A 45-year-old woman with no history of interest, who after an accidental trauma to the right eye (RE) with a kitchen knife came to the emergency department with red eye symptoms and corneal foreign body sensation.
The initial examination revealed a perforating but self-sealed corneal wound, which was not sutured. No involvement of the crystalline lens or other intraocular structures was observed.
Conservative treatment was initially initiated with a tobramycin-corticoid eye drop (Tobradex®, Alcon Cusí S.A.) every 6 h, but the onset of symptoms was accentuated after 15 days.
At that time, puncture and aqueous humour culture were performed and the diagnosis was made by fresh examination of the culture of exogenous yeast endophthalmitis, possibly Candida sp, due to the germ morphology.
The patient was admitted to the hospital and treated with oral fluconazole (Diflucan®, Pfizer, S.A.; Alcobendas, Madrid, 200 mg/12h), topical colic (0.1% H.A.), and locally-enhanced 1% H.
The condition improved with this treatment and was discharged 15 days after admission, maintaining oral and topical treatments.
During admission and successive visits to outpatient clinics, corneal epithelium scrapings were performed every 2-3 days to improve intraocular penetration of eye drops, whose frequency of administration was reduced paulatin.
Two months after discharge, when eye drops were already administered every 8 h, the patient experienced a recurrence of pain, red eye, tapering of the eye and worsening of visual acuity (VA).
The patient was readmitted and at this time amphotericin B IV (Fungizone®) 60 mg/24 was prescribed for 15 days, keeping the eyedrops reinforced with amphotericin B and administering topical corticosteroids.
However, there was no objective or subjective improvement of the condition in this occasion, with the perikeratic injection persisting and the consolidation path of ++/++++.
On the other hand, during admission, whitish plaques appeared in the anterior lens capsule in three locations, with posterior synechiae of iris to plaques.
Antimicrobial susceptibility testing for this strain was then performed, which resulted in the following: (MIC data in micrograms per milliliter for each drug).
- Amphotericin B: 1.
- 5-fluorocytosine: 0,25.
- Fluconazole: 2.
- Ketoconazole: 0,06.
- Itraconazole: 0,03.
C. coliMI worsened during treatment with intravenous amphotericin B, and it was decided to withdraw it and start treatment with itraconazole oral (concreteril®, ISDIN S.A.) 200 mg/24 h.
After starting this treatment, a slow but progressive improvement of the clinical picture began, with a paulatine disappearance of the inflammatory reaction and symptoms over the following weeks.
In contrast, the plates in the crystalline lens and the synechiae grew somewhat in size and thickness for a while, until they remained stable.
After 5 months of continuous treatment with itraconazole and topical fluconazole at the same doses of admission, there were no recurrences, but the patient's VA decreased to 0.3-0.4, due to changes in crystalline lens.
1.
In an attempt to improve the surgical procedure, the patient was operated, performing, in this order, synechotomy, capsulorhexis, affected AV block, implant areas of acrylic IOL and removal of anterior capsule.
At the end of the surgery, samples were taken for culture of the infusion solution according to the diagnostic criteria, which was negative for bacteria.
After surgery, treatment with itraconazole 100 mg/24 h and topical fluconazole 4 h was continued for 3 months and, in the absence of recurrence and vitreous involvement, the patient was withdrawn.
Ten months after surgery, VA was 1.2, with correction of -1 cil. to 180o and continued without recurrence.
