Ocular toxicity of voriconazole: a case report and review of litterature

Purpose Voriconazole is an antifungal therapy widely used for invasive fungal diseases, particularly in aspergillosis. Methods We report a 77 year-old man treated by voriconazole (100mg twice a day) for a pulmonary aspergillosis. Three days after voriconazole initiation, he complained of visual disorders such as dyschromatopsia and visual hallucinations. Visual acuity was measured at 10/10 in both eyes. Goldman visual field found a bilateral enlarged blind spot. Color vision was assessed using the Lanthony desaturate panel D 15 test, and demonstrates disorders along the tritan confusion axe for the left eye. The multifocal electroretinogram (mfERG) found a global decrease of the foveal peak on both eyes. Visual Evoked Potentiel (VEP) showed asymetric data and lower amplitudes of the P(100) wave on the left eye. Results In a first time, according to the dose dependant toxicity, it was decided to reduce the voriconazole dose to 50 mg twice a day. In spite of this, visual acuity decreased at 8/10 in the left eye and visual field worsed. Voriconazole was then switched with itraconazole (SPORANOX). The outcome was improved one month after, visual field and mfERG were better, visual hallucinations disappeared. Conclusion Voriconazole ocular toxicity is not well known and few publications exist on this topic. Visual hallucinations, dose dependant macular toxicity, reversible disorders were described. On our knowledge we report the first case of combined macular and optical nerve dysfonction. This case suggests that voriconazole can induce reversible macular and optical nerve dysfunctions if the treatment is early stopped. Visual symptoms must be checked and patients reffered to ophthalmology.