Intracameral Amphotericin B in Management of Candida Glabrata
Keratouveitis after Penetrating Keratoplasty
Petra Schollmayer, Aleksandra Kraut, Mojca Globocnik-Petrovic, Vladimir Pfeifer
University Eye Hospital, University Medical Centre Ljubljana, Slovenia
Authors have no financial interest
Purpose: To report management of Candida glabrata keratouveitis after penetrating keratoplasty (PK) with intracameral amphotericin B (ICAMB).
Case report:• Seventy-nine-year-old woman• Her right eye was enucleated for posttraumatic
glaucoma. • PK for graft failure in her left eye.
• The corneal donor rim (cold storage): culture-positive for Candida glabrata
• Postoperative treatment: 0.1% dexamethason and neomycin/polymyxin B drops but no prophylactic antifungal therapy because of the absence of clinical signs of fungal keratitis or uveitis in the immediate postoperative course.
• Six weeks after PK: mutton fat keratic precipitates and a dense endothelial plaque at the graft-host junction.
• B-scan ultrasonography: no evidence of posterior segment inflammation. Keratic precipitates and endothelial
plaque
• Anterior chamber tap was performed with aspiration of the endothelial plaque, subsequently 5 µg amphotericin B (ICAMB) and 1mg vancomycin was injected in the anterior chamber (AC).
• Cultures of the anterior chamber: also positive for Candida glabrata, the same pathogen as the corneosleral donor rim.
• Treatment after ICAMB: topical 0,15% amphotericin and topical 0.1% dexamethason every 2 hours in tapering dosage.
• 1 week after ICAMB the eye was white with only few cells in AC. Topical amphotericin B was discontinued after 1 month.
2 weeks after ICAMB 2 months after ICAMB
• However despite of resolution of inflammation her visual acuity did not improve
• OCT (4 months after PK) showed cystoid macular edema. • Macular thickness and BSCVA improved after intravitreal
injection of 4 mg (0.1 ml) triamcinolone acetonide.
• Follow up: 22 months• No evidence of recurrent fungal intraocular infection• BSCVA LE: 0,5 • Graft remained clear with the ECD of 1921 cells/mm2.
1 year after ICAMB-clear graft
Endothelial cell density:
Before ICAMB After 1 month After 2 monthsAfter almost 2
years
ECD (cells/mm2)
2139 2244 2231 1921
BSCVA CF 2m 0.16 0.5 0.6
ICAMB = intracameral amphotericin BECD = endothelial cell densityBSCVA = best spectacle corrected visual acuityCF = counting fingersIVTCA = intravitreal triamcinolone
ICAMB IVTCA
Discussion:
• Only few clinical studies have reported the intracameral injection of amphotericin B (ICAMB) in the treatment of fungal keratitis and endophthalmitis1-6.
• ICAMB is generally considered effective and safe2.
• Reported side effects, which are rare: postoperative pain and anterior chamber inflammation3, anterior subcapsular cataract2.
• Candida glabrata is of low pathogenicity, it is resistant to fluconazole and other azoles but is only highly sensitive to amphotericin B:• Systemic amphotericin B: poor intraocular penetration
and serious side effects (nephrotoxicity)• Topical amphotericin B: poor penetration in corneas with
intact epithelium as in our case1
• Intracameral amphotericin
• Topical corticosteroids (postoperative therapy after PK)
may worsen infective (fungal) disease.
Conclusions:
In our opinion intracameral
amphotericin B is effective and safe in
the therapy of Candida glabrata
keratouveitis after penetrating
keratoplasty.
References1. Yoon KC, Jeong IY, Im SK, Chae HJ, Yang SY. Therapeutic Effect of
Intracameral Amphotericin B Injection in the Treatment of Fungal Keratitis. Cornea. 2007 Aug;26(7)
2. Yilmaz S, Ture M, Maden A. Efficacy of Intracameral Amphotericin B Injection in the Management of Refractory Keratomycosis and Endophthalmitis. Cornea. 2007 May;26(4)
3. Kuriakose T, Kothari M, Paul P, et al. Intracameral amphotericin B injection in the management of deep keratomycosis. Cornea. 2002;21
4. Al-Assiri A, Al-Jastaneiah S, Al-Khalaf A, et al. Late-onset donor-to-host transmission of Candida glabrata following corneal transplantation. Cornea. 2006;25
5. Grueb M, Rohrbach JM, Zierhut M. Amphotericin B in the Therapy of Candida glabrata Endophthalmitis After Penetrating Keratoplasty. Cornea. 2006 Dec;25(10)
6. Chapman FM, Orr KE, Armitage WJ, et al. Candida glabrata endoph- thalmitis following penetrating keratoplasty. Br J Ophthalmol. 1998;82
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