Spectrum of signs, symptoms, and treatment in amphotericin B-resistant Trichosporon endophthalmitis: A series of ten cases of post-cataract surgery cluster endophthalmitis

Abstract

Purpose: The aim of this study was to present the signs, symptoms, management, and outcome of a series of cases of cluster endophthalmitis caused by a multi-drug resistant fungus, Trichosporon.

Methods: This was a retrospective, non-randomized, consecutive interventional case series. Ten cases of postoperative endophthalmitis operated by a surgeon on three consecutive operation theater (OT) days presented 3-5 months after their surgery. All cases were microbiologically confirmed. The pathogen was found to be resistant to most antifungals, including amphotericin B. The cases had a latent period of around 45 days. Management of endophthalmitis included intravitreal injections, anterior chamber (AC) lavage, Pars Plana vitrectomy (PPV), posterior capsulotomy, IOL, and capsular bag removal. Multiple intravitreal injections were required due to recurrence of infections after initial improvement with voriconazole injections.

Results: Structural integrity was maintained and infection-free status was achieved in all the eyes. The presenting vision ranged from 6/60 to PL (perception of light). Seven out of 10 had improvement in their final vision over the presenting vision. Final outcome of four patients had vision of 6/24 or better, 4 patients had vision in the range of 2/60 to 6/36 and 2 patients had PL.

Conclusion: Trichosporon can cause devasting infections even in the immunocompetent, especially in association with implants and catheters. Triazoles form the mainstay of treatment of Trichosporon infection due to the high susceptibility of the organism in vitro. A regimen including voriconazole and amphotericin B may prove to be the most effective. This is the first report of an outbreak of cluster endophthalmitis caused by Trichosporon.

Keywords: Amphotericin B–resistant; Trichosporon; cluster endophthalmitis; intravitreal injections; voriconazole.

Figure 1

Patient 4 after first intravitreal injection – condensation of fibrinous plaque in the pupillary area

Figure 2

Patient 10 (a) at presentation and (b) after treatment

Figure 3

(a) Fundus photograph of patient 2 showing the cotton-wool-like vitreous deposits. (b) Fundus photograph of patient 2 after treatment. Note the old branch retinal vein occlusion (BRVO)

Figure 4

Patient 5. (a) Ring of white deposits on the posterior capsule after first intravitreal injection. (b) Final image after treatment

Figure 5

(a) Growth of the Trichosporon colonies on blood agar (patient 2). (b) Chocolate agar (patient 5)