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This report describes the use of Intracameral Amphotericin B Irrigation for 4 patients with deep fungal corneal ulcers that did not respond to conventional medical treatment. All patients presented with a fungal ulcer not responding to topical and oral antifungal medication.
This report describes the use of Intracameral Amphotericin B Irrigation for 4 patients with deep fungal corneal ulcers that did not respond to conventional medical treatment. All patients presented with a fungal ulcer not responding to topical and oral antifungal medication.
This report describes the use of Intracameral Amphotericin B Irrigation for 4 patients with deep fungal corneal ulcers that did not respond to conventional medical treatment. All patients presented with a fungal ulcer not responding to topical and oral antifungal medication.
Introduction The recognition, diagnosis, and management of fungal keratitis remains
challenging. This report is of the use of intracameral amphotericin B irrigation for 4 patients with deep fungal corneal ulcers that did not respond to conventional medical treatment. There have been few reports of similar use of intracameral amphotericin B in the literature. 1 Case Reports Patient 1 A 40-year-old man presented in 2004 with a corneal ulcer following injury to the left eye with a metal rod. Treatment consisted of ciprofloxacin 0.3% eye drops for 8 days. He presented with pain, hand movement vision, a 4- x 4-mm round corneal ulcer, and hypopyon (Figure 1). A corneal scrape was performed
and he was treated with intensive topical antibiotics. KOH mount showed a few fungal hyphae. Topical fluconazole 0.3%, amphotericin B 0.15% eye drops, and systemic fluconazole were initiated. On day 7, he showed no clinical improvement and a scanty growth of Aspergillus fumigatus was reported. A single intracameral irrigation of amphotericin B (0.1 mL of 50 g/mL) was given. Hypopyon disappeared on the 11th day following injection. The epithelial defect healed by day 20 with no recurrence (Figures 2, 3, and 4). Patient 2 A 53-year-old farmer presented in 2004 with pain, hand movement vision, a round corneal ulcer, and a hypopyon following injury with Intracameral Amphotericin B Irrigation for the Treatment of Deep Keratomycosis Kirit K Mody, Priyanka P Doctor, Rahul P Doctor Department of Ophthalmology, Conwest Jain Group of Hospitals, Mumbai, India This report describes the use of amphotericin B given by the intracameral route for 4 patients with keratomycosis not responding to topical and oral antifungals. All patients presented with a fungal ulcer not responding to topical and systemic antifungal medication. Key words: Amphotericin B, Antifungal agents, Corneal ulcer, Keratitis Asian J Ophthalmol. 2006;8:71-3 2006 Scientific Communications International Limited Case Report a plant stalk to his left eye. Topical fluconazole and chloramphenicol eye drops were prescribed. Corneal scraping showed a few fungal hyphae. Growth revealed Aspergillus fumigatus, and topical amphotericin B 0.15% was added to the treatment regimen. After Figure 1. Initial presentation of patient 1. Figure 2. Patient 1 on day 5 after amphotericin B irrigation. Correspondence: Dr Priyanka P Doctor, 62, Chitrakoot, Altamount Road, Mumbai 400 026, India. Tel: (91 22) 2388 1313/098401 81444; E-mail: priyanka.doctor@gmail.com Intracameral Amphotericin B for Deep Keratomycosis Asian J Ophthalmol. 2006 Vol 8 No 2 72 17 days, there was no clinical improvement, so irrigation of intracameral amphotericin B (0.1 mL of 50 g/mL) was given. The ulcer resolved completely on day 25 (Figure 5). Patient 3 An iron foreign body was removed from a 35-year-old man in 2003. He was treated with chloramphenicol eye drops. He sub- sequently developed a 5- x 6-mm corneal ulcer with hypopyon, which was treated with fortified antibiotics. The corneal scrape yielded a scanty growth of Aspergillus fumigatus. He was given amphotericin B 0.15% eye drops and topical and systemic ketoconazole. In view of the deteriorating clinical condition, intracameral amphotericin B (0.2 mL of 50 g/mL) was given 25 days after presentation. The ulcer regressed completely by day 42 and the patient was discharged with topical amphotericin 0.15%. He had a central corneal scar. Patient 4 A 42-year-old man presented with pain, counting fingers vision, and a corneal ulcer in 2003. The corneal scraping showed a few inflammatory cells and hyphae. The patient failed to respond to intensive topical antibiotics and fluconazole. Aspergillus fumigatus was reported and the patient was treated with hourly natamycin and amphotericin B 0.15%. After further deterioration, he was administered intracameral irrigation with amphotericin B (0.2 mL of 50 g/mL) after 2 weeks. The ulcer continued to heal slowly and at final review 1 month later, his vision was 6/12. Discussion Most fungal keratitis is caused by filamentous fungi with the epidemiology varying throughout the world. 2,3 This report describes the use of amphotericin B administered by the intracameral route for keratomycosis not responding to topical and oral antifungal agents. All patients presented with a fungal ulcer not responding to topical and systemic antifungal medication. Intracameral amphotericin B irrigation was administered as 0.1 to 0.2 mL of 50 g in 1 mL. No clinical evidence of lenticular or corneal toxicity was noted. Two patients had an increase in anterior chamber reaction and pain immediately after injection, which improved over a period of 18 hours. The corneal ulcer resolved in all patients. Other modes of treatment for unresponsive keratomycosis include Gundersons flap or therapeutic penetrating keratoplasty. 4 However, the former is technically difficult to perform, 5 while the latter has poor results due to extensive infiltration of the anterior segment by the fungi. 6 Figure 3. Patient 1 on day 20 after amphotericin B irrigation. Figure 5. Patient 2 on day 20 after amphotericin B irrigation. Figure 4. Patient 1 on day 20 after amphotericin B irrigation, shown with fluorescein staining. Mody, Doctor, Doctor Asian J Ophthalmol. 2006 Vol 8 No 2 73 Intracameral amphotericin B irrigation serves the purpose of targeted drug delivery with a relatively lower incidence of drug toxicity and could therefore be useful for the treatment of keratomycosis. References 1. Kuriakose T, Kothari M, Paul P, et al. Intracameral amphotericin B injection in the management of deep keratomycosis. Cornea. 2002; 21:653-6. 2. Thomas PA. Mycotic keratitis: an underestimated mycosis. J Med Vet Mycol. 1994;32:235-54. 3. Thomas PA, Geraldine P, Kaliamurthy J. Current perspectives in mycotic keratitis: diagnosis, management and pathogenesis. In: Srivastava OP, Srivastava AK, Shukla PK, editors. Advances in medical mycology. Vol 2. Lucknow: Evoker Research Perfecting; 1997. p. 111-31. 4. Johns KJ, ODay DM. Pharmacological management of keratomycosis. Surv Ophthalmol. 1988;33:178-88. 5. Alino AM, Perry HD, Kanellopoulos AJ, et al. Conjunctival flaps. Ophthalmology. 1998;105:1120-3. 6. ODay DM. Fungal keratitis. In: Pepose JS, Holland GN, Wilhelmus KR, editors. Ocular infection and immunity. St Louis: Mosby Year-Book; 1996. p. 1048-61. 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