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Intracameral Amphotericin B in Management of Candida Glabrata Keratouveitis after Penetrating Keratoplasty

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.

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Intracameral Amphotericin B in Management of Candida Glabrata Keratouveitis after Penetrating Keratoplasty

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  1. 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

  2. Purpose: To report management of Candida glabratakeratouveitis 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 forCandida 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 plaqueat the graft-host junction. • B-scan ultrasonography: no evidence of posterior segment inflammation. Keratic precipitates and endothelial plaque

  3. 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

  4. 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

  5. Endothelial cell density: ICAMB IVTCA ICAMB = intracameral amphotericin B ECD = endothelial cell density BSCVA = best spectacle corrected visual acuity CF = counting fingers IVTCA = intravitreal triamcinolone

  6. 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.

  7. Conclusions: In our opinionintracameral amphotericin B is effective and safe in the therapy of Candida glabrata keratouveitis after penetrating keratoplasty.

  8. References • 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) • 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) • Kuriakose T, Kothari M, Paul P, et al. Intracameral amphotericin B injection in the management of deep keratomycosis. Cornea. 2002;21 • 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 • Grueb M, Rohrbach JM, Zierhut M. Amphotericin B in the Therapy of Candida glabrata Endophthalmitis After Penetrating Keratoplasty. Cornea. 2006 Dec;25(10) • Chapman FM, Orr KE, Armitage WJ, et al. Candida glabrata endoph- thalmitis following penetrating keratoplasty. Br J Ophthalmol. 1998;82

  9. THANK YOU FOR YOUR ATTENTION

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