Optical Coherence Tomography Findings in Endogenous Fungal Chorioretinitis, Retinitis, and Endophthalmitis

Optical Coherence Tomography Features of Endogenous Aspergillus Endophthalmitis Secondary to HIV Infection

PURPOSE

To report imaging findings, including optical coherence tomography (OCT), of a case of endogenous Aspergillus endophthalmitis in a patient with newly diagnosed acquired immunodeficiency syndrome.

METHODS

Observational case report.

RESULTS

A 38-year-old patient presented with acute painful vision loss in his right eye (RE). Examination of the RE revealed anterior inflammation, vitritis and a fluffy macular infiltrate; OCT showed preretinal hyperreflective aggregates extending into the vitreous cavity with no evidence of subretinal and/or choroidal involvement. Lab tests showed leukopenia with lymphocyte T CD4+ count of 13 cells/μL and positive HIV serology. Vitreous biopsy was positive for Aspergillus niger and diagnosis of endogenous Aspergillus endophthalmitis secondary to HIV infection was made.

CONCLUSIONS

OCT findings of this case show that ocular aspergillosis may present with disruption of the inner retinal layers and sparing of the outer retina and choroid, suggesting that Aspergillus may reach the eye through the retinal circulation.

Optical Coherence Tomography Findings in Infectious Posterior Uveitis

PURPOSE

To describe and illustrate the main optical coherence tomography (OCT) findings of infectious uveitis.

METHODS

Narrative review.

RESULTS

Posterior segment OCT in patients with infectious uveitis reveals posterior hyaloid face precipitates, superficial retinal precipitates and infiltrates, foveolitis, retinitis, neuro-retinitis, choroidal granulomas, and choroiditis as main imaging biomarkers. Some of these features are specific to the underlying causing etiology and may support the diagnosis and the initiation of treatment. Some OCT features disappear completely with resolution; some others are associated with irreversible retinal damage.

CONCLUSIONS

OCT identifies different features of infectious uveitis into the vitreous, the retina, and the choroid. OCT characteristics, combined with other multimodal imaging features, are helpful in the differential diagnosis of infectious uveitis, the early detection of complications, and the assessment of the response to therapy.

American Academy of Ophthalmology Recommendations on Screening for Endogenous Candida Endophthalmitis

The American Academy of Ophthalmology evaluated the practice of routine screening for intraocular infection from Candida septicemia. In the United States, ophthalmologists are consulted in the hospital to screen for intraocular infection routinely for patients with Candida bloodstream infections. This practice was established in the era before the use of systemic antifungal medication and the establishment of definitions of ocular disease with candidemia. A recent systematic review found a rate of less than 1% of routinely screened patients with endophthalmitis from Candida septicemia. Other studies found higher rates of endophthalmitis but had limitations in terms of inaccuracies in ocular disease classification, lack of vitreous biopsies, selection biases, and lack of longer-term visual outcomes. Some studies attributed ocular findings to Candida infections, rather than other comorbidities. Studies also have not demonstrated differences in medical management that are modified for eye disease treatment; therefore, therapy should be dictated by the underlying Candida infection, rather than be tailored on the basis of ocular findings. In summary, the Academy does not recommend a routine ophthalmologic consultation after laboratory findings of systemic Candida septicemia, which appears to be a low-value practice. An ophthalmologic consultation is a reasonable practice for a patient with signs or symptoms suggestive of ocular infection regardless of Candida septicemia.

Choroidal origin of endogenous Candida endophthalmitis

Endogenous Candida endophthalmitis (ECE) has been established with microscopic histopathology, both by autopsy and experimentation, to primarily originate from and involve the choroid. Zhuang et al. examined a series of patients with ECE using spectral-domain optical coherence tomography (SD-OCT) imaging and present a new classification scheme. The authors conclude the majority of lesions are primarily retinal in location without report of choroidal involvement. This discrepancy may be explained by posterior shadowing artifact and lack of discernment from associated retinal findings like infarction. These considerations are necessary in reviewing SD-OCT, characterizing ECE, and proposing new classification systems.

Acute subretinal abscess in Staphylococcus aureus septicaemia with endophthalmitis showcased by multimodal retinal imaging and with 2-year follow-up

A middle-aged man presented to emergency services with central vision loss in the setting of flu-like illness with fever. A striking subfoveal abscess was observed in the right fundus. Focal acute chorioretinal inflammation was noted in the asymptomatic fellow eye. Staphylococcus aureus septicaemia was subsequently diagnosed. He presented with undiagnosed HIV infection and latent syphilis. Serial high-definition multimodal retinal imaging showcased resolution of the dome-shaped subretinal abscess following treatment with intravenous flucloxacillin. A chorioretinal scar swiftly replaced the subfoveal abscess. Peripheral right vision and full left vision was retained. Vision loss due to endogenous endophthalmitis in systemic sepsis is an emergency requiring prompt multidisciplinary care. Sight and life are at risk-thus this is not a diagnosis to miss! Early recognition is paramount to health and in retaining vision. We briefly review relevant literature and portray how multimodal imaging guided response to treatment of acute subretinal abscess.

Multimodal imaging of multifocal chorioretinitis secondary to endogenous candida infection

PURPOSE

To present multimodal imaging of multifocal chorioretinitis secondary to endogenous candida infection in a young adult.

METHODS

A 49-year-old woman who presented for evaluation of bilateral endogenous candida chorioretinitis underwent complete ophthalmic examination, in addition to fundus photography (FP), enhanced depth imaging optical coherence tomography, fundus autofluorescence (FAF), fluorescein angiography (FA), indocyanine green angiography (ICGA) and optical coherence tomography angiography (OCTA).

RESULTS

Multimodal imaging of both eyes of the patient affected by endogenous candida chorioretinitis was performed. FP showed multiple white chorioretinal lesions at the posterior pole, FAF showed dark dot at the posterior pole surrounded by hyperautofluorescence area, FA showed early hyperfluorescence round perifoveal lesion at the posterior pole and small hyperfluorescence dots under the inferior retinal vessels. Early ICGA showed hypofluorescence dots at the posterior pole. Late ICGA showed dark hypofluorescence dots at the posterior pole surrounded by faint hyperautofluorescent ring. OCTA showed dark areas corresponded to hypoperfusion areas seen with early ICGA.

CONCLUSION

We reported multimodal imaging of an unusual occurrence of multifocal chorioretinitis due to immunosuppression. These findings suggested that the infection resulted from choroidal infiltration via the short posterior ciliary arteries with resultant breakthrough into the retina, rather than via the central retinal artery. By comparing findings on OCTA with data obtained from traditional systems, we are gaining essential information on the pathogenesis of endogenous candida chorioretinitis.