Endophthalmitis, Fungal Treatment & Management

  • Author: Lihteh Wu, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 9, 2010
 

Medical Care

In vitro, minimum inhibitory concentration (MIC) data do not always correlate with in vivo MIC values. Therefore, these should only be used as a guideline.

  • The following drugs are used in treating of fungal endophthalmitis:
    • Amphotericin B
    • Fluconazole
    • Ketoconazole
    • Miconazole
    • Flucytosine
    • Itraconazole
    • Caspofungin
  • Systemic amphotericin has been the treatment of choice because of its broad-spectrum coverage; however, the penetration of the vitreous cavity is poor. Doses of 5- to 10-mg intravitreal amphotericin have been used. Retinal toxicity has been reported in animal models at these doses. Fluconazole and flucytosine have good intraocular penetration, but Candida species show high resistance to flucytosine.
  • A new systemic treatment is voriconazole; when administered orally or intravenously, it has good intravitreal concentrations. Intravitreal administration of voriconazole also seems safe without evidence of retinal toxicity with concentrations up to 25 mg/mL.
  • The echinocandins (caspofungin, micafungin, and anidulafungin) are newer agents that exert their antifungal activity by inhibiting D-glucan synthase, an enzyme involved in fungal cell wall synthesis. Because mammalian cells lack a cell wall, it also represents an ideal and specific target for antifungal therapy. Echinocandins exert antifungal activity against Candida and Aspergillus species[9]
    • In a double-blind multicenter trial of 239 patients, caspofungin was found to be equally as effective as amphotericin B in the treatment of candidemia. Patients were infused with either amphotericin B (0.6–1 mg/kg/d) or caspofungin as a single loading dose of 70 mg with a daily maintenance dose of 50 mg. In this cohort of patients, 7 patients with endophthalmitis were included and the endophthalmitis resolved in all 7 patients. Unfortunately, the authors failed to mention whether or not these 7 patients received caspofungin or amphotericin B. Significantly fewer drug-related adverse events occurred in the caspofungin group than in the amphotericin B group.[10]
    • Gauthier et al reported a case of Candida endophthalmitis that failed treatment with caspofungin because of its poor penetration into the vitreous cavity.[11] Given its limited vitreal penetration, the role of echinocandins remains to be determined in fungal endophthalmitis.
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Surgical Care

  • The advent of pars plana vitrectomy has improved the treatment results of fungal endophthalmitis.
  • The advantages of pars plana vitrectomy are that it provides material for culture, removes viable organisms and inflammatory end products from the infected vitreous, and provides intravitreal access to antifungal agents (eg, amphotericin B).
  • Vitrectomy and intravitreal amphotericin B should be considered in those cases of endogenous fungal endophthalmitis where the disease is progressing despite initial therapy with an appropriate systemic antifungal agent.
  • As a general rule, moderate-to-severe vitreous involvement requires vitrectomy because most systemic antifungals have poor vitreous penetration.
  • Endogenous fungal endophthalmitis without evidence of disseminated disease can be treated successfully with vitrectomy and intravitreal amphotericin B.
  • Given the narrow therapeutic range of amphotericin B, it should not be given in a gas-filled eye.
  • Some authors have advocated the use of 400 µg of intravitreal dexamethasone as an adjuvant.
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Consultations

Because endogenous fungal endophthalmitis is frequently an ocular manifestation of a systemic disease, the patient requires a multidisciplinary approach.

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Contributor Information and Disclosures
Author

Lihteh Wu, MD  Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, 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, Pan-American Association of Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Coauthor(s)

Teodoro Evans, MD  Retina Fellow, St Michael's Hospital, University of Toronto, Canada

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.

Specialty Editor Board

Andrew A Dahl, MD  Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

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

Disclosure: Nothing to disclose.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

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

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

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, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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