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Sections Fungal Endophthalmitis
Overview
Presentation
- History
- Physical
- Causes
- Complications
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DDx
Workup
Treatment
Guidelines
Medication
References

Medication

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.

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)

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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.

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)

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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)

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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)

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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)

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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)

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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.

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)

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

Class Summary

Inhibit cell growth and proliferation.

Flucytosine (Ancobon)

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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.

Class Summary

Inhibit cell wall synthesis.

Caspofungin (Cancidas)

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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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Author

Lihteh Wu, MD Ophthalmologist, Costa Rica Vitreo and Retina Macular Associates

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: Serve(d) as a speaker or a member of a speakers bureau for: Bayer; Quantel Medical, Roche<br/>Received income in an amount equal to or greater than $250 from: Bayer Health; Quantel Medical, Roche.

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 Adjunct Professor, Department of Ophthalmology, University of Texas Health Science Center at San Antonio

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, 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.

Sections Fungal Endophthalmitis
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Guidelines
Medication
References

Fungal Endophthalmitis Medication

Medication Summary

Polyene antibiotics

Class Summary

Amphotericin B (Amphocin, Fungizone)

Amphotericin B (Amphocin, Fungizone)

Imidazoles

Class Summary

Fluconazole (Diflucan)

Fluconazole (Diflucan)

Ketoconazole (Nizoral)

Ketoconazole (Nizoral)

Itraconazole (Sporanox)

Itraconazole (Sporanox)

Miconazole (Absorbine, Femizol)

Miconazole (Absorbine, Femizol)

Voriconazole (Vfend)

Voriconazole (Vfend)

Corticosteroids

Class Summary

Dexamethasone (Ocu-Dex)

Dexamethasone (Ocu-Dex)

Chemotherapeutic agents

Class Summary

Flucytosine (Ancobon)

Flucytosine (Ancobon)

Echinocandins

Class Summary

Caspofungin (Cancidas)

Caspofungin (Cancidas)

Fungal Endophthalmitis Medication

Medication Summary

Polyene antibiotics

Class Summary

Amphotericin B (Amphocin, Fungizone)

Imidazoles

Class Summary

Fluconazole (Diflucan)

Ketoconazole (Nizoral)

Itraconazole (Sporanox)

Miconazole (Absorbine, Femizol)

Voriconazole (Vfend)

Corticosteroids

Class Summary

Dexamethasone (Ocu-Dex)

Chemotherapeutic agents

Class Summary

Flucytosine (Ancobon)

Echinocandins

Class Summary

Caspofungin (Cancidas)

References

Tables

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