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B. SPECIFIC ANTI-FUNGAL REGIMENS

Special Note on Fungal Keratitis: Although the regimens are given for specific organisms, the major differentiation is between ulcers caused by yeast—for which amphotericin B is the drug of choice—or mold (most commonly Fusarium)—for which natamycin is generally the preferred agent. Voriconazole is also often effective for yeasts and molds.Mechanical debridement of superficial lesions removes necrotic tissue and may aid with antifungal medication penetration. Therapeutic penetrating keratoplasty should be considered for progressive disease or deep penetration to prevent development of endophthalmitis.

(1) Yeast

(a) Candidiasis (Candidaalbicans)

Candida albicans involvement of eye beyond eyelid skin and conjunctivitis is usually part of systemic involvement; therefore, a systemic evaluation is needed.

Notes: 1) Eyelid skin or conjunctival involvement: fluconazole 400 mg PO QD with food

2)Keratitisd: Topical amphotericin B drops Q 1/2–1 hr occasionally with either oral voriconazole, ketoconazole, itraconazole, or fluconazole. If no improvement, consider PKP. Some advocate addition of flucytosine drops Q 1/2 – 1 hr (Int. Ophthalmol. Clinics Summer 1996; vol 36 (3):1–15) or voriconazole 1% drops Q 1 hr.

3)Retinitis/Uveitis/Endophthalmitisf: fluconazole 400–800 mg PO QD for 4–6 weeks. In resistant cases, may substitute with intravenous amphotericin B 1 mg/kg/day for total dose of 2 gms or Voriconazole 200 mg PO BID. Intravitreal amphotericin B 5 mg at time of vitrectomy may also be given. There are reports of successful use of intravitreal voriconazole (100 mg/0.1 mL) in Candidal endophthalmitis (Am J Ophthalmol 2005;139:135). If source is traumatic inoculation, refer to endophthalmitis – traumatic in the subject index. If source is endogenous, refer to endophthalmitis – endogenous in the subject index.

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(b) Fusarium (filamentous fungus, septate hyphae)

Notes: 1) Keratitisd: First choice topical agent is natamycin every 30 min to 1 hr for first two days; second line topical agents are voriconazole, miconazole, or flucytosine.

(c) Mucormycosisf (Zygomycosis) (filamentous fungus, nonseptate hyphae)

Notes: 1) Keratitisd/Endophthalmitisf: Due to the highly invasive nature, would recommend local treatment with topical amphotericin B and systemic amphotericin B. Consider surgical debridement.

2)Orbital infectionf: Use intravenous amphotericin B; may require surgical debridement with topical amphotericin B washings.

(3)Dimorphic Fungi

(a) Blastomycosisf (Blastomyces dermatitidis)

Notes: 1) Granulomatous Blepharoconjunctivitis: Itraconazole 200 mg PO QD or voriconazole 200 mg PO BID 6 months. All extrapulmonary blastomycosis needs to be treated systemically. With severely ill patients, consider systemic amphotericin B.

2)Keratitisd: As above with addition of topical voriconazole or miconazole drops.

(b)Coccidioidomycosisf (Coccidioides immitis)

Note: May get phlyctenular conjunctivitis, episcleritis, or scleritis as part of symptomatic primary infection syndrome ‘‘Valley Fever’’. These are self limited and do not require treatment since they are felt to be a hypersensitivity reaction to coccidiodal antigens.

1)Posterior Uveitis: Many times, involvement is asymptomatic and resolve spontaneously. Symptomatic involvement (e.g. chronic granulomatous iridocyclitis, choroiditis, and retinitis) is usually associated with progressive systemic coccidiomycosis. Life threatening disease, such as meningeal involvement, is treated with IV amphotericin B. Non life threatening disease may be treated with fluconazole 400–600 mg PO QD 9–12 months or voriconazole 200 mg PO BID 9–12 months, or itraconazole 200 mg PO BID 9–12 months.