J, Ocampo A, et al. Candida albicans endophthalmitis in brown heroin addicts: response to early vitrectomy preceded and followed by antifungal therapy. Clin Infect Dis. 1998 Nov. 27(5):1130-3. [Medline].

  39. McDonald HR, De Bustros S, Sipperley JO. Vitrectomy for epiretinal membrane with Candida chorioretinitis. Ophthalmology. 1990 Apr. 97(4):466-9. [Medline].

  40. Naoi N, Sawada A. Effect of vitrectomy on epiretinal membranes after endogenous fungal endophthalmitis. Jpn J Ophthalmol. 1996. 40(3):434-8. [Medline].

  41. Okhravi N, Adamson P, Mant R, Matheson MM, Midgley G, Towler HM, et al. Polymerase chain reaction and restriction fragment length polymorphism mediated detection and speciation of Candida spp causing intraocular infection. Invest Ophthalmol Vis Sci. 1998 May. 39(6):859-66. [Medline].

  42. Okhravi N, Dart JK, Towler HM, Lightman S. Paecilomyces lilacinus endophthalmitis with secondary keratitis: a case report and literature review. Arch Ophthalmol. 1997 Oct. 115(10):1320-4. [Medline].

  43. Ozdamar A, Aras C, Ozturk R, Akin E, Karacorlu M, Ercikan C. In vitro antimicrobial activity of silicone oil against endophthalmitis-causing agents. Retina. 1999. 19(2):122-6. [Medline].

  44. Parke DW 2nd, Jones DB, Gentry LO. Endogenous endophthalmitis among patients with candidemia. Ophthalmology. 1982 Jul. 89(7):789-96. [Medline].

  45. Scherer WJ, Lee K. Implications of early systemic therapy on the incidence of endogenous fungal endophthalmitis. Ophthalmology. 1997 Oct. 104(10):1593-8. [Medline].

  46. Sheu SJ, Chen YC, Kuo NW, et al. Endogenous cryptococcal endophthalmitis. Ophthalmology. 1998 Feb. 105(2):377-81. [Medline].

  47. Smiddy WE. Treatment outcomes of endogenous fungal endophthalmitis. Curr Opin Ophthalmol. 1998 Jun. 9(3):66-70. [Medline].

  48. Smith SR, Kroll AJ, Lou PL, Ryan EA. Endogenous bacterial and fungal endophthalmitis. Int Ophthalmol Clin. 2007. 47(2):173-83. [Medline].

  49. Weishaar PD, Flynn HW, Murray TG, Davis JL, Barr CC, Gross JG, et al. Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes. Ophthalmology. 1998 Jan. 105(1):57-65. [Medline].

  50. Weissgold DJ, Maguire AM, Brucker AJ. Management of postoperative acremonium endophthalmitis. Ophthalmology. 1996 May. 103(5):749-56. [Medline].

  51. Zakka KA, Foos RY, Brown WJ. Intraocular coccidioidomycosis. Surv Ophthalmol. 1978 Mar-Apr. 22(5):313-21. [Medline].

  52. Zhang YQ, Wang WJ. Treatment outcomes after pars plana vitrectomy for endogenous endophthalmitis. Retina. 2005 Sep. 25(6):746-50. [Medline].

 
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