Filamentous fungal endophthalmitis: results of combination therapy with intravitreal amphotericin B and voriconazole

Figures & data

Table 1 Filamentous fungal endophthalmitis treated with AmB-Vo therapy: clinical characteristics, microbiology results, treatment strategy, and outcome

Case number	Age/sex	Etiology	Duration of symptoms at presentation (days)/onset	Presenting BCVA	Eye	Organism	Positive ocular specimens	Cornea involved	Surgical intervention AmpB-Vo (days)		Final visual acuity	Follow-up duration (weeks)	Possible factors limiting visual improvement
									Secondary	Primary
1	27/M	s/p open globe injury	7/acute	Counting fingers at 2 feet	OS	Aspergillus flavus	Smear, vitreous Culture, vitreous	No	Vitreous tap, AmpB-Vo	PPV, Re-PPV (1), AmpB-Vo (14)	20/60	16	CD, hypotony
2	58/M	s/p cataract surgery	21/acute	Light perception	OS	Aspergillus terreus	Smear, AC exudates, vitreous Culture, vitreous and IOL	No	Vitreous biopsy, AmpB-Vo	PPV, IOL explantation, Re-PPV (2), AmpB-Vo (16)	20/100	18	Corneal scarring
3	64/F	s/p cataract surgery	21/acute	Hand motion	OS	None	None	No	Vitreous biopsy, AmpB-Vo	PPV, IOL explantation, AmpB-Vo (18)	20/400	16	CD, vitreous opacification, hypotony
4	59/F	s/p cataract surgery	21/acute	Light perception	OD	Aspergillus terreus	Culture, IOL	Yes	PPV, IOL explantation, AmpB-Vo	Re-PPV, PK, AmpB-Vo (27)	Light perception	16	CD, RD, graft failure, hypotony
5	54/M	s/p cataract surgery	21/acute	Hand motion	OS	Aspergillus terreus	Smear, vitreous Culture, IOL	No	PPV, IOL explantation, AmpB-Vo	Re-PPV (3), iris resection, AmpB-Vo (17)	20/400	16	CD, corneal scarring
6	64/M	s/p cataract surgery	21/acute	Light perception	OS	Aspergillus terreus	Smear, scleral tunnel scrapings, vitreous Culture, vitreous, IOL, corneal button	Yes	PPV, IOL explantation, AmpB-Vo	PK, AmpB-Vo (29)	Light perception	15	CD, graft failure, hypotony
7	58/M	s/p cataract surgery	21/acute	Counting fingers close to face	OS	Aspergillus terreus	Smear, scleral tunnel scrapings Culture, vitreous, IOL, corneal button	Yes	Vitreous biopsy, AmpB-Vo	PPV, IOL explantation, Patch graph, AmpB-Vo (21)	Counting fingers at 2 feet	16	Graft failure, hypotony
8	44/M	s/p cataract surgery	21/acute	Counting fingers at 2 feet	OS	Aspergillus terreus	Culture, vitreous, AC exudates	No	Vitreous biopsy, AmpB-Vo	PPV, IOL explantation, AmpB-Vo (16)	20/400	14	CD, corneal scarring, vitreous opacification
9	59/M	s/p cataract surgery	40/acute	Counting fingers at 2 feet	OS	Aspergillus terreus	Culture, vitreous, IOL	No	PPV, IOL explantation, AmpB-Vo	Re-vitrectomy (2), iris resection, AmpB-Vo (20)	20/60	12	Corneal scarring
10	50/F	s/p cataract surgery	62/acute	Light perception	OS	Aspergillus terreus	Culture, vitreous, IOL	Yes	PPV, IOL explantation, AmpB-Vo	Re-vitrectomy (2), AmpB-Vo (27)	Light perception	10	CD, corneal scarring, vitreous opacities
11	19/M	s/p open globe injury	3/acute	Counting fingers at 2 feet	OS	Fusarium	Culture, abscised iris from wound	No	Vitreous biopsy, AmpB-Vo	PPV, re-vitrectomy, AmpB-Vo (29)	20/100	12	Vitreous opacities
12	53/M	s/p pterygium excision	15/acute	Hand motion close to face	OD	Aspergillus flavus	Smear, corneal scrapings Culture, corneal button	Yes	Vitreous biopsy, AmpB-Vo	Cataract extraction, PPV, AmpB-Vo (12), PK	Counting fingers at 2 feet	8	Graft failure, hypotony

Abbreviations: AC, anterior chamber; AmpB-Vo, amphotericin B and voriconazole; BCVA, best corrected visual acuity; CD, choroidal detachment; IOL, intraocular lens; OD, right side; OS, left side; PPV, pars plana vitrectomy; PK, penetrating keratoplasty; RD, retinal detachment; s/p, status post.

Figure 1 Clinical photographs of case 1.

Notes: (A), ball of fungal exudates visible through pupil 2 months following open globe injury repair and vitrectomy. (B) partial response and reappearance of exudates following treatment with intravitreal voriconazole. (C), rapid and complete resolution of exudates with combined antifungal treatment observed at one week. (D), fundus photograph 3 months after resolution of endophthalmitis.

Figure 2 Preoperative clinical photographs of a few exogenous filamentous fungal endophthalmitis cases.

Notes: (A), post cataract surgery endophthalmitis with corneal and scleral tunnel fungal infiltrate. (B), cobweb-like exudates in pupillary area and on intraocular lens. (C), organized coagulum in the anterior chamber. (D), post-pterygium excision keratitis and endophthalmitis.

Figure 3 (A–D) Postoperative clinical photographs after resolution of endophthalmitis following vitrectomy, intravitreal antifungal combination therapy (amp-Vo regimen), and adjuvant procedures.