Mody, Doctor, Doctor

Asian J Ophthalmol. 2006 Vol 8 No 2 71

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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