Clearance of Intravitreal Voriconazole
`
`Ying-Cheng Shen,1,2 Mei-Yen Wang,3 Chun-Yuan Wang,1,4 Tsun-Chung Tsai,3
`Hin-Yeung Tsai,1,4 Yi-Fen Lee,1 and Li-Chen Wei1
`
`PURPOSE To investigate the elimination rate of voriconazole
`after intravitreal injection in rabbits.
`METHODS. Intravitreal injections of 35 ␮g/0.1 mL voriconazole
`were administered to rabbits. Vitreous and aqueous humor
`levels of voriconazole were determined at selected time inter-
`vals (1, 2, 4, 8, 16, 24, and 48 hours), and the in vitreous
`half-life was calculated. Four to six eyes per time point after
`injection were enucleated and immediately stored at – 80°C.
`Aqueous humor samples were withdrawn before enucleation,
`and vitreous samples were obtained from ocular dissection and
`isolation at various time intervals. Voriconazole concentrations
`in vitreous and aqueous humor were assayed with high-perfor-
`mance liquid chromatography (HPLC).
`RESULTS. The concentration of intravitreal voriconazole at var-
`ious time points exhibited exponential decay with a half-life of
`2.5 hours. The mean vitreous concentration was 18.912 ⫾
`2.058 ␮g/mL 1 hour after intravitreal injection; this declined to
`0.292 ⫾ 0.090 ␮g/mL at 16 hours. The mean aqueous concen-
`tration was much lower and showed a decline from 0.240 ⫾
`0.051 ␮g/mL at 1 hour to undetectable levels 8 hours after
`injection.
`CONCLUSIONS. Vitreous concentrations achieved during the first
`8 hours were greater than the previously reported minimum
`inhibitory concentrations (MICs) of organisms most involved in
`fungal endophthalmitis. A rapid decline of intravitreal concen-
`tration suggests that supplementation of intraocular voricon-
`azole to maintain therapeutic levels may therefore be required
`in clinical settings. Further studies are needed to determine the
`elimination rate of voriconazole after intravitreal injection in
`humans. (Invest Ophthalmol Vis Sci. 2007;48:2238 –2241)
`DOI:10.1167/iovs.06-1362
`
`F ungal endophthalmitis, a serious, sight-threatening infec-
`
`tion, is often a complication of intraocular surgery, sys-
`temic infection, and ocular trauma. The most common organ-
`isms encountered in fungal endophthalmitis are Candida,
`Aspergillus, and Fusarium species. Intravitreal antibiotics are
`a mainstay of treatment for fungal endophthalmitis. In the past,
`amphotericin B was the only antifungal agent approved for
`intravitreal injection. However, amphotericin B may cause ret-
`inal necrosis at low concentrations, and a variety of fungal
`
`From the 1Department of Ophthalmology, Taichung Veterans
`General Hospital, Taiwan, Republic of China; 2Overseas Chinese Insti-
`tute of Technology, Taichung, Taiwan, Republic of China; 3Depart-
`ment of Food Science, Tunghai University, Taiwan, Republic of China;
`and 4Hung Kuang University, Taiwan, Republic of China.
`Submitted for publication November 12, 2006; revised December
`26, 2006; accepted March 5, 2007.
`Disclosure: Y.-C. Shen, None; M.-Y. Wang, None; C.-Y. Wang,
`None; T.-C. Tsai, None; H.-Y. Tsai, None; Y.-F. Lee, None; L.-C. Wei,
`None
`The publication costs of this article were defrayed in part by page
`charge payment. This article must therefore be marked “advertise-
`ment” in accordance with 18 U.S.C. §1734 solely to indicate this fact.
`Corresponding author: Li-Chen Wei, Department of Ophthalmol-
`ogy, Taichung Veterans General Hospital, Taiwan, ROC, No. 160,
`Section 3, Taichung Harbor Road, Taichung, Taiwan, Republic of
`China; eric550131@yahoo.com.tw.
`
`2238
`
`species showing resistance to it have been reported.1 Voricon-
`azole, a second-generation triazole, differs from fluconazole by
`the addition of a methyl group to the propyl backbone and by
`the substitution of a triazole moiety with a fluoropyrimidine
`group, resulting in a marked change in activity.2 Voriconazole
`has excellent bioavailability and reaches peak plasma concen-
`tration 2 to 3 hours after oral dosing. The intraocular penetra-
`tion of orally administered voriconazole in the noninflamed
`human eye was found to be 1.13 ⫾ 0.57 ␮g/mL and 0.81 ⫾
`0.31 ␮g/mL in the aqueous and vitreous, respectively.3 Previ-
`ous studies have shown voriconazole to have a broad-spectrum
`of activity against Aspergillus species, Candida species, Pae-
`cilomyces lilacinus, Cryptococcus neoformans, Scedosporium
`species, and others. Furthermore, voriconazole has been
`shown to be effective as primary therapy in the treatment of
`invasive aspergillosis, and it is an effective salvage therapy for
`refractory infections caused by Fusarium species.4 Recently,
`in an experimental study in rat, intravitreal voriconazole has
`been shown to be less toxic to the retina than intravitreal
`amphotericin B.5 More recently, a clinically successful treat-
`ment of endogenous Aspergillus endophthalmitis with intrav-
`itreal voriconazole injection has been reported.6 The purpose
`of this study was to determine the clearance of voriconazole
`after intravitreal injection and thereby the clinical relevance of
`intravitreal voriconazole in the management of fungal endoph-
`thalmitis.
`
`METHODS
`
`Materials
`
`Voriconazole (VFEND; Pfizer, Inc., New York, NY) was obtained in
`pure powder form and reconstituted in sterile water to obtain a
`concentration of 35 ␮g/0.1 mL. Seventeen New Zealand White rabbits,
`each weighing 2 to 2.5 kg, were acclimated for at least 1 week under
`standardized temperature (25°C–28°C), humidity (50%– 60%), and light
`(12 hours light/12 hours dark) conditions before experimentation. All
`care and handling of rabbits was performed in accordance with ARVO
`Statement for the Use of Animals in Ophthalmic and Vision Research
`and with the approval of the Institutional Authority for Laboratory
`Animal Care at Taichung Veterans General Hospital.
`Rabbits were anesthetized with a mixture of ketamine hydrochlo-
`ride (35 mg/kg; Fort Dodge Animal Health; Wyeth, Madison, NJ) and
`xylazine (5 mg/kg; Phoenix Scientific, Inc., St. Joseph, MO) intramus-
`cularly in the hindquarter. Both eyes of each rabbit were included in
`the experiment. Anterior chamber paracentesis was performed, fol-
`lowed by an injection of 35 ␮g voriconazole in 0.1 mL sterilized
`distilled water at a site 3 mm posterior to the limbus. Treatment was
`administered using a 30-gauge needle attached to a regular insulin
`syringe with the bevel positioned upward in the midvitreous of the
`eyes, slowly and under direct visualization. A cotton tip applicator was
`applied to the injection site immediately after removal of the needle to
`prevent fluid reflux from the injection site. Mydriasis was achieved
`with two to three drops of tropicamide 1%, and the fundus was
`examined with indirect ophthalmoscopy before and after injections.
`Aqueous humor samples were obtained with a 30-gauge needle, and
`the sampling was performed on two to three rabbits at each time
`interval (1, 2, 4, 8, 16, 24, and 48 hours) after injection and before
`enucleation of the eyes. Rabbits were killed with lethal cardiac injec-
`
`Investigative Ophthalmology & Visual Science, May 2007, Vol. 48, No. 5
`Copyright © Association for Research in Vision and Ophthalmology
`
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`IOVS, May 2007, Vol. 48, No. 5
`
`Clearance of Intravitreal Voriconazole
`
`2239
`
`tions of pentobarbital sodium and phenytoin sodium (Beuthanasia-D;
`Schering Animal Health, Kenilworth, NJ). Four to six eyes per time
`interval up to 48 hours and both eyes of an additional control rabbit
`were enucleated on the same day and immediately frozen at – 80°C.
`The eyes were dissected while frozen, and the entire vitreous was
`isolated according to the technique described by Abel and Boyle.7
`Vitreous of the control eyes was isolated to obtain standardization
`curves for high-performance liquid chromatography (HPLC) analyses.
`Assays of voriconazole concentration in vitreous and aqueous humor
`samples were performed with HPLC.
`
`HPLC Analysis
`Analysis of the samples was performed in a masked fashion. Rabbit
`vitreous samples and voriconazole standard (150 ␮L) were each pre-
`treated with the addition of 600 ␮L of 100% acetonitrile, followed by
`vortex mixing at high speed for 1 minute at room temperature. The
`mixtures were centrifuged in a microultracentrifuge (CS 120 GX;
`Hitachi, Tokyo, Japan) at 45,000 rpm for 30 minutes at 4°C. Superna-
`tant (450 ␮L) was transferred to a clean tube and dried in a centrifugal
`vacuum concentrator (Speed Vac Plus SC110; Savant Instrument Inc.,
`Holbrook, NY). Samples for injection were redissolved in 120 ␮L of
`20% acetonitrile containing 0.1% trifluoroacetic acid (TFA) followed by
`1 minute of vortex mixing. Insoluble particles were removed by ultra-
`centrifugation at 45,000 rpm for 30 minutes at 4°C. Samples of aqueous
`humor (90 ␮L) were extracted with 450 ␮L of 100% acetonitrile, and
`450 ␮L supernatant was taken for drying after ultracentrifugation. After
`drying, the samples were redissolved in 90 ␮L of 20% acetonitrile
`containing 0.1% TFA.
`Samples were analyzed with an HPLC system including a gradient
`HPLC pump (Aligent 1100; Hewlett-Packard, Waldbronn, Germany)
`and an optical detector (UV-VIS; S-3702; Soma, Honshu, Japan) inter-
`faced to an integrater (D-2500 Chromato-integrater; Hitachi, Tokyo,
`Japan). Gradient eluting system was 0.1% TFA in deionized water
`(buffer A) compared with 0.1% TFA in acetonitrile (buffer B) with a
`flow rate of 1.0 mL/min. A 20-␮L volume of each sample was injected
`onto an RP-column (Lichrospher 100RP-18e, 250 mm ⫻ 4 mm, 5 ␮m;
`Aligent Technologies), pre-equilibrated with 20% buffer B, and vori-
`conazole was eluted with a linear gradient of acetonitrile (20%–50%
`containing 0.1% TFA) in 30 minutes. Voriconazole was monitored by
`absorbance at 257 nm and identified by coinjection with standard.
`Voriconazole was found to have a tR of 21 minutes, with no interfer-
`ence from the sample background. The area of the voriconazole peak
`after baseline subtraction was calculated and compared with the area
`versus mass curve for the standard to quantify the amounts of voricon-
`azole in the samples. The standard curve was linear to 1.0 ␮g/mL
`(correlation coefficient, 0.9997; range, 0.2–10.0 ␮g/mL), and the de-
`tection limit was estimated to be approximately 0.1 ␮g/mL (signal-to-
`noise ratio greater than 2). Samples with higher voriconazole outside
`the linear range were properly diluted with 20% acetonitrile for further
`HPLC analysis.
`
`RESULTS
`
`Indirect ophthalmoscopy of the rabbit eyes revealed no retinal
`damage, hemorrhage, or detachment after intravitreal injection
`of 35 ␮g/0.1 mL voriconazole. Mean voriconazole levels mea-
`sured for vitreous and aqueous humor at all sampling times are
`listed in Table 1. The vitreous concentration declined rapidly
`with time. Mean vitreous concentration was 18.912 ⫾ 2.058
`␮g/mL 1 hour after injection and declined to 7.406 ⫾ 1.783
`␮g/mL at 4 hours and 0.292 ⫾ 0.090 ␮g/mL at 16 hours,
`respectively. An exponential decay model was used to fit the
`data, and least-square regression analysis was performed. The
`elimination half-life was calculated from the slope of the line of
`log concentration versus time. The vitreous voriconazole con-
`centration showed an exponential decay, with a half-life of 2.5
`hours. Mean aqueous concentration was much lower and
`
`TABLE 1. Measured Vitreous and Aqueous Levels of Voriconazole at
`Different Time Intervals after Intravitreal Injection of 35 ␮g/0.1 mL
`in Rabbits
`
`Time (h)
`
`Vitreous
`Concentration (n)
`
`Aqueous
`Concentration (n)
`
`1
`2
`4
`8
`16
`24
`48
`
`18.912 ⫾ 2.058 (4)
`13.702 ⫾ 1.519 (4)
`7.406 ⫾ 1.783 (6)
`2.351 ⫾ 0.680 (6)
`0.292 ⫾ 0.090 (4)
`0.000 ⫾ 0.000 (4)
`0.000 ⫾ 0.000 (4)
`
`0.240 ⫾ 0.051 (4)
`0.187 ⫾ 0.066 (4)
`0.127 ⫾ 0.008 (2)*
`0.000 ⫾ 0.000 (6)
`0.000 ⫾ 0.000 (4)
`0.000 ⫾ 0.000 (4)
`0.000 ⫾ 0.000 (4)
`
`Concentrations of voriconazole were given in ␮g/mL (mean ⫾ SD).
`* Four aqueous samples were below the detection limit (0.1 ␮g/
`mL) 4 hours after injection.
`
`showed a decline from 0.240 ⫾ 0.051 ␮g/mL at 1 hour to
`undetectable levels 8 hours after injection.
`
`DISCUSSION
`
`Fungal endophthalmitis is of great concern because of its rising
`incidence, evident severity, and ominous prognosis even with
`prompt treatment. The difficulty in treatment results from a
`combination of the growth characteristics of fungi, a scarcity of
`effective antifungal agents, and their poor tissue penetration.
`Exogenous
`fungal endophthalmitis
`results
`from surgery,
`trauma, or contiguous spread from keratitis. In contrast, en-
`dogenous fungal endophthalmitis is usually associated with
`immunosuppressive therapy and intravenous infusion from in-
`dwelling catheters. Successful treatment of endophthalmitis
`includes the prompt use of an effective antimicrobial regimen.
`Currently, the treatment options for fungal endophthalmitis are
`limited, and the susceptibility of fungus species is variable. The
`antifungal agent used most often to treat fungal endophthalmi-
`tis is amphotericin B. In vitro activities of amphotericin B are
`variable, with minimum inhibitory concentrations (MICs) rang-
`ing from less than 0.5 ␮g/mL to 6.73 ␮g/mL.8 However, the
`effects created in the laboratory are not necessarily applicable
`to the vitreous cavity in vivo. Drug levels required in endoph-
`thalmitis to eradicate the infecting organisms may be much
`greater than MICs.9 Furthermore, a variety of fungus species,
`including Candida tropicalis, Aspergillus terreus, Scedospo-
`rium, and Fusarium isolates, have shown resistance to am-
`photericin B.1,10 These studies support the necessity of a prom-
`ising and safe intravitreal antibiotic regimen to achieve
`adequate drug levels for the management of fungal endoph-
`thalmitis.
`Voriconazole is a broad-spectrum antifungal agent that in-
`hibits the fungal enzyme cytochrome P450 demethylase. In
`vitro studies have shown voriconazole MIC ranges of 0.06 to
`0.25 ␮g/mL for Candida species, 0.5 ␮g/mL for Aspergillus
`species, and 0.5 to 8 ␮g/mL for Fusarium oxysporum and
`Fusarium solani.8,11–14 Voriconazole exhibited non– concen-
`tration-dependent activity in an in vitro time-kill study, suggest-
`ing that maximizing the duration of exposure of a fungus to
`voriconazole would optimize the fungistatic activity of vori-
`conazole.15 Although individual case reports demonstrate
`the successful use of oral voriconazole, alone or combined
`with caspofungin, to treat fungal endophthalmitis, systemic
`administration achieves a vitreous concentration lower than
`therapeutic levels of some filamentous fungi, particularly
`Fusarium species.16 –20 It has recently been determined that
`an intravitreal injection of voriconazole of up to 25 ␮g/mL of
`final intravitreal concentration causes no electroretinographic
`changes or histologic abnormalities in rat retina.5 Kramer6
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`2240
`
`Shen et al.
`
`IOVS, May 2007, Vol. 48, No. 5
`
`described the first successful treatment of endogenous As-
`pergillus endophthalmitis using one intravitreal voriconazole
`injection. Sen et al.21 also presented intravitreal voriconazole
`injections for the treatment of fungal endophthalmitis caused
`by Aspergillus flavus, Scedosporium apiospermum, and
`Fusarium species. Because intraocular injections of voricon-
`azole have been increasingly used in the treatment of fungal
`endophthalmitis, studies of the postinjection kinetics of the
`drug assume increasing importance. We sought to determine
`the elimination rate of intravitreal voriconazole in rabbits and
`to determine how often administration is required to maintain
`therapeutic levels in vitreous.
`The elimination half-life of a drug in a vitreal cavity depends
`on two pathways, the anterior route passage into the aqueous
`and the posterior route by active transport across the retina.
`Drugs such as penicillin and ␤-lactam antibiotics eliminated
`from vitreous cavities with the use of a retinal pump mecha-
`nism have shorter elimination half-lives than drugs cleared
`through the anterior chamber.22,23 Given the rapid clearance
`rate and the low aqueous concentrations achieved, our data
`suggest that voriconazole is eliminated primarily through the
`posterior route. Aphakia, vitrectomy, and inflamed eyes create
`different effects on the clearance of the drug from the vitreous
`cavity. In the inflamed eye, the mechanism of active transport
`across the retina is compromised, resulting in increased half-
`lives of drugs eliminated primarily through a posterior route.24
`Aminoglycoside antibiotics and vancomycin, in contrast, are
`thought to be cleared by passive transport by way of the
`anterior route and the decreased retention resulting from in-
`flammation.25,26 Drug elimination is faster in inflamed aphakia
`eyes than in inflamed phakia eyes. Similarly, more rapid clear-
`ance of drugs from eyes after vitrectomy has been demon-
`strated for amphotericin B and fluorouracil.27–30
`Assuming the normal volume of the vitreous in rabbit to be
`1.4 mL, the injected dose of 35 ␮g/0.1 mL in rabbit eyes results
`in a vitreous concentration of 23.33 ␮g/mL. Peak vitreous
`levels achieved were thus approximately 50 to 100 times the
`MICs of voriconazole to Candida and Aspergillus species. Even
`with Fusarium species, intravitreal voriconazole achieved an
`effective inhibitory concentration. In contrast, the voricon-
`azole levels achieved were low in aqueous humor. Our study
`showed rapid decline of the vitreous concentration and expo-
`nential decay, with a half-life of 2.5 hours. In such cases,
`vitreous levels will be below the MICs of most fungi by 16
`hours, and supplementation of intraocular voriconazole may
`be required in clinical settings. Fortunately, drug elimination
`has been noted to be slower in humans than in rabbits. Elim-
`ination of voriconazole from the serum has been reported to
`have a half-life of 2.5 to 3 hours in rabbits compared with 6.5
`hours in humans.31,32 The clearance of intravitreal voricon-
`azole in our data was close to the previously reported serum
`elimination rate in rabbits. Additional studies are needed to
`determine whether the half-lives of voriconazole in human
`vitreous and serum are similar; if so, a slower elimination rate
`of vitreous voriconazole would be expected in humans.
`In summary, the clearance of voriconazole after intravitreal
`injection was determined to have an elimination half-life of 2.5
`hours. Considerably low voriconazole levels in aqueous humor
`after injection were shown in the study. Vitreous concentra-
`tions achieved during the first 8 hours were greater than the
`previously reported MICs of organisms most involved in fungal
`endophthalmitis. A rapid decline of intravitreal concentration
`suggests that the supplementation of intraocular voriconazole
`to maintain therapeutic levels may be required in clinical set-
`tings. Further studies are needed to determine the vitreous
`elimination rate in humans.
`
`Acknowledgments
`
`The authors thank the Biostatistics Task Force of Taichung Veterans
`General Hospital, Taichung, Taiwan, Republic of China, for statistical
`assistance.
`
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