Intracameral Amphotericin B in Management of Candida Glabrata Keratouveitis after Penetrating Keratoplasty Petra Schollmayer, Aleksandra Kraut, Mojca Globocnik-Petrovic,

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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