We appreciate the interest in and comments about our article. To evaluate posterior segment in patients with opaque media, ocular echography is a useful instrument. In our patients, ocular echographic examination was performed routinely when the retina could not be viewed directly. In Patient 1, a descemetocele and corneal leukoma resulted in poor visual acuity. The visual outcomes in Patients 2 and 5 resulted from advanced glaucoma and retinal detachment, respectively.
Most cases of fungal endophthalmitis contiguously spreading from keratitis tend to be more localized with the fungal mass, and inflammation often is confined to the anterior chamber, pupillary space, or anterior vitreous. In such cases, repeated injections of intracameral voriconazole may be an effective treatment. We agree that invasion and replication of fungal filaments into the vitreous may occur in postkeratitis fungal endophthalmitis, which is mainly diagnosed based on positive results from culture of vitreous samples. Injection of intravitreal voriconazole with or without vitrectomy should be performed in case of suspected vitreous invasion.
The role of the lens in preventing fungi from invading the posterior segment could not be determined in this study. First, patients in the current series all had phakic eyes. Second, the small number of cases was insufficient for statistical analysis.
It has been shown that the depth and volume of the anterior chamber diminishes with age. Male subjects have larger anterior chamber dimensions than female subjects. The volume of the anterior chamber is approximately 0.3 mL in the phakic eye and probably increases to approximately 0.5 mL in the pseudophakic eye. An in vitro study has shown that no corneal endothelial toxicity could be detected after 30 days of treatment with 250 μg/mL of voriconazole. Even concentrations of up to 1 mg/mL had no influence on corneal endothelial cells and primary human trabecular meshwork cells when administered for 24 hours. With the normal volume of the aqueous humor in the phakic eye assumed to be 0.3 mL, the injected dose of 100 μg/0.1 mL in the anterior chamber resulted in an initial aqueous concentration of 250 μg/mL. The peak levels achieved in the anterior chamber thus were more than 250 times the minimum inhibitory concentration of voriconazole to Candida and Aspergillus species. Moreover, no endothelial toxicity occurred with such a concentration of voriconazole.