Douglas J. Rhee, MD

36B. SPECIFIC ANTIFUNGAL REGIMENSNote on Fungal Keratitis : Although the regimens are given for specific organisms, the major differentiation is between ulcers causedby yeast, for which amphotericin B is the drug of choice, and those caused by mold (most commonly Fusarium), for which natamycin isgenerally the preferred agent. Mechanical debridement of superficial lesions removes necrotic tissue and may aid with antifungal medicationpenetration. Therapeutic penetrating keratoplasty should be considered for progressive disease or deep penetration to prevent developmentof endophthalmitis.(1) Yeast(a) Candidiasis (Candida albicans)C. albicans involvement of eye beyond eyelid skin and conjunctivitis is usually part of systemic involvement; therefore, a systemicevaluation is needed.Notes: 1. Eyelid Skin or Conjunctival Involvement: Fluconazole 400 mg PO QD with food2. Keratitis 1 : Topical amphotericin B drops Q1/2–1 hr occasionally with either oral voriconazole, ketoconazole , itraconazole, orfluconazole . If no improvement, consider PKP. Some advocate addition of flucytosine drops Q1/2–1 hr 2 or voriconazoleQ1 hr.3. Retinitis/Uveitis/Endophthalmitis 3 : Fluconazole 400 mg PO QD for 3 weeks. In resistant cases, may substitute with intravenousamphotericin B 1 mg/kg/day for total dose of 2 gms. Intravitreal amphotericin B 5 µg at time of vitrectomy may also be given.If source is traumatic inoculation, refer to Endophthalmitis, Traumatic. If source is endogenous, refer to Endophthalmitis,Endogerous.(b) Cryptococcus (Cryptococcus neoformans )Must rule out CNS involvement and underlying immunosuppression or AIDS because meningitis is treated differently.