Refractory Candida dubliniensis Retinitis in an Immunocompetent Patient

BACKGROUND

Fungal endophthalmitis is an intraocular infection that rarely develops in immunocompetent individuals.

CASE

A 35-year-old healthy, immunocompetent male presented with a 1-week history of pain and redness in the left eye. Visual acuity was 20/50. Dilated fundus examination revealed focal chorioretinitis in the posterior pole with associated vitritis, suspicious for a fungal etiology. He was started empirically on oral voriconazole and valacyclovir. A comprehensive systemic workup returned negative. Inflammation worsened and a diagnostic vitrectomy was performed which revealed Candida dubliniensis. The dose of oral voriconazole was increased, and intravitreal voriconazole and amphotericin B injections were added for refractory disease. Treatment response was gauged by fungal pillar height on optical coherence tomography. Eight months of oral voriconazole and 68 intravitreal antifungal injections were required to achieve complete regression and a final visual acuity of 20/20.

CONCLUSION

Candida dubliniensis endophthalmitis can affect immunocompetent individuals and require a prolonged treatment course.

Clinical Factors, Treatment Selection, and Outcomes in Postcataract Fungal Endophthalmitis from Contaminated Viscoelastics

PURPOSE

To investigate the factors associated with treatment outcomes of postcataract surgery fungal endophthalmitis outbreaks related to contaminated viscoelastics.

DESIGN

Retrospective analysis of clinical data from multiple institutions.

SUBJECTS

This study included 228 eyes of 210 patients who were diagnosed with postcataract surgery fungal endophthalmitis related to the use of viscoelastic material (Unial, Unimed Pharmaceutical Inc); they were followed up for 6 months after the diagnosis.

METHODS

Clinical features and causative species were identified and treatment outcomes were analyzed in patients who underwent 6 months of follow-up. Propensity score matching was conducted to elucidate the impact of vitrectomy timing and intraocular lens (IOL) removal on treatment outcomes.

MAIN OUTCOME MEASURES

Clinical factors and selection of treatment modalities associated with treatment outcomes at 6 months.

RESULTS

Baseline visual acuity (P < 0.01), age (P = 0.05), and the presence of corneal edema (P < 0.01) were closely associated with poor best-corrected visual acuity (BCVA) at 6 months. Patients who underwent immediate vitrectomy after diagnosis showed significantly better BCVA at 6 months (mean logarithm of minimum angle of resolution 0.26 ± 0.43 vs. 0.52 ± 0.52, P = 0.03) and greater degree of visual improvement (mean -0.17 ± 0.37 improvement vs. 0.10 ± 0.57 deterioration, P = 0.03) than those who underwent deferred vitrectomy. Patients who underwent IOL removal during vitrectomy required a lower number of intravitreal antifungal agent injections (mean 8.9 ± 9.1 vs. 16.7 ± 12.2, P < 0.01) and showed a lower incidence of repeated vitrectomy (20% vs. 82%, P < 0.01) than in those without IOL removal.

CONCLUSIONS

In postcataract fungal endophthalmitis, prompt vitrectomy at the time of diagnosis resulted in better treatment outcomes, and IOL removal reduced the treatment burden. Prompt and aggressive surgical intervention should be considered for postcataract fungal endophthalmitis.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

[Endogenous Candida endophthalmitis]

Endogenous Candida endophthalmitis is a rare but vision-threatening disease. In most cases, endogenous endophthalmitis caused by Candida species has a better prognosis than endogenous endophthalmitis caused by other fungal species or bacteria but the prognosis still depends heavily on the time required for diagnosis and subsequent treatment as well as the initial visual acuity. Suggestions for treatment algorithms have already been made in the past but binding guidelines in ophthalmology only exist sporadically due to the rarity of the disease. This review discusses the current knowledge on endogenous Candida endophthalmitis and draws conclusions from the current study situation.

[Endogenous Candida endophthalmitis: diagnostics and treatment options based on case studies]

BACKGROUND

Endogenous Candida endophthalmitis is an emergency that can threaten vision and the eye as a whole organ but also the life of the patient due to its systemic cause.

MATERIAL AND METHOD

Retrospective case evaluation of the University Hospital for Ophthalmology Halle (Saale) and the Eye Clinic of the Ernst von Bergmann Hospital Potsdam from 2017-2022. (Age, gender, side involvement, underlying diseases, symptoms, preoperative and postoperative visual acuity, diagnostics, treatment and complications). The standardized procedures for endogenous Candida endophthalmitis are explained, the data are compared with the literature and treatment suggestions are presented.

RESULTS

8 patients with 14 eyes were treated for endogenous Candida endophthalmitis. Of the patients 2 were women and 6 were men. The overall average age was 70.25 years (53-82 years), 6 patients had bilateral eye involvement and 2 patients were affected on one side. All patients had several serious immunocompromising underlying diseases that were the cause of the candidemia. All patients underwent a pars plana vitrectomy (ppV) on the affected eyes except for one male patient who did not obtain permission for anesthesia. In addition to systemic treatment with antimycotics, voriconazole was routinely administered intravitreally during ppV. The patients received further intravitreal doses of voriconazole based on the findings. Vitreous body samples were taken from all patients during the ppV and detection of Candida albicans was possible in all cases. As part of the local perioperative treatment 1 patient received parabulbar administration of a triamcinolone depot in both eyes, 7 patients received a dexamethasone depot in 11 eyes and all 8 patients received findings-oriented local treatment with prednisolone acetate eye drops. visual acuity increased from preoperatively 1.2 logMar to 1.0 logMar. Postoperative retinal detachment did not occur and there were no serious perioperative complications. 2 patients died from one of the underlying diseases after 3 and 25 months, respectively.

CONCLUSION

Despite an increasing number of case series, there are still no uniform guidelines for ophthalmologists in Germany. There is agreement regarding systemic treatment and the intravitreal administration of antifungal agents. The role of ppV has not yet been clearly defined and the question of the adjuvant use of steroids (systemic and/or local) has also not been conclusively clarified.

Use of Optical Coherence Tomography and Optical Coherence Tomography Angiography in the Diagnosis and Follow-Up of Endogenous Candida Endophthalmitis: A Case Report

Background: Endogenous Candida endophthalmitis (ECE) is a rare but sight-threatening disease. Patients with ECE present with various clinical signs and symptoms, which can complicate the diagnosis. The aim of this report was to demonstrate the outcomes of treatment and to diagnose macular complications caused by intraocular inflammation. Case presentation: A 41-year-old woman with a history of acute intermittent porphyria presented with a progressive vision loss in her left eye. Left-eye OCT revealed findings consistent with a fungal etiology, which was confirmed by the culture of swabs collected from a central vein catheter. The outcomes of intravenous fluconazole treatment were not satisfactory, and the patient developed recurrent attacks of porphyria, suggesting a porphyrogenic effect of systemic antifungal therapy. Repeated intravitreal injections with amphotericin B led to a gradual regression of inflammatory lesions. However, follow-up examinations revealed active macular neovascularization (MNV) on both OCT and OCTA scans. The patient was administered intravitreal bevacizumab. At the 11th month of follow-up, OCT and OCTA scans showed significant inflammatory lesions regression with macula scarring, and no MNV activity was detected. Conclusions: This case highlights the importance of OCT and OCTA as valuable noninvasive imaging techniques for the identification of ECE, the monitoring of its clinical course, and the diagnosis of macular complications.

Postoperative Aspergillus Infection: A Case Series

PURPOSE

To report the clinical findings, therapy and outcomes of pauci-symptomatic Aspergillus infection in 11 eyes of 11 patients who had recently undergone uneventful cataract surgery and IOL implantation in a single operating room on the same day.

METHODS

Retrospective, observational study that looks at 11 patients who demonstrated Aspergillus infection after cataract surgery. All data were collected and intracameral samples sent for microscopic evaluation and culture. Additional swabs were sent from the operating room and operative consumables.

RESULTS

A total of 11 eyes of 11 patients were included in the analysis and were followed for at least 12 months. All patients responded completely to local and systemic voriconazole therapy. The source of infection was noted to be air-conditioning vents. Eyes with manual small incision cataract surgery (11/17) had a higher propensity for infection.

CONCLUSION

Pauci-symptomatic aspergillosis infection has been reported here following cataract surgery.

Endogenous Endophthalmitis - A Major Review

Endogenous endophthalmitis (EE) is an uncommon but potentially devastating ocular infection involving the inner layers of the eye. The global incidence of EE is on the rise. Common ocular signs and symptoms associated with EE include conjunctival injection, ocular pain, and reduced visual acuity. On clinical examination, a history of prior or coexisting systemic infections, symptoms (e.g., fever, malaise), and localizing features may be noted. Clinical diagnosis is often challenging, resulting in critical delays that contribute to a poor prognosis. Blood cultures and ocular fluid samples can aid in conforming causative pathogen(s), after which empirical antibiotic therapy, both systemic and intravitreal, should be instated. The use of steroids to suppress inflammation remains controversial. Surgical options include pars plana vitrectomy. Overall prognosis varies depending on host and pathogen factors, and early diagnosis and initiation of appropriate treatment are crucial.

Invasive candidiasis: current clinical challenges and unmet needs in adult populations

Invasive candidiasis (IC) is a serious infection caused by several Candida species, and the most common fungal disease in hospitals in high-income countries. Despite overall improvements in health systems and ICU care in the last few decades, as well as the development of different antifungals and microbiological techniques, mortality rates in IC have not substantially improved. The aim of this review is to summarize the main issues underlying the management of adults affected by IC, focusing on specific forms of the infection: IC developed by ICU patients, IC observed in haematological patients, breakthrough candidaemia, sanctuary site candidiasis, intra-abdominal infections and other challenging infections. Several key challenges need to be tackled to improve the clinical management and outcomes of IC patients. These include the lack of global epidemiological data for IC, the limitations of the diagnostic tests and risk scoring tools currently available, the absence of standardized effectiveness outcomes and long-term data for IC, the timing for the initiation of antifungal therapy and the limited recommendations on the optimal step-down therapy from echinocandins to azoles or the total duration of therapy. The availability of new compounds may overcome some of the challenges identified and increase the existing options for management of chronic Candida infections and ambulant patient treatments. However, early identification of patients that require antifungal therapy and treatment of sanctuary site infections remain a challenge and will require further innovations.

Subretinal Aspergillus Abscess in Post COVID-19 Recovered Patients - An Emerging Problem

PURPOSE

To describe endogenous endophthalmitis in the setting of Covid-19 pneumonia post recovery.

METHODS

Retrospective review of five patients of endogenous endophthalmitis following Covid-19 disease done.

RESULTS

All five cases had received systemic corticosteroid for a mean duration of 7 days during severe Covid-19 treatment. Decrease vision was presenting symptom between 1 and 31 days following Covid-19 recovery. All patients had presumed fungal endogenous endophthalmitis based on clinical profile. Four out of five patients subjected to pars plana vitrectomy had microbiologically proven aspergillus species endogenous endophthalmitis on vitreous fluid assessment; two cases each of aspergillus niger and aspergillus fumigates. Four eyes underwent pars plana vitrectomy with silicone oil injection had shown satisfactory anatomical outcome with control of the infection; however, no significant visual gain achieved.

CONCLUSION

We reported five cases of aspergillus endogenous endophthalmitis in Covid-19 recovered patients to document the likely presentation of this rising entity and avoid misdiagnosis.

Comparison of Endogenous Endophthalmitis in Patients with and Without COVID-19 Infection

INTRODUCTION

Endogenous endophthalmitis (EE) is an ophthalmic emergency that can have severe sight-threatening complications. Prompt diagnosis and aggressive treatment are central to the successful management of EE. In recent years, a significant increase has occurred in the number of cases of EE. Some of these individuals had a COVID-19 infection. The current study compared EE in patients with and without COVID-19 infection.

METHODS

All cases of EE admitted to Khalili Hospital between April 2020 and September 2021 were included in this prospective case-control study. Patients were divided into 2 groups: (i) the case group (EE patients with confirmed COVID-19 infection; n = 7) and (ii) the control group (EE patients without a history or evidence of COVID-19 infection; n = 7). Age, sex, presenting and final visual acuity, systemic diseases and risk factors for EE, anterior segment and fundus findings, hospitalization due to COVID-19, intensive care unit (ICU) admission, systemic steroid therapy, results of the sepsis workup, causative microorganism, types of treatment (pars plana vitrectomy vs. intravitreal or antifungal antibiotics), and follow-up period were recorded.

RESULTS

Twenty-four eyes of the 14 patients were included in this study, of which 9 were female. The mean age was 49.57 years. Follow-ups ranged from 1 month to 20 months (mean, 8 months). There were no statistically significant differences in age (P = 0.653), mean follow-up (P = 0.943), gender (P = 0.313), and clinical presentation (P = 0.409) between the case and control groups. Seven patients (50%) had positive intraocular culture results. Two out of 7 patients had a history of COVID-19 infection. The most common causative microorganism was Candida (4 patients [28.57%]; 6 eyes [25%]). No statistically significant differences were observed between the 2 groups in the need for vitrectomy (P = 1.000). The visual outcome between the 2 groups was similar (P = 0.179).

CONCLUSION

The COVID-19 infection does not seem to affect the severity, visual outcomes, improvement rate, or vitrectomy rate of EE. Early diagnosis and management, especially pars plana vitrectomy, can prevent serious complications and save many eyes.

Proteomic profiling of aspergillus flavus endophthalmitis derived extracellular vesicles in an in-vivo murine model

Extracellular Vesicles (EVs) play pivotal roles in cell-to-cell communication, and are involved in potential pathological and physiological cellular processes. The aim of this study was to understand the proteomic cargo of these vesicles, in a murine model of Aspergillus flavus (AF) endophthalmitis. EVs were isolated from A. flavus infected C57BL/6 mice eyes by differential ultracentrifugation at 24 h post infection (p.i) and isolated EVs were characterized by Dynamic Light Scattering (DLS), Scanning Electron Microscopy (SEM), Exocet assay, and western blot. Proteomic profiling of EVs was then evaluated by mass spectrometry (LC-MS/MS) and compared it with control uninfected mice. The average size of the EVs were 180-280 nm by DLS and the number of EVs increased to 1.55 × 1010 in infected mice in comparison to EVs from uninfected eye (1.24 × 109). Western blot was positive for CD9, CD63, and CD81 confirming the presence of EVs. LC-MS/MS analysis, identified 81 differentially expressed proteins, of these 22 were up-regulated and 59 were down-regulated. Gene Ontology (GO) analysis revealed enrichment of lipid metabolism, protein complex binding, and transferase activity, and the proteins associated were Aquaporin-5, CD177 antigen, Solute carrier family-25, and Calcium/calmodulin-dependent protein kinase. Additionally, KEGG pathway analysis indicated that glucagon signalling, metabolic, and PPAR signalling pathway were significantly associated with EVs from A. flavus infected mice eyes. The protein cargo in EVs from A. flavus endophthalmitis provides new insights into the pathogenesis of fungal endophthalmitis and validation of these proteins can serve as diagnostic and/or prognostic biomarkers for patients with a clinical suspicion of fungal endophthalmitis.

LAY SUMMARY

EVs play an important role in cell communication. In our study proteomic profiling of EVs isolated from A. flavus infected mice provided new insights into the understanding of the pathobiology of A. flavus endophthalmitis and validation of these proteins can serve as biomarkers.

Aspergillus Endophthalmitis: Epidemiology, Pathobiology, and Current Treatments

Fungal endophthalmitis is one of the leading causes of vision loss worldwide. Post-operative and traumatic injuries are major contributing factors resulting in ocular fungal infections in healthy and, more importantly, immunocompromised individuals. Among the fungal pathogens, the Aspergillus species, Aspergillus fumigatus, continues to be more prevalent in fungal endophthalmitis patients. However, due to overlapping clinical symptoms with other endophthalmitis etiology, fungal endophthalmitis pose a challenge in its diagnosis and treatment. Hence, it is critical to understand its pathobiology to develop and deploy proper therapeutic interventions for combating Aspergillus infections. This review highlights the different modes of Aspergillus transmission and the host immune response during endophthalmitis. Additionally, we discuss recent advancements in the diagnosis of fungal endophthalmitis. Finally, we comprehensively summarize various antifungal regimens and surgical options for the treatment of Aspergillus endophthalmitis.

Endophthalmitis secondary to donor to host infection in posterior lamellar keratoplasties: A systematic review

Donor to host transmission of infectious agents is a well-recognized entity, more commonly related to Endothelial Keratoplasty (EK) than to Penetrating Keratoplasty (PK), that involves complications ranging from interface keratitis to endophthalmitis. A systematic review of the literature was conducted to identify the published articles until December 2020 reporting cases of endophthalmitis secondary to corneal graft contamination in posterior lamellar keratoplasties (DSAEK and DMEK) along with donor characteristics, microbiological profile, treatment and outcomes. Each identified article was assessed to meet donor to host infection criteria, defined as a post-procedural infection in which the same microbiological agent was identified in both the donor corneoscleral rim or preservation medium and receptor ocular tissue. From 23 research articles, eight reports of endophthalmitis in nine patients following DSAEK or DMEK secondary to donor to host infection fulfilled the inclusion criteria. The majority were male and the median age was 72.0 (45.0-81.0) years old. Indications of surgery were primarily pseudophakic bullous keratopathy and Fuchs dystrophy. A fungal pathogen was identified in eight of nine patients. All the cases underwent surgical management with lenticule removal or endothelial plaque aspiration. The final corrected distance visual acuity (CDVA) in all cases was 20/200 or better. Endophthalmitis after an EK procedure is a rare complication whose outcome depends on the aggressive and precocious treatment. Identification of early signs of interface keratitis and lenticule removal seems mandatory in patients undergoing DSAEK or DMEK to prevent further involvement of the globe.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

Efficacy of intravitreal povidone-iodine administration for the treatment of Candida albicans endophthalmitis in rabbits

This study aimed to investigate the efficacy of intravitreal povidone-iodine (PI) administration for the treatment of Candida albicans endophthalmitis. Forty New Zealand white rabbits were divided into four groups (n = 10 per group). After the induction of endophthalmitis using Candida albicans, groups A, B, and C received single intravitreal injections of 0.035 mg voriconazole, 0.3 mg PI, and their combination, respectively. Rabbits that were administered sham injections were in group D as controls. Fundus photography, vitreous culture, electroretinography (ERG), and histologic examinations of the retina were conducted on day 7. The anterior chamber flare (grade 0 to 4), severity of iritis (grade 0 to 4), and vitreous opacity (grade 0 to 3) were scored. Candida albicans was cultured in the vitreous sample. On day 7, the vitreous opacities were found in all groups. Compared to that in group D, groups A, B, and C showed a lower score for flare (p < 0.001) and iritis (p < 0.001) and less fungal growth in the vitreous culture (n = 2, 1, 1, and 10 in groups A, B, C, and D, respectively; p < 0.001). Furthermore, ERG and histologic findings demonstrated less affected a- and b-waves and damaged retinal tissues in groups A, B, and C. However, these findings were not different among groups A, B, and C. PI significantly improved Candida albicans endophthalmitis, and the effect was comparable that of the voriconazole, although some vitreous opacities remained. No synergistic effect of the combination of PI and voriconazole was observed. Intravitreal PI may be useful to treat Candida albicans endophthalmitis.

Clinical Features of Japanese Patients with Ocular Inflammation and Their Surgical Procedures Over the Course of 20 Years

Purpose

To review clinical characteristics of ocular inflammation patients in Osaka, Japan, over 20 years and investigate the efficacy of required surgeries.

Methods

We conducted a retrospective study involving 2730 eyes of 1815 patients with ocular inflammation examined at the Osaka Medical College Hospital from April 1999 to March 2019.

Results

Patients comprised 843 males and 972 females, with a mean age of 56.3 ± 18.5 years. Anterior uveitis, such as scleritis, acute anterior uveitis, and herpes iritis, was the most common anatomical classification (51.2%), followed by panuveitis (37.2%), posterior uveitis (9.4%), and intermediate uveitis (2.2%). Sarcoidosis occurred in 153 patients (8.4%), Vogt-Koyanagi-Harada disease (VKH) in 83 (4.6%), and Behçet’s disease in 68 (3.7%). Sarcoidosis peaked in two age groups: 30s and 50–70s. Of the 1815 patients, 389 eyes of 271 patients (14.9%) had cataract surgery, 162 eyes of 133 (7.3%) had vitrectomy, and 124 eyes of 103 (5.7%) had glaucoma surgery. Among cataract surgery patients, 49 (18.1%) had sarcoidosis, 14 (5.2%) had VKH, and seven (2.6%) had Behçet’s disease, and visual acuity (VA) was improved in 321 eyes (82.5%). Among vitrectomy patients, 15 (11.3%) had acute retinal necrosis, 14 (10.5%) had sarcoidosis, 12 (9.0%) had fungal endophthalmitis, and 11 (8.3%) had malignant lymphoma (ML); 83 eyes (51.2%) needed vitrectomy due to vitreous opacity, and VA improved in 88 eyes (54.3%). Among glaucoma surgery patients, 13 (12.6%) had sarcoidosis, and nine (8.7%) had Posner-Schlossman syndrome.

Conclusion

Anterior uveitis was the commonest form of uveitis and sarcoidosis was the commonest underlying disease. The age distribution of sarcoidosis was older than in previous reports. 10% of patients with sarcoidosis needed glaucoma surgery, and vitrectomy was required in 50% for vitreous opacity caused by ML or sarcoidosis.

The first case of fungal endogenous endophthalmitis caused by Aspergillus nidulans: Diagnostic and therapeutic challenge

SIGNIFICANCE

Fungal endogenous endophthalmitis is an uncommon and potentially blinding infection. Aspergillus is a causative organism in immunocompromized although is virulent enough to afflict immunocompetents. Their propensity to affect macula usually results in a dismal prognosis; thus, improving visual outcome has always been challenging to clinicians. A. nidulans has only rarely been implicated in exogenous endophthalmitis.

PURPOSE

To report the first case of A. nidulans endogenous endophthalmitis.

CASE REPORT

An asthmatic 42-year-old female presented with sudden unilateral vision loss due to a submacular abscess that progressively worsened in a matter of days. Vitreous PCR analysis after an urgent vitrectomy was positive for A. nidulans with no active systemic foci found. Oral and intravitreal Voriconazole was prescribed but multiple reactivations led to three vitrectomies in total alongside with subretinal Voriconazole, abscess aspiration, and endolaser. There was complete resolution of the infection and, although visual acuity was poor due to macular scar, enucleation was avoided.

CONCLUSION

Although uncommon, we must consider Aspergillus as the causative organism in apparently immunocompetent patients with history of recent systemic corticosteroids treatment, especially if they suffer a broncopulmonary disorder. Aspergillus is an aggressive organism so a high index of suspicion along with early diagnosis and prompt treatment is the key for better outcomes. We highlight A. nidulans as the causative agent as there are no other reported cases.

Diagnostic and Management Strategies of Aspergillus Endophthalmitis: Current Insights

Fungal endophthalmitis is subsequent to endogenous or exogenous infection and represents an important complication of ocular surgery which may lead to significant visual loss and blindness. The prognosis is poor because of delayed diagnosis and limited availability of effective antifungal drugs with good ocular penetration. Furthermore, the critical issue in diagnosing fungal infection of the eye is microbiological identification of the etiologic agent in clinical samples. Aspergillus is among the most frequent isolated organisms in fungal endophthalmitis. Early diagnosis is essential to prevent severe complications and blindness. Treatments include local, systemic and surgical therapeutic strategies. The purpose of the present review is the analysis of the current procedures adopted to promptly diagnose and treat Aspergillus endophthalmitis.

INTRAVITREAL THERAPY OF ENDOGENOUS ENDOPHTALMITIS DUE TO UROSEPSIS - A CASE REPORT

A case report of 58-year-old man with endogenous endophtalmitis due to urosepsis and bronchitis. Patient was hospitalized in Department of Internal Medicine another hospital. He was sent to consiliar examination to our Ophtalmology Department with worsening vision and pain in left eye one day after onset. The diagnose endogenous endophtalmitis was set. Visual aquity was a hand movement on the first visit. Intravitreal therapy was realized promptly that day, a combination of two antibiotic drugs (ceftazidim 2mg/ 0.1 ml a vankomycin 1 mg/ 0.1 ml) and antifungal agent (amfotericin B 10 &#956;g/ 0.1 ml). This therapy was applicated 3x totally, in two weeks. Humour from anterior chamber was taken during first intravitreal application and was negative. Blood culture was positive for staphylococcus aureus. Intravenous treatment with antibiotics (gentamycin 240 mg i.v. á 24hours a amoxicilin with clavulan acid 1.2 g i.v. á 8 hod) was set for two weeks then continued antibiotic (ciprofloxacin 500 mg á 12 hours) and antifungal therapy (itrakonazol 100 mg á 12 hod) per os two months. Visual aquity of the left eye was 20/100 after four weeks and 20/40 after two months. We would like to highlight advantage of multidisciplinary co-operation.

Endogenous Fungal Endophthalmitis Associated with Genitourinary Procedures

Purpose: To summarize the characteristics of endogenous fungal endophthalmitis (EFE) after genitourinary procedures. Methods: Medical records of patients diagnosed with EFE after genitourinary procedures from a single center during a 6-year period were reviewed. Results: Nineteen eyes of 15 patients were included. The interval time between procedure to symptom was 3.6 ± 3.6 weeks. As the initial treatment, 9/19 eyes underwent primary vitrectomy and 10/19 eyes underwent intravitreal antifungal injection . Candida albicans was the pathogen in 15 of 19 eyes. Systemic treatment with itraconazole was used in all patients. LogMAR best corrected visual acuity improved from 2.2 ± 0.9 to 0.9 ± 1.2 after treatment (p = 0.002) in 15 eyes that were followed-up for an average of 4.9 ± 2.1 years. Conclusion: Genitourinary procedure is a predisposing factor for EFE. Candida albicans is the predominant pathogen. Normative systemic and local antifungal treatments improved the final visual outcome.

First endogenous fungal endophthalmitis due to Fusarium dimerum: A severe eye infection contracted during induction chemotherapy for acute leukemia

Endophthalmitis is a rare infection of the vitreous and/or aqueous. It can be bacterial or fungal. Exogenous endophthalmitis is the most common form and results from direct inoculation of a pathogen after eye surgery or penetrating trauma. Endophthalmitis can also be endogenous, secondary to disseminated infection. Fungal endophthalmitis is associated with poor prognosis and treatment is difficult given the low penetration of most of the antifungal agents available and the emergence of resistant filamentous fungi like Fusarium. To our knowledge, we describe the first endogenous fungal endophthalmitis due to Fusarium dimerum, a ubiquitous pathogen found in soil and plants. A 71-year-old woman, diagnosed with acute myeloid leukemia, was hospitalized for surveillance after induction chemotherapy. Prophylaxis by antibiotics and posaconazole was ongoing when she complained of pain and decreased vision in the left eye. A voluminous chorioretinal abscess developed and after multiple sterile aqueous humour samples, only vitrectomy allowed diagnosis with fungal hyphae seen on May-Grünwald Giemsa stained smear and positive cultures. The fungus was identified as Fusarium dimerum. The treatment, that included intravitreal injections of voriconazole and amphotericin B associated with systemic administration of voriconazole, allowed complete control of the infection. The source of this infection could not be confirmed despite the discovery of several possible infection sites including a periungual whitlow on the left hand and a lesion on a nail, from which samples were negative in microbiology laboratories. Unfortunately, damages of the retina were too important and the patient did not recover sight of her left eye.

Antimicrobial Blue Light Therapy for Infectious Keratitis: Ex Vivo and In Vivo Studies

Purpose

To investigate the effectiveness of antimicrobial blue light (aBL) as an alternative or adjunctive therapeutic for infectious keratitis.

Methods

We developed an ex vivo rabbit model and an in vivo mouse model of infectious keratitis. A bioluminescent strain of Pseudomonas aeruginosa was used as the causative pathogen, allowing noninvasive monitoring of the extent of infection in real time via bioluminescence imaging. Quantitation of bacterial luminescence was correlated to colony-forming units (CFU). Using the ex vivo and in vivo models, the effectiveness of aBL (415 nm) for the treatment of keratitis was evaluated as a function of radiant exposure when aBL was delivered at 6 or 24 hours after bacterial inoculation. The aBL exposures calculated to reach the retina were compared to the American National Standards Institute standards to estimate aBL retinal safety.

Results

Pseudomonas aeruginosa keratitis fully developed in both the ex vivo and in vivo models at 24 hours post inoculation. Bacterial luminescence in the infected corneas correlated linearly to CFU (R² = 0.921). Bacterial burden in the infected corneas was rapidly and significantly reduced (>2-log₁₀) both ex vivo and in vivo after a single exposure of aBL. Recurrence of infection was observed in the aBL-treated mice at 24 hours after aBL exposure. The aBL toxicity to the retina is largely dependent on the aBL transmission of the cornea.

Conclusions

Antimicrobial blue light is a potential alternative or adjunctive therapeutic for infectious keratitis. Further studies of corneal and retinal safety using large animal models, in which the ocular anatomies are similar to that of humans, are warranted.

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

Purpose. To report a case of postoperative endophthalmitis caused by Fusarium species successfully treated with intravitreal and systemic voriconazole after treatment failure with amphotericin B. Methods. Clinical case report of a 60-year-old immunocompetent woman who presents with endophthalmitis of unknown origin 4 weeks after uneventful cataract extraction and IOL implantation surgery. IOL explantation, vitrectomy with capsular bag removal, vitreous aspiration for culture, and intravitreal injection of amphotericin B (5 μg/0.1 mL) were performed. Diagnosis was established by culturing the vitreous aspirate on a Sabouraud agar medium and staining with lactophenol blue solution. Five days later, there was no clinical response. The decision was made to administer a single dose of intravitreal voriconazole (2.5 μg/0.1 mL) and oral voriconazole (200 mg BID) for 30 days. Results. Fusarium sp. grew on culture. Treatment with local and systemic voriconazole was started after no improvement with vitrectomy, IOL explantation, and intravitreal amphotericin B. After 1 month of treatment, the infection resolved and best-corrected visual acuity was 20/25. Conclusion. In patients with endophthalmitis caused by Fusarium sp., topical and systemic voriconazole treatment should be considered in cases resistant to intravitreal amphotericin B.

Surgical management of fungal endophthalmitis resulting from fungal keratitis

AIM

To report the fungal organisms, clinical features, surgical treatment strategies, and outcomes of patients with culture-proven exogenous fungal endophthalmitis (EFE) secondary to keratitis, and evaluate the role of surgery in the treatment.

METHODS

The clinical records of 27 patients (27 eyes) with culture-proven EFE resulting from fungal keratitis treated at Shandong Eye Institute from January 2007 to January 2015 were retrospectively reviewed. Information about fungal culture results, clinical features, surgical procedures, and final visual acuity was obtained.

RESULTS

There were 39 positive culture results from samples of cornea, hypopyon, vitreous and lens capsule, accounting for 56%, 26%, 15% and 2.5%, respectively. Fusarium was identified in 44% (12/27) of the eyes, followed by Aspergillus in 22% (6/27). Posterior segment infection was involved in 78% (21/27) of the patients. The corneal infection was larger than 3 mm ×3 mm in 89% (24/27) of the patients, and 22% (6/27) of them had the entire cornea, and even the sclera involved. Three eyes had silicone oil tamponade, and two eyes had retinal detachment. Twenty-two eyes (81.5%) underwent penetrating keratoplasty (PKP), and over half of them (54.5%) were operated within 3d from the onset of antifungal therapy. Fourteen eyes (52%) underwent intracameral antifungal drug injection, and three of them required repeated injections. Fifteen eyes (55.6%) underwent pars plana vitrectomy (PPV). The rate of the eyes undergoing PPV as the initial surgical procedure was 60% (9/15), lower than 77% in PKP. Intravitreal injection was given in 59% of the eyes (16/27), and 75% of them required repeated injections. The final visual acuity was 20/100 or better in 37% of the eyes, and better than counting fingers in 55.6% of the eyes. Five eyes (18.5%) were eviscerated. In the two eyes with concurrent retinal detachment, one achieved retinal reattachment, and the other was eviscerated. In the three eyes with silicone oil tamponade, two eyes received silicone oil removal, and the other one was eviscerated.

CONCLUSION

Fusarium and Aspergillus are the dominant pathogens in EFE resulting from keratitis. Aggressive antifungal surgeries including multiple intravitreal injections, PKP and core vitrectomy (especially in the initial surgery) are helpful procedures to improve prognosis of severe EFE secondary to keratitis.

Virulence Attributes and Antifungal Susceptibility Profile of Opportunistic Fungi Isolated from Ophthalmic Infections

Investigations of both virulence factors and antifungal susceptibility profiles are crucial for understanding the pathogenesis and prognosis of ophthalmic mycoses. In this study, we investigated the in vitro antifungal susceptibility of amphotericin B (AMB), voriconazole (VRC), and natamycin (NAT) against a set of 50 fungal isolates obtained from patients with ocular mycoses using the Clinical and Laboratory Standards Institute broth microdilution method. In addition, putative virulence factor, such as secretory phospholipases and proteinases, and biofilm formation activity were analyzed. The geometric means (GMs) of the minimum inhibitory concentrations (MICs) of the antifungals across all isolates were the following (in increasing order): VRC (0.70 μg/mL), AMB (0.81 μg/mL), and NAT (1.05 μg/mL). The highest activity against 14 Aspergillus strains was exhibited by VRC (GM MIC: 0.10 μg/mL), followed by AMB and NAT (GM MICs: 0.21 and 0.27 μg/mL), respectively. However, for 12 Fusarium spp., the GM MIC of VRC (2.66) was higher than those of NAT and AMB (GM MICs 1.3 and 0.8 μg/mL, respectively). Proteinase and phospholipase activity were observed in 30 % and 42 % of the isolates, respectively, whereas only 8 % of the isolates were able to produce biofilms. Phospholipase activity was observed in all Fusarium isolates, but not in any of the Aspergillus isolates. In contrast, biofilm-forming capability was detected in 25 % of the Fusarium isolates, but none of the Aspergillus isolates. The differences in the MICs of AMB, VRC, and NAT, biofilm-forming ability and proteinase and phospholipase activities among the isolates were not significant (p > 0.05). Overall, our study suggests no significant correlation between the antifungal susceptibility profiles and virulence attributes of ocular fungal isolates.

Delayed fungal endophthalmitis secondary to Curvularia

Purpose

To describe a case of fungal endophthalmitis secondary to Curvularia after cataract surgery.

Observations

This case showed delayed and recalcitrant fungal endophthalmitis secondary to Curvularia despite treatment with pars plana vitrectomy, intravitreal antifungal therapy, and systemic antifungals.

Conclusions and importance

Curvularia-associated endophthalmitis should be considered in the differential diagnosis of delayed post-cataract endophthalmitis, especially in tropical or subtropical geographical areas. Awareness and early identification, timely removal of the nidi of sequestration, and prolonged antifungal treatments are important for the eradication of Curvularia-associated endophthalmitis.

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Outcomes of Primary Transconjunctival 23-Gauge Vitrectomy in the Diagnosis and Treatment of Presumed Endogenous Fungal Endophthalmitis

PURPOSE

To report the outcomes of primary transconjunctival 23-gauge (23-G) vitrectomy in the diagnosis and treatment of presumed endogenous fungal endophthalmitis (EFE).

METHODS

Retrospective analysis of patients with EFE who underwent diagnostic transconjunctival 23-G vitrectomy at a tertiary referral center.

RESULTS

Nineteen eyes of 15 patients with EFE were included in the study. Four patients had bilateral and 11 patients unilateral disease. Sixteen eyes of 15 patients underwent 23-G vitrectomy to confirm the diagnosis using vitreous culture, polymerase chain reaction, and histopathologic examinations. All affected eyes were treated with intravitreal amphotericin B 5 µg/0.1 mL. Fourteen patients received additional systemic antifungal therapy. Diagnostic 23-G vitrectomy confirmed the diagnosis of EFE in 75% of the eyes (12/16). Candida was found to be a causative agent in 62.5% and Aspergillus in 12.5% of the eyes. Retinal detachment was the most common complication (42% of eyes).

CONCLUSIONS

EFE can be easily confirmed using primary 23-G vitrectomy.

Corneal infection in Shandong peninsula of China: a 10-year retrospective study on 578 cases

AIM

To determine the epidemiological characteristics, clinical signs, laboratory findings, and outcomes in patients with corneal infection in Shandong peninsula of China.

METHODS

The medical records of 578 inpatients (578 eyes) with corneal infection were reviewed retrospectively for demographic characteristics, risk factors, seasonal variation, clinical signs, laboratory findings, and treatment strategy. Patient history, ocular examination findings using slit-lamp biomicroscopy, laboratory findings resulted from microbiological cultures, and treatment.

RESULTS

Fungal keratitis constituted 58.48% of cases of infectious keratitis among the inpatients, followed by herpes simplex keratitis (20.76%), bacterial keratitis (19.03%) and acanthamoeba keratitis (1.73%). The most common risk factor was corneal trauma (71.80%). The direct microscopic examination (338 cases) using potassium hydroxide (KOH) wet mounts was positive in 296 cases (87.57%). Among the 298 fungal culture-positive cases, Fusarium species were the most common isolates (70.47%). A total of 517 cases (89.45%) received surgical intervention, including 255 (44.12%) cases of penetrating keratoplasty, 74 (12.80%) cases of lamellar keratoplasty which has become increasingly popular, and 77 cases (13.32%) of evisceration or enucleation.

CONCLUSION

At present, infectious keratitis is a primary corneal disease causing blindness in China. With Fusarium species being the most commonly identified pathogens, fungal keratitis is the leading cause of severe infectious corneal ulcers in Shandong peninsula of China.

Aspergillus tubingensis: a major filamentous fungus found in the airways of patients with lung disease

The black Aspergillus group comprises A. niger and 18 other species, which are morphologically indistinguishable. Among this species subset, A. tubingensis, described in less than 30 human cases before 2014, is primarily isolated from ear, nose, and throat samples. Recently, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry has emerged as a powerful technique to identify microbes in diagnostic settings. We applied this method to identify 1,720 filamentous fungi routinely isolated from clinical samples our laboratory over a two-year study period. Accordingly, we found 85 isolates of A. niger, 58 of A. tubingensis, and six other black Aspergillus (4 A. carbonarius and 2 A. japonicus). A. tubingensis was the fifth most frequent mold isolated in our mycology laboratory, primarily isolated from respiratory samples (40/58 isolates). In this study, we mainly aimed to describe the clinical pattern of Aspergillus tubingensisWe analyzed the clinical features of the patients in whom A. tubingensis had been isolated from 40 respiratory samples. Thirty patients suffered from cystic fibrosis, chronic obstructive pulmonary disease or other types of chronic respiratory failure. Strikingly, 20 patients were experiencing respiratory acute exacerbation at the time the sample was collected. Antifungal susceptibility testing of 36 A. tubingensis isolates showed lower amphotericin B MICs (P < 10(-4)) and higher itraconazole and voriconazole MICs (P < 10(-4) and P = .0331, respectively) compared with 36 A. niger isolates. Further studies are required to better establish the role that this fungus plays in human diseases, especially in the context of cystic fibrosis and chronic pulmonary diseases.

Endogenous endophthalmitis: diagnosis, management, and prognosis

Endogenous endophthalmitis is an ophthalmic emergency that can have severe sight-threatening complications. It is often a diagnostic challenge because it can manifest at any age and is associated with a number of underlying predisposing factors. Microorganisms associated with this condition vary along a broad spectrum. Depending upon the severity of the disease, both medical and surgical interventions may be employed. Due to rarity of the disease, there are no guidelines in literature for optimal management of these patients. In this review, treatment guidelines based on clinical data and microorganism profile have been proposed.

Risk of Fungal Endophthalmitis Associated with Cataract Surgery: A Mini-Review

Fungal endophthalmitis is a rare complication after cataract surgery and is associated with significant morbidity including vision loss. The common causative fungal pathogens implicated in fungal endophthalmitis after cataract surgery include Candida species (spp.) and molds such as Aspergillus spp. and Fusarium spp. Early diagnosis and effective antifungal treatment after a high index of clinical suspicion are required to reduce unfavorable complications and to preserve eye function. This review discusses epidemiology, pathogenesis, clinical features, diagnosis, management, and outcomes associated with fungal endophthalmitis after cataract surgery.

Bacterial and fungal keratitis in Upper Egypt: in vitro screening of enzymes, toxins and antifungal activity

Purpose:

This work was conducted to study the ability of bacterial and fungal isolates from keratitis cases in Upper Egypt to produce enzymes, toxins, and to test the isolated fungal species sensitivity to some therapeutic agents.

Materials and Methods:

One hundred and fifteen patients clinically diagnosed to have microbial keratitis were investigated. From these cases, 37 bacterial isolates and 25 fungal isolates were screened for their ability to produce extra-cellular enzymes in solid media. In addition, the ability of fungal isolates to produce mycotoxins and their sensitivity to 4 antifungal agents were tested.

Results:

Protease, lipase, hemolysins, urease, phosphatase, and catalase were detected respectively in 48.65%, 37.84%, 59.46%, 43.24%, 67.57%, and 100% out of 37 bacterial isolates tested. Out of 25 fungal isolates tested during the present study, 80% were positive for protease, 84% for lipase and urease, 28% for blood hemolysis, and 100% for phosphatase and catalase enzymes. Thirteen fungal isolates were able to produce detectable amounts of 7 mycotoxins in culture medium (aflatoxins (B1, B2, G1, and G2), sterigmatocystin, fumagillin, diacetoxyscirpenol, zearalenone, T-2 toxin, and trichodermin). Among the antifungal agents tested in this study, terbinafine showed the highest effect against most isolates in vitro.

Conclusion:

In conclusion, the ability of bacterial and fungal isolates to produce extracellular enzymes and toxins may be aid in the invasion and destruction of eye tissues, which, in turn, lead to vision loss.

Potential role of nuclear receptor ligand all-trans retinoic acids in the treatment of fungal keratitis

Fungal keratitis (FK) is a worldwide visual impairment disease. This infectious fungus initiates the primary innate immune response and, later the adaptive immune response. The inflammatory process is related to a variety of immune cells, including macrophages, helper T cells, neutrophils, dendritic cells, and Treg cells, and is associated with proinflammatory, chemotactic and regulatory cytokines. All-trans retinoic acids (ATRA) have diverse immunomodulatory actions in a number of inflammatory and autoimmune conditions. These retinoids regulate the transcriptional levels of target genes through the activation of nuclear receptors. Retinoic acid receptor α (RAR α), retinoic acid receptor γ (RAR γ), and retinoid X receptor α (RXR α) are expressed in the cornea and immune cells. This paper summarizes new findings regarding ATRA in immune and inflammatory diseases and analyzes the perspective application of ATRA in FK.

The first case of endophthalmitis due to Rhinocladiella basitona in an immunocompetent patient

Rhinocladiella, a genus of black yeast-like fungi, is related to many infections in humans, including not only mild cutaneous lesions but also fatal brain infections. However, endophthalmitis caused by Rhinocladiella has never been reported by far. Herein, we present the first case of endophthalmitis due to Rhinocladiella basitona. The diagnosis was based on histopathology, mycology, and molecular identification. A 53-year-old female was struck by a piece of wood in her right eye. The wound in the central cornea became an ulcer and was aggravated continuously. Hyphae were found in the corneal scraping smear. Then endophthalmitis occurred and could not be controlled by the combined intravitreal antibiotic injections and vitrectomy. Finally, penetrating keratoplasty combined with retinal reattachment surgery was performed. Topical and systemic antifungal agents were administered for more than 1 month. The patient was cured, with improved visual acuity and clear corneal graft.

Infected Baerveldt Glaucoma Drainage Device by Aspergillus niger

Fungal endophthalmitis is rare but may complicate glaucoma drainage device surgery. Management is challenging as the symptoms and signs may be subtle at initial presentation and the visual prognosis is usually poor due to its resistant nature to treatment. At present there is lesser experience with intravitreal injection of voriconazole as compared to Amphotericin B. We present a case of successfully treated Aspergillus endophthalmitis following Baerveldt glaucoma drainage device implantation with intravitreal and topical voriconazole.

Exogenous fungal endophthalmitis: an analysis of isolates and susceptibilities to antifungal agents over a 20-year period (1990-2010)

PURPOSE

To describe the isolates and susceptibilities to antifungal agents for patients with culture-proven exogenous fungal endophthalmitis.

DESIGN

Noncomparative case series.

METHODS

The clinical records of all patients treated for culture-proven exogenous fungal endophthalmitis at a university referral center from 1990 to 2010 were reviewed. Specimens initially used for diagnosis were recovered from the microbiology department and then underwent antifungal sensitivity analysis.

RESULTS

The antifungal susceptibilities of 47 fungal isolates from culture-positive fungal endophthalmitis are reported. Included are 14 isolates from yeast and 33 from mold. The mean (±standard deviation) minimum inhibitory concetrations (MICs) for amphotericin B (2.6 ± 3.5 μg/mL), fluconazole (36.9 ± 30.7 μg/mL), and voriconazole (1.9 ± 2.9 μg/mL) are reported. Presumed susceptibility to oral fluconazole, intravenous amphotericin B, intravitreal amphotericin B, oral voriconazole, and intravitreal voriconazole occurred in 34.8%-43.5%, 0-8.3%, 68.8%, 69.8%, and 100% of isolates, respectively.

CONCLUSIONS

Based on this laboratory study of isolates from exogenous fungal endophthalmitis, intravitreal voriconazole appears to provide the broadest spectrum of antifungal coverage and, as such, may be considered for empiric therapy of endophthalmitis caused by yeast or mold.

Spectrum of fungal keratitis: clinicopathologic study of 44 cases

AIM

To determine the causative agents of fungal keratitis and study the predisposing factors over a period of ten years in a single tertiary care hospital.

METHODS

A retrospective analysis of fungal corneal ulcers was done from 2003-2012. Patients' clinical data were noted from the file records. Correlation of histopathological diagnosis was done with the report on fungal culture.

RESULTS

Mycotic keratitis was established in 44 cases by a positive fungal culture. Direct microscopic examination of potassium hydroxide (KOH) mounts revealed fungal elements in 39 cases while 40 cases showed fungus on Gram stained smears. Males (54.55%) were more commonly affected than the females (45.45%). The age ranged from 18 to 82 years. Most common age group to be involved was 41-60 years. Predisposing risk factors were seen in 34 (77.27%) cases. Most common findings on clinical examination were anterior chamber reaction and conjunctival injection seen in all the cases. Other common findings were stromal infiltration and hypopyon seen in 20 (45.45%) and 18 (40.91%) cases respectively. On histopathological examination the fungus was typed, as aspergillus in 34 cases while no definite typing was possible in 10 cases. The predominant isolate was aspergillus flavus (59.09%) followed by fusarium (15.91%). Mixed fungal and bacterial infection was seen in 3 (6.82%) cases.

CONCLUSION

Although culture is the gold standard for definitive diagnosis of fungal keratitis, direct microscopic examination of corneal scrapings or histomorphological evaluation of biopsies allow a rapid preliminary diagnosis. Early administration of antifungal treatment helps in preventing dreadful complications.

Fungal endophthalmitis associated with compounded products

Fungal endophthalmitis is a rare but serious infection. In March 2012, several cases of probable and laboratory-confirmed fungal endophthalmitis occurring after invasive ocular procedures were reported nationwide. We identified 47 cases in 9 states: 21 patients had been exposed to the intraocular dye Brilliant Blue G (BBG) during retinal surgery, and the other 26 had received an intravitreal injection containing triamcinolone acetonide. Both drugs were produced by Franck's Compounding Lab (Ocala, FL, USA). Fusarium incarnatum-equiseti species complex mold was identified in specimens from BBG-exposed case-patients and an unopened BBG vial. Bipolaris hawaiiensis mold was identified in specimens from triamcinolone-exposed case-patients. Exposure to either product was the only factor associated with case status. Of 40 case-patients for whom data were available, 39 (98%) lost vision. These concurrent outbreaks, associated with 1 compounding pharmacy, resulted in a product recall. Ensuring safety and integrity of compounded medications is critical for preventing further outbreaks associated with compounded products.

Etiological agents of fungal endophthalmitis: diagnosis and management

Endophthalmitis caused by fungi is commonly diagnosed around the world in apparently healthy and immunocompromised individuals. An accurate clinical diagnosis for endophthalmitis confirmed by laboratory techniques is essential for early treatment with antifungal drugs, such as amphotericin B, imidazoles, and other antifungals. Here, we review endophthalmitis caused by fungi according to its classification into endogenous fungal endophthalmitis (EFE) and exogenous fungal endophthalmitis (EXFE). EFE is caused by endogenously acquired fungi, whereas the traumatic implantation of opportunistic fungal pathogens is the main feature of EXFE. We highlight the most important etiologies causing endophthalmitis and the steps required for a rapid diagnosis and management.

Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections

Background

The purpose of the current study was to analyze risk factors, clinical features, and treatment outcomes in patients with endogenous fungal endophthalmitis with yeast and mold infections. For this retrospective consecutive case series, microbiologic and clinical records were reviewed to identify all patients with intraocular culture-proven endogenous fungal endophthalmitis treated at a single institution between January 1, 1990 and December 31, 2011.

Results

Sixty-seven eyes of 53 patients were identified; 51 eyes of 39 patients had positive cultures for yeast and 16 eyes of 14 patients had positive cultures for molds. Patients with molds as a causative organism had significantly shorter duration of symptoms prior to diagnosis (molds 3.8 days, yeast 21.0 days, p = 0.002), were more likely to be receiving iatrogenic immunosuppression (molds 57.1%, yeast 7.7%, p = 0.001), have a history of whole-organ transplantation (molds 35.7%, yeast 2.6%, p = 0.001), and were more likely to have hypopyon at the time of diagnosis (molds 37.5%, yeast 6.0%, p = 0.001). Patients with endogenous endophthalmitis caused by molds had significantly worse visual acuity at the time of diagnosis (logMAR visual acuity molds 1.80, yeast 1.15, p = 0.008) and at final visit (logMAR visual acuity molds 1.97, yeast 1.05, p = 0.005) compared to those patients with yeast as a causative organism. There was no significant difference in the rate of retinal detachment between the two groups (mold 12.5%, yeast 30.6%, p = 0.201). Patients with cultures positive for mold were significantly more likely to undergo enucleation (molds 25.0%, yeast 0%, p < 0.001).

Conclusions

Systemic risk factors for patients with endogenous fungal endophthalmitis caused by molds were iatrogenic immunosuppression and a history of whole-organ transplantation. Shorter duration of symptoms before diagnosis and higher rates of hypopyon occurred in mold cases. While endogenous fungal endophthalmitis is generally associated with poor visual acuity outcomes, infection with mold species was associated with worse visual acuity on presentation and on final follow-up than infection with yeast species. Enucleation rates were much higher in mold cases.