First Author: M.Relimpio Lopez SPAIN
Co Author(s): M. Gessa Sorroche A. Garrido Hermosilla M. Diaz Ruiz J. Montero Iruzubieta
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To present the different evolutions of our experience in the past 10 years and how we have modified our surgical manoeuvres treating endophthalmitis caused by Fusarium solani, an aggressive filamentous fungus with an unsuccessful response to medical treatment and delayed penetrating keratoplasty (PK).
Cornea and Retina Units, Ophthalmology Department, Virgin Macarena University Hospital (Seville, Spain). RETICS OftaRed, Institute of Health Carlos III (Madrid, Spain).
We present our personal experience comparing two cases of endophthalmitis caused by Fusarium solani with an unsuccessful response to topical, intrastromal, intravitreal and systemic antifungal treatment (natamycin, voriconazole, amphotericin B). Once the perforation of the cornea occurred, it was necessary to perform a hot PK thinking that the problem was only in the cornea and maybe in the sclera. In both cases, PK was not sufficient to solve the problem because a microbiological analysis of the lens showed a colonization by Fusarium solani. In our successful case, the problem worsened with an hypopyon, supraretinal colonies and corneal recurrence detected by confocal microscopy, so a second PK and a pars plana vitrectomy (PPV) were performed. The other one was unsuccessfully treated with intravitreal anti-fungal injections, ending up with an evisceration. In the successful case, we developed different procedures to improve our results, such as iridectomy of the suspected infiltrated areas, cauterization of other suspicious lesions, injection of povidone-iodine 5% during 1 minute before exchanging the cornea, aspiration of fungal colonies with vitrector, several air/fluid/amphotericin/voriconazole exchanges during PPV, endodiathermy-endophotocoagulation of chorioretinitis foci and intrascleral angle injections of voriconazole and amphotericin.
These were the only cases of endophthalmitis caused by resistant Fusarium solani to either voriconazole or amphotericin B that were attended to at our hospital during the last 10 years. In both cases, the first surgery failed. The first one ended up with an evisceration in spite of constant medical treatment. In the second one, after all the procedures explained above and despite aphakia, we can say that currently the patient is able to see hand motion and distinguish colours.
Current treatment options for endophthalmitis caused by Fusarium solani are far from being optimal, so extreme medical and surgical procedures were developed in order not to end up with an evisceration to control the infection as it happened 10 years ago with our other patient. The main objectives of these surgical procedures are to control the fungal infection and preserve the ocular globe. It is essential to eliminate all the ocular structures (iris, lens, vitreous, etc.) affected by this strain of fungi in order to reduce the risk of recurrence. Early treatment and appropriate manoeuvres will avoid an evisceration, even recovering some visual acuity in extreme cases as the one presented here.