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 µ g 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 ICAMB2 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/mm 2. 1 year after ICAMB-clear graft

Endothelial cell density: Before ICAMBAfter 1 monthAfter 2 months After almost 2 years ECD (cells/mm 2 ) BSCVACF 2m ICAMB = intracameral amphotericin B ECD = endothelial cell density BSCVA = best spectacle corrected visual acuity CF = counting fingers IVTCA = 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 endophthalmitis 1-6. ICAMB is generally considered effective and safe 2. Reported side effects, which are rare: postoperative pain and anterior chamber inflammation 3, anterior subcapsular cataract 2. 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 case 1 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.

References 1.Yoon KC, Jeong IY, Im SK, Chae HJ, Yang SY. Therapeutic Effect of Intracameral Amphotericin B Injection in the Treatment of Fungal Keratitis. Cornea 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 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 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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