Fusarium Endophthalmitis following Cataract Surgery: Successful Treatment with Intravitreal and Systemic Voriconazole

An Outbreak of Fungal Endophthalmitis After Cataract Surgery in South Korea

Importance

Fungal endophthalmitis caused by contaminated medical products is extremely rare; it follows an intractable clinical course with a poor visual prognosis.

Objective

To report the epidemiologic and clinical features and treatment outcomes of a nationwide fungal endophthalmitis outbreak after cataract surgery as a result of contaminated viscoelastic agents in South Korea.

Design, Setting, and Participants

This was a retrospective case series analysis of clinical data from multiple institutions in South Korea conducted from September 1, 2020, to October 31, 2021. Data were collected through nationwide surveys in May and October 2021 from the 100 members of the Korean Retinal Society. Patients were diagnosed with fungal endophthalmitis resulting from the use of the viscoelastic material sodium hyaluronate (Unial [Unimed Pharmaceutical Inc]). Data were analyzed from November 1, 2021, to May 30, 2022.

Main Outcomes and Measures

The clinical features and causative species were identified, and treatment outcomes were analyzed for patients who underwent 6 months of follow-up.

Results

The fungal endophthalmitis outbreak developed between September 1, 2020, and June 30, 2021, and peaked in November 2020. An official investigation by the Korea Disease Control and Prevention Agency confirmed contamination of viscoelastic material. All 281 eyes of 265 patients (mean [SD] age, 65.4 [10.8] years; 153 female individuals [57.7%]) were diagnosed with fungal endophthalmitis, based on clinical examinations and supportive culture results. The mean (SD) time period between cataract surgery and diagnosis was 24.7 (17.3) days. Patients exhibited characteristic clinical features of fungal endophthalmitis, including vitreous opacity (212 of 281 [75.4%]), infiltration into the intraocular lens (143 of 281 [50.9%]), and ciliary infiltration (55 of 281 [19.6%]). Cultures were performed in 260 eyes, and fungal presence was confirmed in 103 eyes (39.6%). Among them, Fusarium species were identified in 89 eyes (86.4%). Among the 228 eyes included in the treatment outcome analysis, the mean (SD) best-corrected visual acuity improved from 0.78 (0.74) logMAR (Snellen equivalent, 20/120 [7.3 lines]) to 0.36 (0.49) logMAR (Snellen equivalent, 20/45 [4.9 lines]) at 6 months. Furthermore, disease remission with no signs of fungal endophthalmitis (or cells in the anterior chamber milder than grade 1) was noted in 214 eyes (93.9%).

Conclusions and Relevance

This was a retrospectively reviewed case series of a fungal endophthalmitis outbreak resulting from contaminated viscoelastic material. Findings of this case series study support the potential benefit of prompt, aggressive surgical intervention that may reduce treatment burden and improve prognosis of fungal endophthalmitis caused by contaminated medical products.

Fungal Endophthalmitis: A Comprehensive Review

Endophthalmitis is a serious ophthalmologic condition involving purulent inflammation of the intraocular spaces. The underlying etiology of infectious endophthalmitis is typically bacterial or fungal. The mechanism of entry into the eye is either exogenous, involving seeding of an infectious source from outside the eye (e.g., trauma or surgical complications), or endogenous, involving transit of an infectious source to the eye via the bloodstream. The most common organism for fungal endophthalmitis is Candida albicans. The most common clinical manifestation of fungal endophthalmitis is vision loss, but other signs of inflammation and infection are frequently present. Fungal endophthalmitis is a clinical diagnosis, which can be supported by vitreous, aqueous, or blood cultures. Treatment involves systemic and intravitreal antifungal medications as well as possible pars plana vitrectomy. In this review, we examine these essential elements of understanding fungal endophthalmitis as a clinically relevant entity, which threatens patients’ vision.

Fusarium Causing Recalcitrant Post-operative endophthalmitis-Report of a Case with Review of Literature

PURPOSE

To study the clinical profile and management of a case of fungal postoperative endophthalmitis caused by fusarium solani.

CASE REPORT

A 40-year-old male underwent an uneventful cataract surgery developed postoperative endophthalmitis. The infection was fulminant and was treated aggressively with pars plana vitrectomy with intravitreal and oral antifungals. The microbiology culture of vitreous sample showed fusarium solani. There was a late recurrence in the form of a fungal ball behind the iris after 6 months of the initial episode. This fungal ball was then managed by transscleral cryotherapy. The eye became hypotonus due to chronic inflammation and silicone oil was instilled to salvage the eye.

CONCLUSION

Fusarium endophthalmitis needs an aggressive management. Due to late recurrence regular follow-up is mandatory. Early vitrectomy with oral and intravitreal voriconazole is the treatment of choice. Transscleral cryotherapy is a useful option to treat fungal balls behind the iris tissue.

Utility of Intraocular Fluid β-D-glucan Testing in Fungal Endophthalmitis: A Series of 5 Cases

BACKGROUND In clinical practice, the presentation of fungal endophthalmitis is often occult and confusing, so it is difficult to make an early diagnosis. The aim of this study was to evaluate the utility of ß-d-glucan (BDG) testing in diagnosis, management, and prognosis of fungal endophthalmitis. CASE REPORT We present a retrospective, observational case series of 5 fungal endophthalmitis cases, 3 of which were endogenous and 2 exogenous. There were significantly elevated BDG levels in all cases, which was consistent with the pathological diagnosis. Four cases were diagnosed as fungal endophthalmitis through smear or culture and gene chip analysis of intraocular fluid. CONCLUSIONS Fungal endophthalmitis is rare, and its diagnosis is difficult because of its occult nature. Therefore, BDG testing may be required as an auxiliary examination for the early diagnosis of fungal endophthalmitis. Compared to cultures and smears, intraocular fluid BDG testing has a higher sensitivity for detecting fungal endophthalmitis.