We describe two patients with fungal keratitis refractory to standard antifungal therapy whose conditions were managed with voriconazole. The first case is a patient with endophthalmitis and corneal ulcer due to Candida parapsilosis after receiving a corneal transplant. The patient was treated with amphotericin but showed no signs of improvement. Topical voriconazole, oral voriconazole, and intravitreal voriconazole yielded signs of improvement. The second case is a 63-year-old male who underwent a month of empiric treatment with 0.2% topical amphotericin for fungal keratitis but showed no signs of improvement. Treatment was then provided with 1% voriconazole. Both cases showed effective treatment with voriconazole. Voriconazole may be considered as a new method to treat fungal keratitis refractory to standard antifungal therapy.
Administration, Oral ; Antifungal Agents/*administration & dosage ; Candidiasis/diagnosis/*drug therapy/microbiology ; Cornea/microbiology/pathology ; Diagnosis, Differential ; Dose-Response Relationship, Drug ; Eye Infections, Fungal/diagnosis/*drug therapy/microbiology ; Follow-Up Studies ; Humans ; Keratitis/diagnosis/*drug therapy/microbiology ; Male ; Middle Aged ; Ophthalmic Solutions ; Pyrimidines/*administration & dosage ; Triazoles/*administration & dosage

A 59-year-old woman was referred to our clinic with sudden visual loss in her right eye after she was treated with 40 mg/day of oral prednisolone for 2 weeks under the diagnosis of idiopathic optic neuritis. At that time, computerized tomography (CT) of the brain showed no evidence of optic nerve or brain pathology. However, there was progressive diminution of right visual acuity associated with a limitation of adduction and abduction in the right eye. On magnetic resonance imaging and repeated CT, a malignant lesion was suggested, and was confirmed as an Aspergillus fungus colony by histopathologic examination. Postoperatively, she was treated with intravenous administration of amphotericin B for 13 weeks. However, her condition continued to deteriorate. She developed ptosis and total ophthalmoplegia in the right eye and blindness in both eyes. After discharge, she was given itraconazole for 20 weeks. She has shown no recovery of visual acuity or extraocular motion during a two-year follow-up period. The clinical features of our case suggest that early diagnosis in a case of aspergilloma presenting with visual loss is difficult and that a high index of suspicion, repeated radiological examination and adequate biopsy may be required for diagnosis.
Amphotericin B/therapeutic use ; Antifungal Agents/therapeutic use ; Aspergillosis/diagnosis/drug therapy/*microbiology ; Blindness/etiology ; Diagnosis, Differential ; Eye Infections, Fungal/diagnosis/drug therapy/*microbiology ; Female ; Human ; Itraconazole/therapeutic use ; Magnetic Resonance Imaging ; Middle Aged ; Optic Neuritis/diagnosis/drug therapy/*microbiology ; Visual Acuity

A 54-yr-old male, who was treated by chemotherapy for gastric cancer 15 months ago, presented to Yongdong Severance Hospital, Seoul, with complaints of pain in his right eye caused by a foreign body from the ground in the previous week. He had been treated with topical and oral antibacterial in addition to antifungal agents, but did not show significant clinical improvement. After a positive corneal culture with mold, topical amphotericin B was added to the initial regimen. The mold was identified as Scedosporium apiospermum by macroscopic and microscopic morphologies and the nucleotide sequences of a fungal PCR product showing 99% homology with those of S. apiospermum (EF151349). He recovered with good results at 25 days after corneal epithelial debridement. The early diagnosis of S. apiospermum keratitis is very important for proper treatment. It is recommended that molecular diagnostic methods such as fungal PCR and sequencing be done with conventional cultures whenever a fungal infection is suspected.
Amphotericin B/therapeutic use ; Anti-Bacterial Agents/therapeutic use ; Antifungal Agents/therapeutic use ; Cornea/microbiology ; Drug Therapy, Combination ; Eye Infections, Fungal/*diagnosis/microbiology ; Humans ; Keratitis/*diagnosis/microbiology ; Male ; Middle Aged ; Polymerase Chain Reaction ; Scedosporium/genetics/growth & development/*isolation & purification ; Sequence Analysis, DNA