Endogenous Aspergillus endophthalmitis. Clinical features and treatment outcomes

Endogenous endophthalmitis: a 10-year review of culture-positive cases in northern China

PURPOSE

The aim of this study was to report the clinical features and treatment outcomes in a series of patients with endogenous endophthalmitis treated over a 10-year period in a single hospital in northern China.

METHODS

The authors conducted a retrospective chart review of 19 patients (23 eyes) treated for culture-proven endogenous endophthalmitis at the First Hospital of China Medical University between 1998 and 2007.

RESULTS

Patients were followed up for a mean of 15.9 months (range: 0.5-41 months). The main systemic predisposing risk factors were diabetes mellitus (52.6%), immunosuppressive therapy (36.8%), and malignancies (31.6%). Fungal isolates were present in 14 eyes (60.9%), gram-positive isolates in 8 eyes (34.8%), and gram-negative isolates in 1 eye (4.3%). All patients received intravenous antibiotics or antifungal agents, and other treatments included injection of intravitreal medication in 7 eyes (30.4%) and pars plana vitrectomy with injection of intravitreal medication in 14 eyes (60.9%). Final visual outcomes were obtainable for 21 eyes (one patient died 15 days after diagnosis). Ten (47.6%) of these 21 eyes achieved a visual acuity of 20/400 or better, and 11 (52.4%) achieved a visual acuity worse than 20/400, including 5 that were eviscerated. The median visual acuity was counting fingers (range: 20/25 to no light perception). Eyes with endophthalmitis caused by Candida species tended to have better visual outcomes than did eyes with bacterial and Aspergillus causes.

CONCLUSIONS

Similar to the findings of previous studies, this study showed that fungi, especially Candida species, were the most common causative organisms of endogenous endophthalmitis. Endogenous endophthalmitis is generally associated with poor visual acuity outcomes, particularly when caused by more virulent species of fungi, such as Aspergillus.

A case of aspergillus endophthalmitis in an immuncompetent woman: intra-ocular penetration of oral voriconazole: a case report

Background

There are very few reports of Aspergillus fumigatus causing endogenous endophthalmitis (EAE) in immunocompetent individuals although it is well recognised in the immunocompromised. Treatment can be with intravitreal, intravenous and oral antifungal agents. The benefit of an oral agent is clear however the concentration of voriconazole in the inflamed eye after oral administration has not previously been documented.

Case presentation

We present a case of EAE in an immunocompetent 78-year-old Caucasian female who was subsequently managed with oral voriconazole. Using a bioassay, we show an appropriate voriconazole concentration in serum and vitreous samples.

Conclusion

This case adds to the limited literature on the prevalence of endogenous endophthalmitis in immunocompetent patients and supports the use of voriconazole in such cases.

Bilateral simultaneous endogenous Aspergillus endophthalmitis in an immunocompetent patient

PURPOSE

To report a case of bilateral endogenous Aspergillus endophthalmitis in an immunocompetent patient.

METHODS

We report a young immunocompetent 26-year-old Indian woman who presented with bilateral simultaneous endogenous endophthalmitis and was managed with pars plana vitreous surgery in both the eyes.

RESULTS

Smear examination of the vitrectomy specimen from the left eye identified septate hyphae with acute-angle branching, which on culture showed growth of Aspergillus fumigatus. A detailed systemic evaluation failed to reveal any systemic focus or predisposing factor for fungal infection. The patient had received an intravenous dextrose infusion 2 weeks before this episode while being treated at a rural hospital for malarial infection. During follow-up, she developed bilateral rhegmatogenous retinal detachment requiring revised pars plana vitreous surgery with silicon oil tamponade.

CONCLUSION

An immunocompetent patient can present with bilateral simultaneous endogenous Aspergillus endophthalmitis after receiving an intravenous infusion of presumably contaminated dextrose solution.

Intravitreal injection of therapeutic agents

BACKGROUND

Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study.

METHODS

A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated.

RESULTS

The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects.

CONCLUSION

The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.

Aspergillus iris granuloma: a case report with review of literature

We report the case of a 25-year-old male patient who presented with complaints of redness, photophobia, and decreased vision in the right eye of a week's duration. Slit-lamp biomicroscopic examination revealed a cream-colored, irregular elevated inferior iris mass, extending on to the anterior lens surface. Differential diagnoses of a fungal granuloma, a medulloepithelioma, and an amelanotic melanoma were considered. An excisional biopsy of the mass was performed through a superior clear corneal incision. Polymerase chain reaction analysis of the aqueous humor showed a positive pan fungal genome. Histopathology of the biopsied mass showed a giant cell granuloma with surrounding numerous branching, septate hyphae. Culture growth revealed Aspergillus fumigatus We report this case because of the rarity of Aspergillus iris granuloma as a primary presentation of endogenous Aspergillosis and review the relevant literature. Absence of a significant systemic history compounded the diagnostic dilemma in our patient. Definitive differentiation of this rare entity from a foreign body, amelanotic melanoma, and other inflammatory conditions such as sarcoidosis and tuberculosis, may be possible only on microbiological and histo-pathological evaluation.

Endogenous Candida albicans infection causing subretinal abscess

PURPOSE

We report a case of Candida albicans endophthalmitis with subretinal abscess formation in a patient who underwent liver transplantation.

METHODS

Case report.

RESULTS

A 51-year-old Japanese woman complained of deep pain and ciliary injection in her right eye. Three months prior, the patient had undergone liver transplantation for cirrhosis caused by hepatitis C. A slit-lamp examination revealed intense anterior chamber inflammation with hypopyon and fundoscopy showed a yellowish-white subretinal mass lesion in the inferior peripheral fundus. Systemic and topical antibiotics did not prevent further progression of the infection. The patient underwent pars plana vitrectomy treatment three times and a histopathological study of a vitreous specimen revealed C. albicans to be the causative organism.

CONCLUSION

A subretinal abscess, previously reported in Nocardia, Pseudomonas, Staphylococcus, and Aspergillus infection cases, can also occur in patients infected with Candida. Therefore, Candida infection should be considered as a potential cause of subretinal abscess in organ transplant recipients.

Fungal endophthalmitis: fourteen years' experience from a center in India

BACKGROUND

As fungal endophthalmitis is an emerging challenge, the study was carried out to determine the prevalence and the spectrum of fungal agents causing endophthalmitis from a single center, to identify the risk factors, and to correlate clinical course of illness with the agents involved.

METHODS

The microbiological and clinical records of all fungal endophthalmitis diagnosed during January 1992 through December 2005 at a tertiary center in India were reviewed retrospectively. During this period, treatment protocol of the patients with fungal endophthalmitis was pars plana vitrectomy, instillation of intravitreal amphotericin B (5 microg) and dexamethasone (400 microg). Additionally, oral fluconazole (27 patients) or itraconazole (78 patients) was given in 105 patients.

RESULTS

Fungal endophthalmitis was diagnosed in 113 patients and they were categorized into: postcataract surgery (53 patients), posttrauma (48), and endogenous (12) groups. Aspergillus species was the most common (54.4%) agent isolated, followed by yeasts (24.6%), and melanized fungi (10.5%). Among Aspergilli, Aspergillus flavus was the most common (24.6%) species whereas Candida tropicalis (8.8%) was in the yeast. Other rare agents isolated include Fonsecaea pedrosoi, Fusarium solani, Paecilomyces lilacinus, Pseudallescheria boydii, Colletotrichum dematium, Cryptococcus neoformans, and Trichosporon cutaneum. Visual acuity after therapy remained <20/400 in 77.4%, 64.3%, 50.0%, and 16.7% patients infected with Aspergillus species, yeasts, melanized fungi and other mycelial fungi, respectively. The outcome was unfavorable in 52.8%, 66.7%, and 33.3% patients with postoperative, posttrauma, and endogenous groups, respectively.

CONCLUSIONS

This study is the largest series of fungal endophthalmitis from a single center and highlights the fact that a vast array of fungi can cause endophthalmitis though Aspergilli are the common agents. The combination of pars plana vitrectomy and intravitreal amphotericin B with or without fluconazole/itraconazole was the common mode of therapy in such patients. However, the main challenge is suspecting fungal etiology at the time of presentation and accurately diagnosing those patients.

Intravitreal voriconazole as primary treatment for endogenous Aspergillus endophthalmitis

This report describes the first case of Aspergillus endophthalmitis after heart transplantation which was successfully treated with intravitreal voriconazole. A 62-year-old man receiving immunosuppressive agents after a heart transplant presented with pain, reduced visual acuity and redness of the left eye. The patient had been diagnosed with invasive pulmonary aspergillosis and was being treated with intravenous voriconazole. Endogenous endophthalmitis was diagnosed. Aspergillus fumigatus was isolated in a vitreous sample. After five intravitreal voriconazole injections (50 μg/0.1 ml), pars plana vitrectomy, intravenous and topical voriconazole treatment, there was no ocular inflammation and the visual acuity improved from counting fingers at 50 cm to 20/20. This case report shows that intravitreal voriconazole, in addition to topical and systemic treatment, was safe and very effective in treating Aspergillus endophthalmitis. More clinical studies are needed to determine the optimal treatment for this condition.

Aspergillus-Endophthalmitis nach Lebertransplantation bei einem Säugling

Immunosuppressed patients and transplant patients bear an increased risk for invasive aspergillosis and Aspergillus endophthalmitis. An 8-month-old boy developed severe unilateral panuveitis after liver transplantation. Bronchopulmonary infiltrates were present, but a pulmonary Aspergillus infection was not confirmed. An enucleation was performed in order to prevent a life-threatening disseminated Aspergillus infection.

Intravitreal Voriconazole for the Treatment of Endogenous Aspergillus Endophthalmitis

OBJECTIVE

To describe the first use of intravitreal voriconazole in a human eye for the treatment of Aspergillus endophthalmitis.

DESIGN

Interventional case report.

PATIENT

A 22-year-old woman receiving immunosuppressive agents 5 weeks after lung transplantation who presented with blurred vision and redness in the right eye.

INTERVENTIONS

Intravitreal injection of voriconazole (100 microg/0.1 ml) with pars plana vitrectomy, given after isolation of A. terreus in the vitreous sample. Previous treatment modalities, including vitrectomy with repeated intravitreal amphotericin B and systemic voriconazole, failed to prevent deterioration.

MAIN OUTCOME MEASURES

Visual acuity (VA) and ocular inflammation.

RESULTS

Significant improvement was observed in VA (to 6/15) and in ocular inflammatory reaction. The patient recovered with no evidence of systemic fungal infection.

CONCLUSION

Intravitreal voriconazole may be used as an adjunct to systemic treatment in patients with Aspergillus endophthalmitis. Further clinical studies are needed to determine how often this approach can safely treat this condition.

Did the spectrum of endophthalmitis change? A study comprising 13 years experience with operative therapy of endophthalmitis

PURPOSE

The authors wondered whether the spectrum of endophthalmitis and the type of therapy had changed.

METHODS

Files of patients who were operated upon for endophthalmitis between 1988 and 2000 were retrospectively analyzed. They were divided into Group 1 (operated upon 1988 to 1994) and Group 2 (1995 to 2000).

RESULTS

Group 1 consisted of 83 patients (43.4% female, mean age 63.9 years), Group 2 of 108 (38.9% female, mean age 64.6 years). Bilateral endophthalmitis occurred in 8.4% of Group 1 patients (3.7% of Group 2 patients). Patients in both groups took on average 1.2 drug types against various internal diseases. The mean interval between first symptoms and presentation in the clinic was 45.7 days in Group 1 (19 days in Group 2; difference statistically significant). There were 63% (Group 1) (70% [Group 2]) cases of postoperative endophthalmitis, among them 58% (Group 1) (63% [Group 2]) after cataract extraction, 6% (Group 1) (5% [Group 2]) after glaucoma surgery, 20% (Group 1) (17% [Group 2]) endogenous and 17% (Group 1) (13% [Group 2]) post traumatic. In Group 2 slightly more Gram-negative bacteria were found. As an initial procedure the following were performed: vitrectomy (70% [Group 1], 88% [Group 2]), removal of crystalline lens (11% [Group 1], 10% [Group 2]), removal of pseudophakos (2% [Group 1], 12% [Group 2]), opening of posterior capsule (1% [Group 1], 9% [Group 2]), and anterior chamber irrigation (36% [Group 1], 43% [Group 2]), often combining procedures. There were significantly more vitrectomies and openings of the posterior capsule in Group 2. Neither the spectrum of secondary and tertiary procedures nor the reasons for such surgery differed in both groups. Neither visual acuity at initial presentation (0.1) nor at final follow-up (0.3) differed between the two groups. The rate of enucleation was less in Group 2 (6% versus 11%) although not statistically significantly.

CONCLUSIONS

In Group 2 there were slightly more Gram-negative bacteria and the time interval between initial symptoms and presentation in the clinic had decreased. This can be interpreted as an increase in the severity of the endophthalmitis cases. The final visual acuity was identical in both groups, the enucleation rate improved.

Conjunctival aspergilloma with multiple mulberry nodules: a case report

A 30-year-old healthy female presented with a 1-year history of chronic mucous discharge, tearing, and irritation in the left eye. Slit-lamp examination revealed severe papillary and follicular reaction surrounding a movable subconjunctival mass on the left upper tarsal conjunctiva. Incision and curettage were performed to establish the diagnosis. Multiple peculiar black mulberry nodules were obtained. The clumps of septate hyphae seen with periodic acid-Schiff stain were characteristic of fungus ball (aspergilloma). The patient's symptoms improved significantly after surgery without any antifungal therapy. Although rarely reported, aspergillus is a common fungus in the conjunctiva that may seed into the subconjunctiva. We present this case to remind ophthalmologists of such a rare cause of recalcitrant conjunctival inflammation in immunocompetent patients.

Endogenous endophthalmitis: a 13-year review at a tertiary hospital in South Australia

This retrospective report presents a series of patients with endogenous endophthalmitis treated over a 13-y period in a tertiary care centre in South Australia. 16 eyes of 13 patients (8 M, 5 F) with a mean age 62 y were included. Systemic predisposing risk factors were mainly diabetes mellitus (30.7%), chronic obstructive airway disease (23.1%) and end-stage renal disease (15.4%). Isolated organisms included fungal species in 11 eyes (7 eyes with Candida albicans and 4 with Aspergillus fumigatus), Gram-positive isolates in 4 eyes, and Pseudomonas aeruginosa in 1 eyes. Presenting visual acuity was 20/200 or lower in 8 patients (61.5%). Final visual improvement of more than 2 lines was noted in 5 patients, it was stable or worse in 6 patients and in 2 patients the eye was either enucleated or eviscerated. Systemic aspergillosis resulted in death of both patients. In conclusion, the clinical course and microbiological profile of pathogens in patients with endogenous endophthalmitis in our series are similar to other recent western reports. Candida species are the leading isolates, with an overall poor visual prognosis, especially in Aspergillus infections. Close monitoring of immune-compromised patients with systemic infections may enable early diagnosis and treatment and improve prognosis.

Necrotising retinopathies simulating acute retinal necrosis syndrome

AIM

To determine an aetiological diagnosis in patients presenting with necrotising retinopathies that simulate acute retinal necrosis (ARN).

METHODS

Retrospective non-comparative case series. The charts of 16 patients presenting with a clinical impression of ARN at Pitie-Salpetriere Hospital, Paris, France, between 1994 and 1999, who required initial antiviral therapy were reviewed. All of the patients had extensive laboratory tests. Anterior chamber paracentesis was performed on 14 patients and evaluated by polymerase chain reaction (PCR) and/or the Witmer-Goldmann coefficient to determine the cause of retinitis. Three of the 14 cases also had diagnostic vitrectomy. Responses to specific treatment, initiated based on laboratory results, and the final outcome were evaluated.

RESULTS

Seven of the 16 patients were female and nine were male. The retinitis was bilateral in five patients and unilateral in 11 patients. The average age of the patients at presentation was 53.6 years. 13 patients were immune deficient for various reasons. Upon initial presentation, the patients' visual acuities were less than 20/200 in 68% of the affected eyes. The final diagnoses, based on laboratory data and therapeutic response were toxoplasmic retinochoroiditis (62.5%), syphilitic retinitis (12.5%), aspergillus endophthalmitis (12.5%), Behcet's disease (6.2%), and intraocular lymphoma (6.2%). Visual acuity was stabilised or improved in 12 patients (75%). Two patients with aspergillosis died despite antifungal therapy.

CONCLUSIONS

Toxoplasmic retinochoroiditis is the major cause of retinal necrosis that simulates ARN, and PCR analysis of the aqueous humour is helpful in establishing the diagnosis. Such atypical toxoplasma retinochoroiditis may be associated with poor visual outcome.

The eye in systemic infection

Bacterial, fungal, viral, and parasitic pathogens all cause systemic infection and can spread to the eye. Dissemination of pathogens via the bloodstream can lead to direct involvement of the eye. Visual loss is common in bacterial or fungal endophthalmitis, and toxoplasmosis is a major cause of ocular morbidity and poor vision after congenital or acquired infection. Some infections cause intraocular damage by indirect mechanisms (eg, HIV-mediated immunosuppression), leading to opportunistic infections such as cytomegalovirus infection, periocular nerve involvement due to leprosy, and hypersensitivity reactions in tuberculosis. Eye symptoms might indicate the outcome of an underlying infection, such as development of retinal ischaemia in severe malaria, which is associated with a poor prognosis. Successful outcome for patients with ocular infection depends on close collaboration between clinicians identifying and treating underlying disease, specialist ophthalmic review, and ophthalmic interventional skills (when needed).

Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes

PURPOSE

To investigate clinical features and visual acuity outcomes associated with endogenous endophthalmitis.

DESIGN

Retrospective, observational case series.

METHODS

Twenty-one eyes of 21 patients treated at Bascom Palmer Eye Institute for culture-proven endogenous endophthalmitis between 1996 and 2002 were reviewed.

RESULTS

Patients were followed a mean of 3 months (range, 1 to 12 months). Fungal isolates occurred in 13 eyes (62%), gram-positive isolates in 7 (33%), and gram-negative isolates in 1 (5%). Twelve patients (57%) were hospitalized at the time of diagnosis and 6 patients (29%) died within 2 months of diagnosis. Initial treatment included tap and injection of intravitreal medication in 10 eyes (48%) and pars plana vitrectomy with injection of intravitreal medication in 11 eyes (52%). Final visual outcomes were obtainable for 18 eyes (two patients died within 10 days of diagnosis, and one patient was lost to follow-up). Eight (44%) of these 18 eyes achieved a visual acuity of 20/400 or better and 10 (56%) of 18 eyes achieved a visual acuity worse than 20/400, including 3 that were either enucleated or eviscerated. Three eyes with Aspergillus endophthalmitis had worse visual outcomes than eyes with either Candida (P =.036) or bacterial endophthalmitis (P =.024).

CONCLUSIONS

Compared with published series of postoperative or post-traumatic endophthalmitis, patients with endogenous endophthalmitis are more likely to have fungal isolates with a predominance of Candida albicans. Endogenous endophthalmitis is generally associated with high mortality and poor visual acuity outcomes, particularly when caused by more virulent species such as Aspergillus.

Histological examination of an eye with endogenous Aspergillus endophthalmitis treated with oral voriconazole: a case report

PURPOSE

To report the histological findings of an eye with severe Aspergillus endophthalmitis after oral treatment with voriconazole. METHODS. Case report.

RESULTS

Histopathological examination revealed no fungal elements in choroidal or retinal vessels. The hyphae were mainly restricted to the vitreal side of the preretinal inflammatory infiltrate. Since the treatment with voriconazole had not been completed at the time of enucleation, the clinical course with potential further limitation or regression of the lesion remains unsettled.

CONCLUSIONS

Endogenous Aspergillus endophthalmitis is a devastating condition often associated with immunodeficiency. The pathogenesis of this entity implies the primary invasion of choroidal and retinal vessels. The lack of antifungal drugs with high blood-ocular permeability results in an extremely poor visual prognosis. Our histological examination indicates promising activity and ocular penetration of the new antifungal agent voriconazole.

Aspergillus endophthalmitis: an unusual complication of disseminated infection in renal transplant patients

Endogenous Aspergillus endophthalmitis (AE) is a rare complication of invasive aspergillosis (IA) in transplant patients. In this report, we describe two patients with polycystic kidney disease, who developed AE with cerebral involvement after renal transplantation. Both patients received intense immunosuppression with methyl prednisolone and mycophenolate mofitil (MMF) because of persistent rejection, which rendered them diabetic and vulnerable to opportunistic infections. Endophthalmitis developed within six months of transplantation and was confirmed by microscopy and culture of the vitreous fluid. Patients were treated with combinations of different anti-fungal agents including liposomal amphotericin B, 5-flucytosine, itraconazole, voriconazole and terbinafine. In an electronic MEDLINE review, we found eight further cases of AE in renal transplant patients between 1959 and September 2002. Based on this review, we identified possible risk factors including CMV infection, diabetes mellitus and treatment for rejection with agents such as methyl prednisolone and MMF. In 70% of cases the histology, microscopy or culture of vitreous fluid confirmed the diagnosis. The outcome of AE in renal transplant patients was poor with 70-100% mortality. The review of reported cases and current practice guidelines suggests that vitrectomy and intravitreal amphoterecin B is the treatment of choice. In addition, new antifungal agents with good CSF and ocular penetration such as voriconalzole should be considered for the treatment of invasive cerebral/ocular aspergillosis.

Endogenous endophthalmitis: an 18-year review of culture-positive cases at a tertiary care center

A retrospective chart review of all patients seen at the Cleveland Clinic Foundation with infectious endogenous endophthalmitis between January 1982 and August 2000 revealed 34 affected eyes in 27 patients. During this time, the median incidence of endogenous endophthalmitis was 1.8 cases/year, and 48.1% of patients presented as outpatients. Twenty-six patients presented to an ophthalmologist, and the diagnosis was initially missed in almost half the cases. Eleven patients had an unremarkable physical exam except for eye findings. We found an equal incidence of bacterial and fungal endophthalmitis and a predominance of among the fungal etiologic agents. We did not, however, note a predominance of Gramnegative organisms seen mostly in reports from Asia. The microbiologic diagnosis was based on aqueous and vitreous cultures or positive eye histopathology stains in almost two-thirds of cases. The sensitivity of the Gram stain was poor, but its specificity and positive predictive value were excellent. The vitreous cultures obtained by vitrectomy instruments were more sensitive in making the diagnosis than the vitreous needle biopsy. Aside from blood cultures and eye specimen cultures, half the patients had an additional infectious focus, most frequently a urinary tract infection, whereas infectious endocarditis was seen in a small minority. Twelve patients had visual improvement with treatment with a final visual acuity better than 20/200 in 44% of the eyes. Good visual outcome was associated with visual acuity of 20/200 or better at diagnosis and with the absence of hypopyon.

Aspergillus niger endophthalmitis after cataract surgery

We report a 65-year-old diabetic woman who developed Aspergillus niger endophthalmitis after cataract surgery. She presented 9 weeks after extracapsular cataract extraction with a black growth covering the cornea and moderate echoes in the vitreous on ultrasonography. After microbiological confirmation of fungal endophthalmitis, the patient received intravitreal amphoterecin B 5 micro g, topical natamycin 5% hourly, atropine 1% 3 times, and oral antifungal therapy. The patient was told the visual prognosis and was advised to have penetrating keratoplasty and vitrectomy, which she refused.

Ocular manifestations of injection drug use

Injection drug use can result in a variety of severe ocular conditions. Hematogenous dissemination of various fungi and bacteria may produce endophthalmitis with resultant severe visual loss. Retinal arterial occlusive disease may result from talc and other particulate emboli. Most commonly, life-threatening systemic diseases such as endocarditis and HIV infection secondarily affect the eye. Because many of these conditions may result in blindness if untreated, accurate diagnosis and prompt initiation of therapy are essential.

Endogenous endophthalmitis

Endogenous endophthalmitis still presents a diagnostic and therapeutic challenge even with improvements in therapeutic modalities. The main prognostic factor is the virulence of the causative organism: once the organism enters the eye, it rapidly destroys ocular tissues. With the increasing ability to prolong the life of very ill patients, incidence of endogenous endophthalmitis is expected to increase. Ophthalmologists must be ever more vigilant, because prompt treatment offers the best chance of saving the eye.

Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis

PURPOSE

To describe clinical and/or histopathologic features that could help distinguish endogenous Candida endophthalmitis from endogenous Aspergillus intraocular inflammation and to provide histologic documentation of intraocular spread of these agents.

METHODS

Twenty-five patients who underwent enucleation, 13 with morphologic features and/or positive culture for Aspergillus and 12 with histologic evidence and/or positive culture for Candida were included in the study. Clinical information was sought from each case. Patients with AIDS were excluded. The enucleated globes were analyzed to detect location of the fungi, vascular invasion by these agents, and inflammatory response.

RESULTS

Candida endophthalmitis was noted in patients with a history of gastrointestinal surgery, hyperalimentation, or diabetes mellitus, whereas aspergillosis was present in patients who had undergone organ transplantation or cardiac surgery. Histopathologically, the vitreous was the primary focus of infection for Candida, whereas subretinal/subretinal pigment epithelium infection was noted in eyes with aspergillosis. Retinal and choroidal vessel wall invasion by fungal elements was noted in cases of aspergillosis but not in cases with candidiasis. Both infectious agents induced suppurative nongranulomatous inflammation.

CONCLUSIONS

Unlike Candida endophthalmitis, aspergillosis clinically presents with extensive areas of deep retinitis/choroiditis, and vitreous biopsy may not yield positive results. Histopathologically, it appears that Aspergillus grows preferentially along subretinal pigment epithelium and subretinal space. This intraocular infection is usually associated with a high rate of mortality caused by cerebral and cardiac complications.

Aspergillosis case-fatality rate: systematic review of the literature

To update the case-fatality rate (CFR) associated with invasive aspergillosis according to underlying conditions, site of infection, and antifungal therapy, data were systematically reviewed and pooled from clinical trials, cohort or case-control studies, and case series of >/=10 patients with definite or probable aspergillosis. Subjects were 1941 patients described in studies published after 1995 that provided sufficient outcome data; cases included were identified by MEDLINE and EMBASE searches. The main outcome measure was the CFR. Fifty of 222 studies met the inclusion criteria. The overall CFR was 58%, and the CFR was highest for bone marrow transplant recipients (86.7%) and for patients with central nervous system or disseminated aspergillosis (88.1%). Amphotericin B deoxycholate and lipid formulations of amphotericin B failed to prevent death in one-half to two-thirds of patients. Mortality is high despite improvements in diagnosis and despite the advent of newer formulations of amphotericin B. Underlying patient conditions and the site of infection remain important prognostic factors.

Fungal and parasitic infections of the eye

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures.

Fungal and parasitic infections of the eye

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures.

Bacterial subretinal abscess: a case report and review of the literature

PURPOSE

To report a case of Klebsiella subretinal abscess with a successful visual outcome with treatment and to review the literature pertaining to focal intraocular infection in bacterial endophthalmitis.

METHODS

Clinical data including medical history, findings on physical examination, blood cultures, and an abdominal computed tomographic scan were collected in a 32-year-old man with Klebsiella sepsis, liver abscesses, and a focal subretinal abscess. Ocular data including visual acuity, fundus photographs, fluorescein angiography, and ultrasound were evaluated, as were results of culture and histopathologic studies.

RESULTS

Despite immediate intervention, including vitreous tap and intravitreal antibiotics, the eye deteriorated, with enlargement of the abscess. A pars plana vitrectomy was performed in which the subretinal abscess material was removed after an extensive retinectomy of the involved area in association with an endophotocoagulative barrier and intravitreal amikacin without gas or oil tamponade. Culture confirmed Klebsiella subretinal infection. A retinal detachment occurred 1 month postoperatively and was successfully repaired. Visual acuity was 20/30 and has remained stable for 14 months.

CONCLUSION

Klebsiella endophthalmitis with subretinal abscess formation is a rare but devastating ocular condition. In the present case, prompt intervention with extensive retinectomy, complete abscess excision, and intravitreal antibiotic therapy resulted in unprecedented visual recovery.