Multimodal imaging of refractory Candida chorioretinitis progressing to endogenous endophthalmitis

Abstract

Background: Endogenous fungal endophthalmitis is a serious vision-threatening condition that occurs in immunosuppressed patients with candidemia.

Findings: We report a complicated case of Candida albicans chorioretinitis that progressed to endophthalmitis. The patient required intravitreal and systemic anti-fungal medications with pars plana vitrectomy for successful treatment. Multimodal imaging using fundus photography, fluorescein angiography, spectral domain optical coherence tomography, and fundus autofluorescence was obtained throughout treatment. These modalities localized the Candida infection in the choroid, penetrating Bruch's membrane, the retinal pigment epithelium, and the retina to enter the vitreous cavity. This infectious route resulted in loss of the retinal pigment epithelium, photoreceptors, and outer retinal layers, with scar formation that resulted in vision loss and increased future risk of choroidal neovascular membranes.

Conclusions: Multimodal imaging of C. albicans chorioretinitis allows for accurate diagnosis, assessment of response to therapy, and prognosis for visual recovery and future complications.

Fig. 1

Initial appearance of the chorioretinitis. Color fundus photograph (a) showing the white, elevated, and fluffy chorioretinal lesion. Early (b) and late (c) phases of the FA demonstrating early hyperfluorescence and late staining. Color fundus photography 2 weeks later displaying significant vitritis that obscures retinal detail (d)

Fig. 2

Regression of the chorioretinal lesion. SD-OCT imaging performed 1 week after intravitreal amphotericin B treatment (a), 2 months after three intravitreal voriconazole injections (b), and after PPV (c). The inner retinal hyperreflective lesion regresses with time. At its borders, the RPE is elevated and discontinuous with loss of outer plexiform, outer nuclear, external limiting membrane, IS/OS, and RPE. Inner retinal tissues are preserved and subretinal scar is present

Fig. 3

Final appearance of the chorioretinal lesion. Color fundus photography (a), FAF (b), and SD-OCT (c) were performed 2 months after PPV. A subfoveal scar is present (a) with destruction of outer plexiform, outer nuclear, external limiting membrane, IS/OS, and RPE (c). The inner retinal layers, however, are preserved (c). The FAF shows loss of autofluorsescence corresponding to RPE destruction (b)