Endogenous fungal endophthalmitis: risk factors, clinical course, and visual outcome in 13 patients

Abstract

Aim: To analyze the risk factors, ophthalmological features, treatment modalities and their effect on the visual outcome in patients with endogenous fungal endophthalmitis (EFE).

Methods: Data retrieved from the medical files included age at presentation to the uveitis clinic, gender, ocular symptoms and their duration before presentation, history of fever, eye affected, anatomical diagnosis and laboratory evidence of fungal infection. Medical therapy recorded included systemic antifungal therapy and its duration, use of intravitreal antifungal agents and use of oral/intravitreal steroids. Surgical procedures and the data of ophthalmologic examination at presentation and at last follow-up were also collected.

Results: Included were 13 patients (20 eyes, mean age 58y). Ten patients presented after gastrointestinal or urological interventions and two presented after organ transplantation. In one patient, there was no history of previous intervention. Diagnostic vitrectomy was performed in 16 eyes (80%) and vitreous cultures were positive in 10 of the vitrectomized eyes (62.5%). In only 4 patients (31%), blood cultures were positive. All patients received systemic antifungal therapy. Sixteen eyes (80%) received intravitreal antifungal agent with voriconazole being the most commonly used. Visual acuity (VA) improved from 0.9±0.9 at initial exam to 0.5±0.8 logMAR at last follow-up (P=0.03). A trend of greater visual improvement was noted in favor of eyes treated with oral steroids (±intravitreal dexamethasone) than eyes that were not treated with steroids. The most common complication was maculopathy. Twelve eyes (60%) showed no ocular complications.

Conclusion: High index of suspicion in patients with inciting risk factors is essential because of the low yield of blood cultures and the good general condition of patients at presentation. Visual prognosis is improved with the prompt institution of systemic and intravitreal pharmacotherapy and the immediate surgical intervention. Oral±local steroids could be considered in cases of prolonged or marked inflammatory responses in order to hasten control of inflammation and limit ocular complications.

Keywords: candida endophthalmitis; endogenous endophthalmitis; endogenous fungal endophthalmitis; endophthalmitis; fungal endophthalmitis.

Figure 1. Wide-angle fundus photograph of the left eye (patient 1) showing dense central vitreous opacities obscuring the optic disc and the posterior pole with string-of-pearl vitreous opacities in inferior temporal part of the vitreous cavity

A fuzzy white retinal lesion is also noted in superotemporal periphery.

Figure 2. Follow-up photographs of the left eye (patient 1) 13mo following presentation

A: Wide-angle fundus photograph showing clear vitreous with normal looking optic disc, macula, and blood vessels. An atrophic retinal lesion is seen in the superotemporal periphery. B: Spectral-domain optical coherence tomography showing preserved foveal contour with fine ERM in the papillomacular bundle.

Figure 3. Color fundus photograph of the right eye (patient 3) at presentation (A) shows fluffy white retinal lesion along the inferotemporal arcade with preretinal extension and hazy view because of associated vitritis. Spectral-domain optical coherence tomography shows a hyperreflective dense retinal elevated lesion in the area of the white retinal infiltrate with vitreous infiltration and CME. Color fundus photograph of the right eye 10d later shows clear vitreous with marked regression of the white retinal lesion along the inferotemporal arcade (B). Spectral-domain optical coherence tomography shows resolution of the CME with fine hard exudates in the outer retinal layers and resolving retinal infiltrate.