Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans

Aspergillus terreus panophthalmitis with orbital cellulitis

An eleven year old male reported a ten-day history of unilateral pain, redness, and sudden loss of vision. Ophthalmic examination revealed panophthalmitis that did not respond to conventional intravenous antibiotics, and systemic deterioration raised suspicion of a fungal aetiology. However, the worsening of the ocular condition from panophthalmitis to orbital cellulitis upon commencement of amphotericin B suggests the presence of a fastidious microorganism. Aspergillus terreus was isolated from a vitreous tap sample and responded well to intravenous voriconazole, exhibiting a distinct antimicrobial susceptibility spectrum and emphasising its possible involvement in relatively healthy early adolescence. To the author's knowledge, panophthalmitis with orbital cellulitis in early adolescence, without prior ocular insult, paranasal sinus involvement, or immunocompromised status, has not been reported previously.

Endogenous Fungal Endophthalmitis: A Single-Center Retrospective Study and Review of the Literature

PURPOSE

To evaluate factors that inform systemic antifungal choices in patients with endogenous fungal endophthalmitis (EFE).

DESIGN

Single-institution retrospective case series.

METHODS

Charts of EFE patients from 2010 to 2023 were reviewed. Patients treated systemically for EFE with a minimum of 14 days of follow-up were included. Outcome measures included time to improvement in vitritis or chorioretinitis, systemic therapy modification, and need for surgical intervention.

RESULTS

A total of 20 eyes of 16 patients were included. Candida species were most common (43.8%), followed by culture-negative EFE (37.5%) and Aspergillus species (18.8%). In all, 90% of eyes had vitritis and/or macula-involving chorioretinitis. The majority of Candida infections (60%) or culture-negative EFE (75%) were treated initially with oral antifungals. Patients with a history of immune compromise, positive fungal culture, or positive Fungitell assay were more likely to be treated with early intravenous (IV) antifungal therapy. Two patients required systemic antifungal therapy modification because of worsening chorioretinitis, in 1 case due to voriconazole-resistant Aspergillosis that demonstrated chorioretinal lesion growth despite intravitreal amphotericin B injections and systemic voriconazole, and in the second case due to worsening chorioretinitis from Candida dubliniensis infection that regressed upon switch from oral to IV fluconazole.

CONCLUSIONS

Initial systemic treatment decisions in patients with EFE were driven by systemic culture positivity, systemic symptoms, or comorbidities. Intravitreal antifungal therapy may be insufficient to arrest progression of chorioretinal lesions in some cases. Larger studies are needed to determine whether visible end-organ damage in the form of chorioretinitis may be useful for guiding systemic therapy changes.

Humans vs. Fungi: An Overview of Fungal Pathogens against Humans

Human fungal diseases are infections caused by any fungus that invades human tissues, causing superficial, subcutaneous, or systemic diseases. Fungal infections that enter various human tissues and organs pose a significant threat to millions of individuals with weakened immune systems globally. Over recent decades, the reported cases of invasive fungal infections have increased substantially and research progress in this field has also been rapidly boosted. This review provides a comprehensive list of human fungal pathogens extracted from over 850 recent case reports, and a summary of the relevant disease conditions and their origins. Details of 281 human fungal pathogens belonging to 12 classes and 104 genera in the divisions ascomycota, basidiomycota, entomophthoromycota, and mucoromycota are listed. Among these, Aspergillus stands out as the genus with the greatest potential of infecting humans, comprising 16 species known to infect humans. Additionally, three other genera, Curvularia, Exophiala, and Trichophyton, are recognized as significant genera, each comprising 10 or more known human pathogenic species. A phylogenetic analysis based on partial sequences of the 28S nrRNA gene (LSU) of human fungal pathogens was performed to show their phylogenetic relationships and clarify their taxonomies. In addition, this review summarizes the recent advancements in fungal disease diagnosis and therapeutics.

Fungal Endophthalmitis: Clinical Characteristics, Pathogens, and Factors Affecting Visual Outcome

AIMS

The aims of this study are to investigate the etiology, microbiological spectrum, and risk factors associated with visual outcomes of fungal endophthalmitis (FE) in a tertiary eye specialty hospital in Shanghai, China.

METHODS

This was a retrospective, single-center case series. The clinical characteristics, etiology, microbiological spectrum, and management, as well as the visual outcomes, were analyzed. Logistic regression was used to analyze the factors related to visual outcomes.

RESULTS

This study involved 102 eyes of 92 patients with FE, including 63 males (66.3%). The mean age was 44.4 ± 19.8 years. The most common etiology of FE was trauma (56.5%). The predominant fungal species isolated were Aspergillus spp. (31/93, 33.3%). Pars plana vitrectomy (PPV) and intravitreal antifungal agents was performed initially in 86 (84.3%) and 83 (81.4%) eyes, respectively. Only 35 (34.3%) eyes achieved final best corrected visual acuity (BCVA) of 20/400 or better. Ten (9.8%) eyes had a final BCVA of light perception or worse, and five (4.9%) had to be enucleated. The factors determining better visual outcomes included initial visual acuity better than finger-counting (FC) (odds ratio (OR) 5.811, p = 0.036), the absence of corneal infiltrate (OR 10.131, p = 0.002), and Candida species infection (OR 6.325, p = 0.011).

CONCLUSIONS

Early diagnosis of FE and a timely vitrectomy, combined with an intravitreal injection of an antifungal drug, can mitigate the devastating results of intraocular fungal infection. Not being infected by Aspergillus spp., an initial BCVA that was no worse than FC, and the absence of corneal involvement were related to better visual prognosis.

Use of Optical Coherence Tomography and Optical Coherence Tomography Angiography in the Diagnosis and Follow-Up of Endogenous Candida Endophthalmitis: A Case Report

Background: Endogenous Candida endophthalmitis (ECE) is a rare but sight-threatening disease. Patients with ECE present with various clinical signs and symptoms, which can complicate the diagnosis. The aim of this report was to demonstrate the outcomes of treatment and to diagnose macular complications caused by intraocular inflammation. Case presentation: A 41-year-old woman with a history of acute intermittent porphyria presented with a progressive vision loss in her left eye. Left-eye OCT revealed findings consistent with a fungal etiology, which was confirmed by the culture of swabs collected from a central vein catheter. The outcomes of intravenous fluconazole treatment were not satisfactory, and the patient developed recurrent attacks of porphyria, suggesting a porphyrogenic effect of systemic antifungal therapy. Repeated intravitreal injections with amphotericin B led to a gradual regression of inflammatory lesions. However, follow-up examinations revealed active macular neovascularization (MNV) on both OCT and OCTA scans. The patient was administered intravitreal bevacizumab. At the 11th month of follow-up, OCT and OCTA scans showed significant inflammatory lesions regression with macula scarring, and no MNV activity was detected. Conclusions: This case highlights the importance of OCT and OCTA as valuable noninvasive imaging techniques for the identification of ECE, the monitoring of its clinical course, and the diagnosis of macular complications.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

Toxicity of simultaneous intrastromal and intracameral injection of voriconazole on corneal endothelium in a rabbit model

PURPOSE

To investigate the toxicity of repeated simultaneous intrastromal and intracameral injections of voriconazole in corneal endothelial cells in a rabbit model.

METHODS

Thirty-six eyes of 18 New Zealand white rabbits (six eyes per group) were divided into 6 groups according to the concentration of voriconazole (Group A, 0%; Group B, 0.05%; Group C, 0.1%; Group D, 0.25%; Group E, 0.5%; Group F, 1%). A combination of intrastromal and intracameral voriconazole injections were administrated to the eyes of each group three times on days 0, 3, and 7. Corneal clouding grades and central corneal thickness (CCT) were examined on days 0, 3, 7, 10, and 14. The endothelial cell counts (ECC) were measured on days 0 and 14. Scanning electron microscopy (SEM) and transmission electron microscopy (TEM) were performed on day 14.

RESULTS

Group F (1%) showed more severe corneal clouding than the other groups (Groups A-E) from day 7 (p < 0.05, respectively). There were no significant differences in CCT and ECC among the six groups at any time point (p > 0.05, respectively). SEM revealed blurring of the cell border and loss of microvilli at concentrations ≥0.25% (Groups D-F). TEM revealed microstructural changes in endothelial cells at concentrations ≥0.1% (Groups C-F), and multiple vacuoles were observed at a concentration of 1% voriconazole (Group F).

CONCLUSIONS

Repeated simultaneous intrastromal and intracameral voriconazole injections at a concentration of 0.1% or higher induced microstructural endothelial damage in rabbit corneal endothelial cells.

Wickerhamomyces Anomalus Postoperative Endophthalmitis

INTRODUCTION

We describe the case of a postoperative fungal endophthalmitis caused by Wickerhamomyces anomalus, an opportunistic yeast common in nature but rare as a causative agent in ocular infections. This would be the second reported case of W. anomalus endophthalmitis.

CASE REPORT

A patient came to our hospital with a dense hemovitreous caused by an inadvertent ocular perforation and retinal detachment during a cataract surgery. In the days following the first vitreoretinal surgery a chronic postoperative endophthalmitis was evidenced. Only after several surgeries as well as intravitreal antibiotics and sample takings, Wickerhamomyces was detected. The treatment with oral voriconazole and an intraocular lens extraction controlled the infection.

DISCUSSION

Wickerhamomyces anomalus, despite not being particularly aggressive in our case, was resistant to various consequent vitreoretinal surgeries. The unresponsiveness to treatment led us to contemplate the fungal etiology, and fortunately the cultures were positive for this yeast. In conjunction to antifungal therapy, it is possible that the IOL explantation played an important role in the treatment.

CONCLUSION

A high index of suspicion must be held in cases of fungal endophthalmitis. Both IOL explantation and oral antifungal therapy are useful treatment options in cases of W. anomalus endophthalmitis.

Oral voriconazole monotherapy for fungal keratitis: efficacy, safety, and factors associated with outcomes

Purpose

To provide preliminary data on the efficacy and safety of oral voriconazole (VCZ) as a primary treatment for fungal keratitis (FK).

Method

We performed a retrospective histopathological analysis of data on 90 patients with FK at The First Affiliated Hospital of Guangxi Medical University between September 2018 and February 2022. We recorded three outcomes: corneal epithelial healing, visual acuity (VA) improvement, and corneal perforation. Independent predictors were identified using univariate analysis, and multivariate logistic regression analysis was used to identify independent predictive factors associated with the three outcomes. The area under the curve was used to evaluate the predictive value of these factors.

Results

Ninety patients were treated with VCZ tablets as the only antifungal drug. Overall, 71.1% (n = 64) of the patients had extreme corneal epithelial healing, 56.7% (n = 51) showed an improvement in VA, and 14.4% (n = 13) developed perforation during treatment. Non-cured patients were more likely to have large ulcers (≥5 × 5 mm²) and hypopyon.

Conclusion

The results indicated that oral VCZ monotherapy was successful in the patients with FK in our study. Patients with ulcers larger than 5 × 5 mm² and hypopyon were less likely to respond to this treatment.

Microbiological Profiles of Ocular Fungal Infection at an Ophthalmic Referral Hospital in Southern China: A Ten-Year Retrospective Study

Purpose

Methods

Results

Conclusion

Saprochaete clavata Chorioretinitis in a Post-chemotherapy Immunocompromised 9-Year-Old Child

PURPOSE

To describe the management of bilateral chorioretinitis with Saprochaete clavata in a post-chemotherapy immunocompromised young patient.

METHOD

A retrospective case report.

RESULT

A 9-year-old boy treated with chemotherapy for type 2 acute myeloid leukaemia was diagnosed with Saprochaete clavata (formerly called Geotrichum clavatum) fungaemia. Systematic ocular examination revealed chorioretinitis of the left eye becoming bilateral within the next 3 days. Therapy was based on systemic administration of voriconazole, amphotericin B and flucytosine associated with granulocytic stimulation without stabilizing the ophthalmological situation. Bilateral intravitreal injections of amphotericin B were administered. Voriconazole residual blood concentration was monitored to adjust daily dose. Final best corrected visual acuity in the right eye was 20/50 and 20/20 in the left eye.

CONCLUSION

This is the first report of chorioretinitis with Saprochaete clavata. Because of its unpredictable pharmacokinetics, especially in pediatric population, therapeutic drug monitoring of voriconazole is essential to control fungal infection.

Aspergillus flavus endogenous endophthalmitis in an immunocompetent man: treatment outcomes and swept-source optical coherence tomography findings

A non-diabetic man in his 40s presented with a 4-day history of sudden, painless, rapidly progressive severe vision loss in his right eye. Anterior segment was unremarkable. A dense, solitary vitreous abscess with feathery margins obscured the macula. Retinal haemorrhages, exudates and retinal vasculitis were noted. There was no history of ocular surgery, trauma, intravenous drug abuse or immunocompromise. He received intravenous fluids during a spinal procedure 5 days prior. Prompt diagnostic and therapeutic pars-plana vitrectomy was done and Aspergillus flavus was cultured. Postoperatively, he was treated with oral Voriconazole and four intravitreal Voriconazole injections, till the chorioretinitis lesions had completely healed and was objectively confirmed on follow-up swept-source optical coherence tomography (OCT). He achieved a best-corrected visual acuity of 6/36. A high index of suspicion, early vitrectomy and OCT-based treatment were key to favourable outcomes in this case. Intravenous fluid bottles must be checked for contamination prior to administration.

Endophthalmitis secondary to donor to host infection in posterior lamellar keratoplasties: A systematic review

Donor to host transmission of infectious agents is a well-recognized entity, more commonly related to Endothelial Keratoplasty (EK) than to Penetrating Keratoplasty (PK), that involves complications ranging from interface keratitis to endophthalmitis. A systematic review of the literature was conducted to identify the published articles until December 2020 reporting cases of endophthalmitis secondary to corneal graft contamination in posterior lamellar keratoplasties (DSAEK and DMEK) along with donor characteristics, microbiological profile, treatment and outcomes. Each identified article was assessed to meet donor to host infection criteria, defined as a post-procedural infection in which the same microbiological agent was identified in both the donor corneoscleral rim or preservation medium and receptor ocular tissue. From 23 research articles, eight reports of endophthalmitis in nine patients following DSAEK or DMEK secondary to donor to host infection fulfilled the inclusion criteria. The majority were male and the median age was 72.0 (45.0-81.0) years old. Indications of surgery were primarily pseudophakic bullous keratopathy and Fuchs dystrophy. A fungal pathogen was identified in eight of nine patients. All the cases underwent surgical management with lenticule removal or endothelial plaque aspiration. The final corrected distance visual acuity (CDVA) in all cases was 20/200 or better. Endophthalmitis after an EK procedure is a rare complication whose outcome depends on the aggressive and precocious treatment. Identification of early signs of interface keratitis and lenticule removal seems mandatory in patients undergoing DSAEK or DMEK to prevent further involvement of the globe.

Candida Endophthalmitis Treated Successfully With Isavuconazole: A Case Report

Candida endophthalmitis is a serious complication of candidemia. Diagnosis requires identification of ocular lesions on dilated fundoscopy, aided by isolation of the organism from blood and/or vitreous humor. However, the initial ophthalmological examination may be negative in some cases. Experience with isavuconazole for the treatment of Candida endophthalmitis is limited. We present a case of a 65-year-old woman with metastatic breast cancer on chemotherapy who developed Candida dubliniensis endophthalmitis with initial negative ophthalmological examination. She was treated with vitrectomy and 6 weeks of oral fluconazole. Despite vitrectomy and culture-directed antifungal treatment, management was complicated by lack of response to fluconazole and intolerance to other antifungals, necessitating the use of isavuconazole, which proved efficacious.

Efficacy of Voriconazole Corneal Intrastromal Injection for the Treatment of Fungal Keratitis

Purpose

To evaluate efficacy and safety of novel tricyclic corneal stroma injection (TCSI) voriconazole for the treatment of fungal keratitis.

Methods

This retrospective cohort study included data of 57 patients (57 eyes) with fungal keratitis. The TCSI group consisted of 27 patients (27 eyes) who were injected voriconazole once via TCSI procedure within one week after enrollment, in addition to conventional antifungal treatment. The control group consisted of 30 patients (30 eyes) who were treated using conventional antifungal treatment modalities. The outcome measures consist of the 3-week and 3-month best-corrected visual acuity (BCVA) values and size of infiltrate or scar, time to re-epithelialization, corneal perforation rate and/or therapeutic penetrating keratoplasty (TPK) requirement, the preoperative and post-TCSI corneal endothelial cell density (ECD), and the intraocular pressure (IOP) of the treated eye and the respective contralateral eye.

Results

There were no significant differences in the baseline demographic and clinical characteristics between the two groups. 3 weeks and 3 months after enrollment, the TCSI group exhibited an increase in visual acuity (P < 0.05), and there was no significant difference in the size of infiltrate or scar between two groups (P > 0.05). Time to re-epithelialization was shorter in the TCSI group than in the control group (P < 0.05). There was no statistically significant difference between corneal ECD on the day before and 7 days after TCSI and the IOP of treated and contralateral healthy eyes on the day before and 1 day, 3 days, 7 days, and 1 month after TCSI (P > 0.05). The difference in the risk of perforation and/or TPK requirement was not statistically significant between two groups (P > 0.05).

Conclusion

Localized injection of voriconazole using TCSI may be a minimally invasive, safe, and effective adjuvant treatment modality for fungal keratitis.

American Academy of Ophthalmology Recommendations on Screening for Endogenous Candida Endophthalmitis

The American Academy of Ophthalmology evaluated the practice of routine screening for intraocular infection from Candida septicemia. In the United States, ophthalmologists are consulted in the hospital to screen for intraocular infection routinely for patients with Candida bloodstream infections. This practice was established in the era before the use of systemic antifungal medication and the establishment of definitions of ocular disease with candidemia. A recent systematic review found a rate of less than 1% of routinely screened patients with endophthalmitis from Candida septicemia. Other studies found higher rates of endophthalmitis but had limitations in terms of inaccuracies in ocular disease classification, lack of vitreous biopsies, selection biases, and lack of longer-term visual outcomes. Some studies attributed ocular findings to Candida infections, rather than other comorbidities. Studies also have not demonstrated differences in medical management that are modified for eye disease treatment; therefore, therapy should be dictated by the underlying Candida infection, rather than be tailored on the basis of ocular findings. In summary, the Academy does not recommend a routine ophthalmologic consultation after laboratory findings of systemic Candida septicemia, which appears to be a low-value practice. An ophthalmologic consultation is a reasonable practice for a patient with signs or symptoms suggestive of ocular infection regardless of Candida septicemia.

New Antimycotics in the Pipeline - For Ophthalmology Too?

Seven new antimycotics are presented that are at different points of development or approval. These substances are mainly first-in-class drugs. They are primarily developed for systemic administration. However, with the support of a pharmacist, the intravenous formulation may be used as eyedrops. In this short review, the activities of the substances against various fungal infections are described. After unsuccessful conventional therapy of fungal eye infections, one of these new substances might be suitable to cure the mycosis.

Clinical Pharmacokinetics of Triazoles in Pediatric Patients

Triazoles represent an important class of antifungal drugs in the prophylaxis and treatment of invasive fungal disease in pediatric patients. Understanding the pharmacokinetics of triazoles in children is crucial to providing optimal care for this vulnerable population. While the pharmacokinetics is extensively studied in adult populations, knowledge on pharmacokinetics of triazoles in children is limited. New data are still emerging despite drugs already going off patent. This review aims to provide readers with the most current knowledge on the pharmacokinetics of the triazoles: fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole. In addition, factors that have to be taken into account to select the optimal dose are summarized and knowledge gaps are identified that require further research. We hope it will provide clinicians guidance to optimally deploy these drugs in the setting of a life-threatening disease in pediatric patients.

Endogenous fungal endophthalmitis: risk factors, clinical course, and visual outcome in 13 patients

AIM

To analyze the risk factors, ophthalmological features, treatment modalities and their effect on the visual outcome in patients with endogenous fungal endophthalmitis (EFE).

METHODS

Data retrieved from the medical files included age at presentation to the uveitis clinic, gender, ocular symptoms and their duration before presentation, history of fever, eye affected, anatomical diagnosis and laboratory evidence of fungal infection. Medical therapy recorded included systemic antifungal therapy and its duration, use of intravitreal antifungal agents and use of oral/intravitreal steroids. Surgical procedures and the data of ophthalmologic examination at presentation and at last follow-up were also collected.

RESULTS

Included were 13 patients (20 eyes, mean age 58y). Ten patients presented after gastrointestinal or urological interventions and two presented after organ transplantation. In one patient, there was no history of previous intervention. Diagnostic vitrectomy was performed in 16 eyes (80%) and vitreous cultures were positive in 10 of the vitrectomized eyes (62.5%). In only 4 patients (31%), blood cultures were positive. All patients received systemic antifungal therapy. Sixteen eyes (80%) received intravitreal antifungal agent with voriconazole being the most commonly used. Visual acuity (VA) improved from 0.9±0.9 at initial exam to 0.5±0.8 logMAR at last follow-up (P=0.03). A trend of greater visual improvement was noted in favor of eyes treated with oral steroids (±intravitreal dexamethasone) than eyes that were not treated with steroids. The most common complication was maculopathy. Twelve eyes (60%) showed no ocular complications.

CONCLUSION

High index of suspicion in patients with inciting risk factors is essential because of the low yield of blood cultures and the good general condition of patients at presentation. Visual prognosis is improved with the prompt institution of systemic and intravitreal pharmacotherapy and the immediate surgical intervention. Oral±local steroids could be considered in cases of prolonged or marked inflammatory responses in order to hasten control of inflammation and limit ocular complications.

Treating Fungal Keratitis with Oral Voriconazole Only: A Case Series

BACKGROUND

To report the clinical effect of oral voriconazole only as a treatment for fungal keratitis.

HISTORY AND SIGNS

Three patients (1 female and 2 males) with culture-proven fungal keratitis (1 Mucoraceae, 1 Aspergillus, 1 Fusarium) were included in this study. The patients were treated with oral voriconazole 200 mg twice daily to observe the clinical response in the treatment of fungal keratitis.

THERAPY AND OUTCOME

The mean age of the patients was 51 years and the average treatment duration was 6 weeks. The corneal inflammation in these three patients was eliminated by oral voriconazole only.

CONCLUSIONS

This is the first reported case of oral voriconazole only as a treatment for fungal keratitis. We found that oral voriconazole has a significant clinical effect on the treatment of fungal keratitis.

Antimicrobial guide to posterior segment infections

PURPOSE

This review article is meant to serve as a reference guide and to assist the treating physician in making an appropriate selection and duration of an antimicrobial agent.

METHODS

Literature review.

RESULTS

Infections of the posterior segment require prompt medical or surgical therapy to reduce the risk of permanent vision loss. While numerous options exist to treat these infections, doses and alternative therapies, especially with contraindications for first-line therapy, are often elusive. Antimicrobial agents to treat posterior segment infections can be administered via various routes, including topical, intravitreal, intravenous, and oral.

CONCLUSIONS

Although there are many excellent review articles on the management of endophthalmitis, we take the opportunity in this review to comprehensively summarize the appropriate antimicrobial regimen of both common and rare infectious etiologies of the posterior segment, using evidence from clinical trials and large case series.

Antifungal drugs: An updated review of central nervous system pharmacokinetics

Invasive fungal infections (IFIs) in the central nervous system (CNS) are particularly hard to treat and are associated with high morbidity and mortality rates. Four chemical classes of systemic antifungal agents are used for the treatment of IFIs (eg meningitis), including polyenes, triazoles, pyrimidine analogues and echinocandins. This review will address all of these classes and discuss their penetration and accumulation in the CNS. Treatment of fungal meningitis is based on the antifungal that shows good penetration and accumulation in the CNS. Pharmacokinetic data concerning the entry of antifungal agents into the intracranial compartments are faulty. This review will provide an overview of the ability of systemic antifungals to penetrate the CNS, based on previously published drug physicochemical properties and pharmacokinetic data, for evaluation of the most promising antifungal drugs for the treatment of fungal CNS infections. The studies selected and discussed in this review are from 1990 to 2019.

Histological Effects of Intravitreal Injection of Antifungal Agents in New Zealand White Rabbits: An Electron Microscopic and Immunohistochemical Study

Fungal endophthalmitis is a serious and vision-threatening infection which requires an immediate and effective treatment approach. Our research aims to elucidate the histological effects of the intravitreal injection of the maximum safe dosage of voriconazole and micafungin on retina. Six albino New Zealand White Rabbits were used. In experimental animals, a solution of voriconazole (Group V) or micafungin (Group M) was intravitreally injected in the right eye, while in control animals, balanced salt solution was intravitreally injected in the left eye (Group C). Euthanasia was performed ten days post injection and the retina was removed and prepared for histological examination with a light and electron microscope. Eosin-hematoxylin staining did not reveal any pathological changes in any of the samples examined. The immunohistochemical staining for Tumor Necrosis Factor alpha (TNF-a) marker was detected as negative in all samples, while Interleukin 6 (IL-6) marker was detected as mild only in the group injected with voriconazole. Electron microscopy revealed several ultrastructural alterations in retinal layers in both groups of experimental animals. Histological retinal lesions, revealed with electron microscopy in the present investigation, raises the question of the safe usage of these antifungal agents in the treatment of fungal intraocular infections in the future.

Intravitreal Voriconazole for Treatment of Bilateral Endogenous Candida Chorioretinitis

This report describes a patient with bilateral endogenous candida chorioretinitis. The patient had a 2-day history of bilateral blurred vision. Fundus photography revealed multiple chorioretinal infiltrations in both eyes and a parafoveal hemorrhage in the left eye. After 2 days, fundus examination showed an increased number of infiltrations and hemorrhages in both eyes and worsening vitreous inflammation. A large infiltrative intraretinal lesion and a retinal hemorrhage of the left eye were discovered on optical coherence tomography. <i>Candida albicans</i> was diagnosed from blood culture. The bilateral candida chorioretinitis had not responded to systemic or topical antifungal medication. The chorioretinitis was refractory to intravitreal amphotericin B as well. Intravitreal voriconazole injection in both eyes and intravitreal bevacizumab injection in the left eye were performed thereafter. The chorioretinal infiltrations and hemorrhages decreased in both eyes. Intravitreal voriconazole injection was effective in the treatment of intractable candida chorioretinitis.

Utility of Ophthalmologic Screening for Patients With Candida Bloodstream Infections: A Systematic Review

Importance

The Infectious Diseases Society of America recommends ophthalmologic examinations for everyone with positive Candida blood culture results (candidemia) to screen for endophthalmitis, a practice that remains controversial because of multiple concerns for its limited usefulness and potential for harm.

Objective

To determine guideline efficacy by reconciling discrepancies in the incidence of endophthalmitis and evaluating outcomes of studies assessing ophthalmologic screening for candidemia.

Evidence Review

PubMed literature searches, including the search terms candidemia, fungemia, chorioretinitis, and endophthalmitis, identified longitudinal studies prior to 2018 of patients who underwent ophthalmologic evaluations in the setting of positive fungal blood culture results regardless of symptoms or clinical status. Additional studies not captured by these queries were found by manually scanning references within the articles captured by the queries. Ambiguous studies of patients with concomitant bacterial or viral infections were excluded.

Findings

Thirty-eight applicable studies of 7472 patients who underwent ophthalmologic screening for candidemia or fungemia were identified. Criteria were compared with the conventional definition of endophthalmitis based on present (concordant) or absent (discordant) frank vitreous involvement. Concordant (59 of 6693 [0.9%]) and discordant (114 of 779 [14.6%]) endophthalmitis incidence rates differed by 13.8% (95% CI, 11.4%-16.4%; P < .001). Visual acuity for each case was recorded verbatim as subjective report provided by each study, when available. None of the concordant endophthalmitis cases reported direct, intraocular, microscopic evidence of Candida or other fungal organisms. Outcomes were available for 19 patients with concordant endophthalmitis; 6 died within 4 weeks of screening. The rate of substantial vision loss was associated (φ = 0.58; 95% CI, 0.01-0.86; P = .046) with additional invasive intervention (3 of 6 [50.0%]) compared with medical management alone (0 of 6).

Conclusions and Relevance

In this systematic review without meta-analysis, inconsistent definitions of endophthalmitis accounted for discrepancies of its incidence and overreporting among patients with candidemia, contributing to bias and resulting in the construction of guidelines. As few as 3 of 7472 patients had potential improvement, while routine examination overall could lead to additional interventions and harm in this population. These findings suggest that indiscriminate screening based on candidemia alone does not appear to be supported by the literature and should be reevaluated for inclusion as a recommendation from the Infectious Diseases Society of America.

Pseudozyma aphidis endophthalmitis post-cataract operation: Case discussion and management

Purpose

To present a case of fungal endophthalmitis with a novel organism and our management.

Observations

A 46 year old male presented with delayed-onset acute endophthalmitis 6 weeks after routine phacoemulsification and intraocular lens implantation. Initial treatment with intravitreal antibiotics did not improve his condition. With repeated vitreal taps, the causative organism was eventually identified as a fungus, Pseudozyma aphidis. Treatment with oral and intravitreal voriconazole, as well as pars plana vitrectomy, led to resolution of the endophthalmitis and recovery of vision to 20/25.

Conclusions and importance

Fungal endophthalmitis is a rare, potentially blinding complication of cataract surgery. We report our approach to this previously unreported organism, that led to an excellent visual outcome. There are no specific guidelines for fungal endophthalmitis. The management approach has to be tailored to the clinical response and emerging laboratory data from the microbiologist. Identification of the organism will require specialist laboratory references that may not be available in all hospitals. Ophthalmologists must work closely with microbiologists in order to ensure an optimal outcome.

Isavuconazole for Treatment of Experimental Fungal Endophthalmitis Caused by Aspergillus fumigatus

Fungal endophthalmitis remains a significant cause of vision impairment and blindness. Moreover, the prognosis is poor, in part due to delay in diagnosis and to limited availability of effective antifungal agents with good ocular penetration. Thus, it is imperative to evaluate the therapeutic efficacy in fungal endophthalmitis of newer antifungal agents. In this study, we assessed the efficacy of isavuconazole in treating Aspergillus fumigatus endophthalmitis in an exogenous mouse model of the disease. Briefly, endophthalmitis was induced by intravitreal (IVT) injection of A. fumigatus spores into immunocompetent C57BL/6 (B6) mouse eyes. Mice were randomized into five groups that received isavuconazole via (i) oral gavage, (ii) IVT injections, (iii) intravenous injection, (iv) IVT injection followed by oral gavage, and (v) IVT injection followed by intravenous injection. Our data showed that isavuconazole treatment via all routes reduced fungal burden in A. fumigatus-infected eyes. This coincided with the preservation of retinal structural integrity (histology analysis) and retinal function (electroretinography [ERG] analysis), resulting in significantly improved disease outcome. Furthermore, isavuconazole treatment reduced the levels of inflammatory cytokines (tumor necrosis factor α [TNF-α], interleukin 1β [IL-1β], and IL-6) and cellular infiltration in the eyes. Notably, oral administration of isavuconazole was as effective in ameliorating endophthalmitis as intravitreal injection of the drug. Collectively, our study demonstrates that isavuconazole is effective in treating A. fumigatus endophthalmitis in mice, indicating its potential use in human ocular infections.

Fundoscopy screening for intraocular candida in patients with positive blood cultures-is it justified?

INTRODUCTION

Although the worldwide prevalence of disseminated candidaemia is rising, reported intraocular candidiasis rates are variable, even as low as 1%. The Infectious Diseases Society of America recommends fundoscopy screening for all fungal blood culture positive patients. We wished to evaluate the impact of this recommendation on our department.

METHODS

A retrospective observational study was performed in NHS Greater Glasgow and Clyde (population = 1.15 million) for all patients with candida positive blood culture results over a 2-year period.

RESULTS

From January 2015 to December 2016, 258 candida positive cultures were obtained from 168 adults (mean age = 62 years, range: 17-94 years; 85 females, 83 males). Candida species were isolated in 161/168 (95.8%) cases (43.5% Candida albicans, 35.7% Candida glabrata). All 168 cases were treated with intravenous antifungals. 84 patients (50%) were formally referred to ophthalmology. Of those not referred, 21 were deceased prior to culture result (12.5%) and 14 patients subsequently deteriorated (8.3%). Six patients reported visual symptoms. In total, 65% had no ocular findings and 32.5% had unrelated ocular signs. Only one patient had signs consistent with Candida chorioretinitis, making the prevalence of intraocular candida in our population 1.3% (1/80).

CONCLUSIONS

The prevalence of ocular candidiasis is low, presumably due to potent systemic antifungal agents and good intraocular penetration. Our findings support the view that routine fundoscopy screening may not be indicated in every culture positive patient. This paper provides an evidence base for the Royal College's Eyecare in intensive care unit recommendations regarding targeted screening of non-verbal, symptomatic or high-risk patients.

Prevalence of, and risk factors for, hematogenous fungal endophthalmitis in patients with Candida bloodstream infection

PURPOSE

Endogenous fungal endophthalmitis (EFE) is a severe consequence of candidemia. The prevalence of, and risk factors for, EFE is not well studied.

METHODS

We retrospectively collected cases of patients with candidemia who had undergone ophthalmological examination between April 2011 and March 2016 in five regional hospitals. We conducted bivariate and multivariate analyses using patients' age, gender, causative Candida species, diabetes status, corticosteroid use, cancer status, neutropenia, intensive care unit admission, presence of central venous catheter (CVC), presence of shock, prior antibiotic use, 30-day mortality, and highest Sequential Organ Failure Assessment (SOFA) score. Data on sustained positive blood culture, β-D glucan, CVC removal, empirical antifungal drug used, and time to appropriate antifungal therapy were also collected if available.

RESULTS

Of 174 patients with candidemia, 35 (20.1%) were diagnosed with EFE, including 31 (17.8%) with chorioretinitis and 4 (2.3%) with vitritis. Bivariate analysis (EFE group vs. non-EFE group) found that Candida albicans candidemia (77.1 vs. 34.5%, P < 0.001), neutropenia (14.3 vs. 5.8%, P = 0.141), CVC placement (94.3 vs. 71.2%, P = 0.004), and the presence of shock (28.6 vs. 16.5%, P = 0.145) were each higher in the EFE group. Multivariate logistic regression analysis found C. albicans candidemia (adjusted odds ratio 6.48; [95% CI 2.63-15.95]) and CVC placement (7.55 [1.56-36.53]) to be significant risk factors for EFE.

CONCLUSIONS

Candida albicans is the most common causative agent for Candida EFE. Patients with candidemia and CVC placement should be closely monitored by ophthalmologists.

Fungal endophthalmitis in a case of granulomatosis with polyangitis

A 70-year-old immuno-compromised man, due to multiple comorbidities, particularly granulomatosis with polyangitis (GPA) and its related treatment, presented with generalized weakness, odynophagia and loss of taste sensation. After a complete evaluation, a diagnosis of right frontal lobe brain abscess was made. The patient then developed headache and sudden painful loss of vision in the right eye. Clinical examination revealed anterior chamber cells and flare, vitreous haze and cells, and hemorrhagic chorioretinitis with severe vasculitis in the right eye. Culture from the drained pus of the frontal brain abscess came positive for Aspergillus fumigatus. Incidental echocardiogram showed large vegetation in the mitral valve. Pars plana vitrectomy was done and a specimen was sent for culture that came positive for Aspergillus fumigatus. Although all the necessary medical and surgical interventions were timely carried out in the affected right eye, the patient’s vision worsened due to retinal damage.

CANDIDA ENDOPHTHALMITIS FROM THE REACTIVATION OF A DORMANT LENTICULAR FUNGAL ABSCESS IN A PREMATURE INFANT

BACKGROUND/PURPOSE

To report a case of fungal endophthalmitis from reactivation of a dormant lenticular fungal abscess in a severely premature infant.

METHODS

Single retrospective case report.

RESULTS

A female born at 23 and 6/7 weeks and weighing 620 g was diagnosed at age 29 weeks post menstrual age with persistent tunica vasculosa lentis, lenticular opacity, and aggressive posterior retinopathy of prematurity, and received bilateral intravitreal injection of bevacizumab. At the time of injection she was receiving systemic antibiotics for sepsis and fungemia. The retinopathy of prematurity regressed, as did the tunica vasculosa lentis, but a small plaque remained on the lens. At 5.5 months of age, patient presented with hypopyon and elevated intraocular pressure. Culture of intraocular fluid demonstrated Candida albicans.

CONCLUSION

Candida lenticular abscess is a rare complication of systemic fungemia in premature infants. Bevacizumab-induced regression of tunica vasculosa lentis may have decreased the ability of systemically administered antifungal medications to reach the colonized lens.

Scedosporium Keratitis: An Experience From a Tertiary Eye Hospital in South India

PURPOSE

To determine the clinical profile and prognosis of Scedosporium keratitis.

METHODS

All culture-proven cases were retrospectively analyzed for demographics, clinical characteristics, treatment offered, and resolution time with sequel.

RESULTS

Among the 1792 culture-proven fungal keratitis cases in the study period, 10 (0.6%) were the result of Scedosporium. The mean age of patients was 44.2 years. Eight patients were male. A history of trauma was present in 8 patients. The infiltrate involved the center of the cornea in 5 patients, whereas 4 patients had paracentral involvement and 1 patient had limbal involvement. The mean maximum diameter of infiltrate was 3.4 mm. Five cases were prescribed topical natamycin alone: 4 patients were successfully treated with this monotherapy, whereas 1 patient was lost to follow-up, but the records of the last visit revealed healing. Three patients were treated with a combination therapy of topical natamycin and 1% voriconazole: 2 patients showed complete healing of the ulcer, and 1 patient progressed to corneal perforation necessitating penetrating keratoplasty.

CONCLUSIONS

To our knowledge, this is the largest case series on Scedosporium keratitis to date. This is the first study to report successful treatment of this infection with topical natamycin monotherapy. The outcome may improve if appropriate medical therapy is started early.

Aspergillus Endophthalmitis Resulting in Development of Retinal Aspergilloma

A 78-year-old immunocompetent man presented with a 3-month history of painless decreased vision and panuveitis with a macular lesion presumed to be due to endogenous endophthalmitis. He had been treated with systemic, intravenous, and intravitreal antibiotics and antifungal agents as well as intravitreal steroids. A culture from a prior vitrectomy had grown a single colony of Aspergillus thought to be a contaminant. The macular lesion enlarged and caused a tractional retinal detachment. The patient underwent surgery including resection of what appeared to be an invasive retinal aspergilloma, from which polymerase chain reaction and histopathology confirmed Aspergillus fumigatus. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:680-683.].

Paecilomyces Keratitis in Western India: A Case Report

Cases of ocular trauma with vegetative matter are commonly encountered in ophthalmic practice in India. Many of these present with keratitis/corneal ulceration, of which fungi have a predominant share. We report a case of fungal keratitis and graft infection with Paecilomyces lilacinus, which was successfully treated with topical and systemic Voriconazole. A farmer presented with corneal ulcer and hypopyon in left eye following vegetative trauma during farming. A provisional diagnosis of fungal corneal ulcer was made based on clinical features and topical anti-fungal therapy with Natamycin was initiated. After deterioration, Therapeutic Penetrating Keratoplasty (TPK) was performed to prevent corneal perforation. Postoperatively, the graft responded well to treatment initially. Signs of graft infection appeared on the second postoperative day with perforation within 72 hours. Culture report of recipient corneal button obtained after first TPK revealed growth of P.lilacinus. A second TPK was performed and patient was started on local and oral Voriconazole. After one month follow up, the graft was clear of infection. To our knowledge, this is a rare case reported from western India, at least in recent years. With no definite consensus existing regarding management in such a scenario, extensive research is needed in this direction.

OCHROCONIS GALLOPAVA ENDOPHTHALMITIS SUCCESSFULLY TREATED WITH INTRAVITREAL VORICONAZOLE AND AMPHOTERICIN B

PURPOSE

Ochroconis gallopava is a darkly pigmented septated fungus that rarely infects humans, almost universally immunocompromised individuals. Only one previous case has been reported of O. gallopava endophthalmitis, in which the patient progressed to a visual acuity of no light perception. The authors currently describe the first successfully treated case of O. gallopava endophthalmitis.

METHODS

A 65-year-old Hispanic woman on chronic immunosuppression after a right lung transplant was admitted to the hospital for O. gallopava respiratory tract infection and was found to have bilateral endogenous endophthalmitis. Examination revealed multiple, cream-colored, chorioretinal lesions in the fundus, including one near the temporal macula in the left eye. There was no diffuse vitritis. Visual acuity was 20/30 in both eyes at presentation but dropped to 20/400 in the right eye and counting fingers at 3 feet in the left eye over the hospital course despite receiving an intravitreal injection of voriconazole in the left eye and concurrent IV amphotericin B, posaconazole, and micafungin. The patient was then treated with multiple simultaneous intravitreal amphotericin B and voriconazole injections bilaterally, as well as IV posaconazole, which was switched to IV voriconazole for improved intraocular penetration.

RESULTS

The chorioretinal lesions were noted to regress with treatment. Concomitantly, the patient's respiratory status improved, and she was discharged with a visual acuity of 20/40 in the right eye and 20/60 in the left eye. The patient completed a 1-year course of oral voriconazole as an outpatient without signs of recurrent activity. Seventeen months after the initial presentation, the patient had 20/40 vision bilaterally with a residual, white, fibrotic scar at the temporal macula in the left eye.

CONCLUSION

This report describes the first successful treatment regimen against O. gallopava endophthalmitis using a combination of intravitreal amphotericin B and voriconazole injections, as well as IV posaconazole and voriconazole, which resulted in an excellent visual outcome.