Original Article
Management of endogenous fungal endophthalmitis with voriconazole and caspofungin

Presented in part at the Annual Meeting of the American Ophthalmological Society in Hot Springs, Virginia, May 23–26, 2004.
https://doi.org/10.1016/j.ajo.2004.08.077Get rights and content

Purpose

Voriconazole, a new generation triazole, has been shown to achieve therapeutic intraocular levels after oral administration. Caspofungin is the first approved agent from a new class of antifungals, the echinocandins. This series describes experience at two centers using these novel antifungals to treat endogenous fungal endophthalmitis.

Design

Retrospective review.

Methods

Treatment of five patients with Candida endophthalmitis are reviewed. Postmortem intraocular voriconazole concentrations on a sixth patient are presented as well.

Results

All patients had systemic cultures positive for Candida species. Three patients had prompt resolution of intraocular mycosis with intravenous and oral voriconazole, caspofungin, or both. The fourth patient with bilateral disease responded well to IV voriconazole and caspofungin but had a recurrence when discharged on oral voriconazole and IV caspofungin. This patient had a bowel resection with an ileostomy; therefore, absorption of oral voriconazole may have been inadequate. Bilateral amphotericin B intravitreal injection ultimately treated this patient. The fifth patient received 100 μg/0.1 ml of intravitreal voriconazole (final vitreous concentration approximately 25 μg/ml) followed by oral voriconazole and responded favorably. Our sixth patient had multisystem failure and passed away 1 week after initiating intravenous voriconazole for non-ocular candidemia. Postmortem HPLC analysis of the aqueous and vitreous revealed voriconazole concentrations of 1.52 μg/ml and 1.12 μg/ml, respectively (MIC90 of Candida albicans is 0.06 μg/ml).

Conclusions

Voriconazole and caspofungin appear to be powerful weapons to add to the existing armamentarium against fungal endophthalmitis. Further studies are warranted to define precisely the role of these new agents alone or in combination with other antifungals.

Section snippets

Methods

A retrospective review of five patients with fungal endophthalmitis treated with new-generation antifungal agents was initiated after obtaining approval from the institutional review board. Postmortem intraocular voriconazole concentrations on a sixth patient without ocular infection will be reviewed as well. All patients were treated at the Barnes Retina Institute (St. Louis, Missouri, USA) and the Cullen Eye Institute (Houston, Texas, USA) from August 2003 to May 2004.

Patient 1

A 66-year-old woman with adenocarcinoma of the colon and an enterocutaneous fistula presented with Candida glabrata septicemia. She had been treated with fluconazole for 3 weeks before being transferred to the Barnes Jewish Hospital (St. Louis, Missouri, USA). She complained of visual decline in her right eye for several days. Ophthalmic examination of the this eye revealed a visual acuity of 20/70 with vitreous cell with a solitary subretinal yellow infiltrate. Examination of the left eye was

Discussion

Therapy of ocular mycotic infections can be difficult and prolonged. The difficulty in treatment is due to a combination of the growth characteristics of fungi, a scarcity of effective antifungal agents, and the poor tissue penetration of previously investigated agents. The most important therapeutic principle in endophthalmitis is early diagnosis and correct identification of the fungus, because early treatment is more likely to yield a better visual outcome.10

When reviewing this series, we

References (19)

There are more references available in the full text version of this article.

Cited by (0)

View full text