Fungal Endophthalmitis Clinical Presentation
- Author: Lihteh Wu, MD; Chief Editor: Hampton Roy, Sr, MD more...
Risk factors for Candida endophthalmitis
The most common risk factor for the development of endogenous Candida endophthalmitis is intravenous drug abuse.
Other risk factors include patients with long-standing indwelling catheters; postpartum women; premature infants; patients undergoing hyperalimentation; patients with a history of recent abdominal surgery; and patients with debilitating diseases, such as diabetes mellitus, postorgan transplantation, or malignancies.
Risk factors for Aspergillus endophthalmitis
Patients with a history of renal transplantation who are receiving corticosteroids, leukemia and other hematological disorders, Goodpasture syndrome, alcoholism, and prematurity.
The most common predisposing factor is intravenous drug abuse.
Notably, chest x-ray film findings are normal in up to 20% of patients with invasive pulmonary aspergillosis.
Aspergillus endogenous endophthalmitis tends to present more acutely than Candida endophthalmitis and to progress more rapidly.
Aspergillus endocarditis is often found together with Aspergillus endophthalmitis; therefore, a thorough cardiac workup is necessary.
Risk factors for Cryptococcus endophthalmitis
Patients who are known to be at risk of developing this condition are those with lymphoproliferative diseases, collagen vascular diseases, sarcoidosis, tuberculosis, diabetes mellitus, Cushing syndrome, or AIDS; those who are pregnant or abuse drugs; and those who have had organ transplants.
A few cases of cryptococcosis have been reported in individuals with no known risk factors or immune deficiencies.
Since the arthroconidia of C immitis are found in the dust of endemic areas, agricultural workers and construction crews are at risk of acquiring the infection.
Symptoms include the following:
Visual loss may be present; however, several studies have shown that visual acuity is not a useful factor in assessing the presence of endogenous fungal endophthalmitis in patients who are at risk.
In addition, patients may be asymptomatic if the lesion is in the peripheral retina or if the patient is moribund.
Candida chorioretinitis typically presents as several, small, creamy white, circumscribed chorioretinal lesions with overlying vitreous inflammation.
In certain cases, these chorioretinal lesions may be surrounded by hemorrhage, giving them the appearance of a white-centered hemorrhage (Roth spot).
In the area of the lesion, the retinal vessels may be sheathed.
The vitreous opacities resemble fluffy balls, and they may be linked to each other by strands giving them the so-called string of pearls appearance.
If the infection is not suspected and the disease advances, epiretinal membranes may develop, leading to vitreoretinal traction and retinal detachment.
As the lesions heal with treatment, chorioretinal scarring evolves in the areas of prior inflammation.
Choroidal neovascular membranes may develop at the site of these scars.
Two thirds of patients have bilateral disease, and more than one half of patients have vitreous involvement.
Iridocyclitis often is present, and a hypopyon also may be present.
Infection of the iris and ciliary body is rare.
In Aspergillus endophthalmitis, an iridocyclitis with or without a hypopyon may be present; yellow subretinal and retinal infiltrates that preferentially affect the macula are observed.
Inflammatory cells within the infiltrate may layer secondary to gravity, thereby creating a pseudohypopyon.
As the disease progresses, the vitreous becomes severely involved, concealing all fundus details. With time, the macular lesions scar.
In addition, Aspergillus species have a propensity for vascular invasion, leading to thrombosis and necrosis.
If the fungus invades the choroidal vessels, an exudative retinal detachment may result.
When the retinal vessels become involved, retinal necrosis may occur.
Cryptococcus neoformans usually presents intraocularly as a multifocal chorioretinitis characterized by discrete yellow-white lesions of different sizes.
Retinal vessels may be sheathed, and a vitritis of variable intensity may develop.
Retinal necrosis accompanied by retinal hemorrhage and exudative retinal detachments also have been known to occur.
If the central nervous system is involved, papilledema is present.
A mild inflammatory reaction is present in the anterior segment.
If treatment is not instituted, iris neovascularization and cataract may result.
Ocular coccidioidomycosis is an uncommon finding in patients with disseminated disease.
Usually, a severe granulomatous iridocyclitis characterized by mutton-fat keratic precipitates is present.
Multifocal choroiditis, typified by several, scattered, discrete, yellow-white lesions measuring less than the disc diameter in size, is observed.
Occasionally, vascular sheathing, vitreous haze, serous retinal detachment, and retinal hemorrhage also may be seen.
C albicans is by far the most common cause of endogenous fungal endophthalmitis.
Other organisms that can cause fungal endophthalmitis include the following:
Essman TF, Flynn HW Jr, Smiddy WE, Brod RD, Murray TG, Davis JL. Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis. Ophthalmic Surg Lasers. 1997 Mar. 28(3):185-94. [Medline].
Klotz SA, Penn CC, Negvesky GJ, Butrus SI. Fungal and parasitic infections of the eye. Clin Microbiol Rev. 2000 Oct. 13(4):662-85. [Medline].
Sridhar J, Flynn HW Jr, Kuriyan AE, Miller D, Albini T. Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections. J Ophthalmic Inflamm Infect. 2013. 3(1):60. [Medline].
Sridhar J, Flynn HW Jr, Kuriyan AE, Miller D, Albini T. Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections. J Ophthalmic Inflamm Infect. 2013 Sep 20. 3 (1):60. [Medline].
Smith TC, Benefield RJ, Kim JH. Risk of Fungal Endophthalmitis Associated with Cataract Surgery: A Mini-Review. Mycopathologia. 2015 Dec. 180 (5-6):291-7. [Medline].
Mikosz CA, Smith RM, Kim M, Tyson C, Lee EH, Adams E. Fungal endophthalmitis associated with compounded products. Emerg Infect Dis. 2014 Feb. 20(2):248-56. [Medline].
Schiedler V, Scott IU, Flynn HW, Davis JL, Benz MS, Miller D. Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. Am J Ophthalmol. 2004 Apr. 137(4):725-31. [Medline].
Shah CP, McKey J, Spirn MJ, Maguire J. Ocular candidiasis: a review. Br J Ophthalmol. 2008 Apr. 92(4):466-8. [Medline].
Rao NA, Hidayat A. A comparative clinicopathologic study of endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared to aspergillosis. Trans Am Ophthalmol Soc. 2000. 98:183-93; discussion 193-4. [Medline].
Lundquist O, Osterlin S. Glucose concentration in the vitreous of nondiabetic and diabetic human eyes. Graefes Arch Clin Exp Ophthalmol. 1994 Feb. 232(2):71-4. [Medline].
Paulus YM, Cheng S, Karth PA, Leng T. PROSPECTIVE TRIAL OF ENDOGENOUS FUNGAL ENDOPHTHALMITIS AND CHORIORETINITIS RATES, CLINICAL COURSE, AND OUTCOMES IN PATIENTS WITH FUNGEMIA. Retina. 2015 Dec 11. [Medline].
Lalwani GA, Flynn HW Jr, Scott IU, Quinn CM, Berrocal AM, Davis JL, et al. Acute-onset endophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology. 2008 Mar. 115(3):473-6. [Medline].
Anand A, Madhavan H, Neelam V, Lily T. Use of polymerase chain reaction in the diagnosis of fungal endophthalmitis. Ophthalmology. 2001 Feb. 108(2):326-30. [Medline].
Sakai T, Kohzaki K, Watanabe A, Tsuneoka H, Shimadzu M. Use of DNA microarray analysis in diagnosis of bacterial and fungal endophthalmitis. Clin Ophthalmol. 2012. 6:321-6. [Medline].
William A, Spitzer MS, Deuter C, Blumenstock G, Partsch M, Voykov B, et al. Outcomes of Primary Transconjunctival 23-Gauge Vitrectomy in the Diagnosis and Treatment of Presumed Endogenous Fungal Endophthalmitis. Ocul Immunol Inflamm. 2016 Jan 30. 1-7. [Medline].
Khan FA, Slain D, Khakoo RA. Candida endophthalmitis: focus on current and future antifungal treatment options. Pharmacotherapy. 2007 Dec. 27(12):1711-21. [Medline].
Mora-Duarte J, Betts R, Rotstein C, Colombo AL, Thompson-Moya L, Smietana J. Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med. 2002 Dec 19. 347(25):2020-9. [Medline].
Gauthier GM, Nork TM, Prince R, Andes D. Subtherapeutic ocular penetration of caspofungin and associated treatment failure in Candida albicans endophthalmitis. Clin Infect Dis. 2005 Aug 1. 41(3):e27-8. [Medline].
Mikosz CA, Smith RM, Kim M, Tyson C, Lee EH, Adams E, et al. Fungal endophthalmitis associated with compounded products. Emerg Infect Dis. 2014 Feb. 20 (2):248-56. [Medline].
Sallam A, Taylor SR, Khan A, McCluskey P, Lynn WA, Manku K. FACTORS DETERMINING VISUAL OUTCOME IN ENDOGENOUS CANDIDA ENDOPHTHALMITIS. Retina. 2012 Jan 31. [Medline].
Tanaka H, Ishida K, Yamada W, Nishida T, Mochizuki K, Kawakami H. Study of ocular candidiasis during nine-year period. J Infect Chemother. 2016 Mar. 22 (3):149-56. [Medline].
Akler ME, Vellend H, McNeely DM, Walmsley SL, Gold WL. Use of fluconazole in the treatment of candidal endophthalmitis. Clin Infect Dis. 1995 Mar. 20(3):657-64. [Medline].
Blumenkranz MS, Stevens DA. Therapy of endogenous fungal endophthalmitis: miconazole or amphotericin B for coccidioidal and candidal infection. Arch Ophthalmol. 1980 Jul. 98(7):1216-20. [Medline].
Breit SM, Hariprasad SM, Mieler WF et al. Management of endogenous fungal endophthalmitis with voriconazole and caspofungin. Am J Ophthalmol. 2005 Jan. 139(1):135-40. [Medline].
Brod RD, Flynn HW, Clarkson JG, Pflugfelder SC, Culbertson WW, Miller D. Endogenous Candida endophthalmitis. Management without intravenous amphotericin B. Ophthalmology. 1990 May. 97(5):666-72; disc: 672-4. [Medline].
Brooks RG. Prospective study of Candida endophthalmitis in hospitalized patients with candidemia. Arch Intern Med. 1989 Oct. 149(10):2226-8. [Medline].
Christmas NJ, Smiddy WE. Vitrectomy and systemic fluconazole for treatment of endogenous fungal endophthalmitis. Ophthalmic Surg Lasers. 1996 Dec. 27(12):1012-8. [Medline].
Cornely OA, Schmitz K, Aisenbrey S. The first echinocandin: caspofungin. Mycoses. 2002. 45 Suppl 3:56-60. [Medline].
Crump JR, Elner SG, Elner VM, Kauffman CA. Cryptococcal endophthalmitis: case report and review. Clin Infect Dis. 1992 May. 14(5):1069-73. [Medline].
Donahue SP, Greven CM, Zuravleff JJ, Eller AW, Nguyen MH, Peacock JE Jr, et al. Intraocular candidiasis in patients with candidemia. Clinical implications derived from a prospective multicenter study. Ophthalmology. 1994 Jul. 101(7):1302-9. [Medline].
Edwards JE Jr, Foos RY, Montgomerie JZ, Guze LB. Ocular manifestations of Candida septicemia: review of seventy-six cases of hematogenous Candida endophthalmitis. Medicine (Baltimore). 1974 Jan. 53(1):47-75. [Medline].
Gao H, Pennesi ME, Shah K, Qiao X, Hariprasad SM, Mieler WF, et al. Intravitreal voriconazole: an electroretinographic and histopathologic study. Arch Ophthalmol. 2004 Nov. 122(11):1687-92. [Medline].
Griffin JR, Pettit TH, Fishman LS, Foos RY. Blood-borne Candida endophthalmitis. A clinical and pathologic study of 21 cases. Arch Ophthalmol. 1973 Jun. 89(6):450-6. [Medline].
Gross JG. Endogenous Aspergillus-induced endophthalmitis. Successful treatment without systemic antifungal medication. Retina. 1992. 12(4):341-5. [Medline].
Henderson DK, Edwards JE Jr, Montgomerie JZ. Hematogenous candida endophthalmitis in patients receiving parenteral hyperalimentation fluids. J Infect Dis. 1981 May. 143(5):655-61. [Medline].
Hunt KE, Glasgow BJ. Aspergillus endophthalmitis. An unrecognized endemic disease in orthotopic liver transplantation. Ophthalmology. 1996 May. 103(5):757-67. [Medline].
Luttrull JK, Wan WL, Kubak BM, Smith MD, Oster HA. Treatment of ocular fungal infections with oral fluconazole. Am J Ophthalmol. 1995 Apr. 119(4):477-81. [Medline].
Martinez-Vazquez C, Fernandez-Ulloa J, Bordón J, Sopena B, de la Fuente J, Ocampo A, et al. Candida albicans endophthalmitis in brown heroin addicts: response to early vitrectomy preceded and followed by antifungal therapy. Clin Infect Dis. 1998 Nov. 27(5):1130-3. [Medline].
McDonald HR, De Bustros S, Sipperley JO. Vitrectomy for epiretinal membrane with Candida chorioretinitis. Ophthalmology. 1990 Apr. 97(4):466-9. [Medline].
Naoi N, Sawada A. Effect of vitrectomy on epiretinal membranes after endogenous fungal endophthalmitis. Jpn J Ophthalmol. 1996. 40(3):434-8. [Medline].
Okhravi N, Adamson P, Mant R, Matheson MM, Midgley G, Towler HM, et al. Polymerase chain reaction and restriction fragment length polymorphism mediated detection and speciation of Candida spp causing intraocular infection. Invest Ophthalmol Vis Sci. 1998 May. 39(6):859-66. [Medline].
Okhravi N, Dart JK, Towler HM, Lightman S. Paecilomyces lilacinus endophthalmitis with secondary keratitis: a case report and literature review. Arch Ophthalmol. 1997 Oct. 115(10):1320-4. [Medline].
Ozdamar A, Aras C, Ozturk R, Akin E, Karacorlu M, Ercikan C. In vitro antimicrobial activity of silicone oil against endophthalmitis-causing agents. Retina. 1999. 19(2):122-6. [Medline].
Parke DW 2nd, Jones DB, Gentry LO. Endogenous endophthalmitis among patients with candidemia. Ophthalmology. 1982 Jul. 89(7):789-96. [Medline].
Scherer WJ, Lee K. Implications of early systemic therapy on the incidence of endogenous fungal endophthalmitis. Ophthalmology. 1997 Oct. 104(10):1593-8. [Medline].
Sheu SJ, Chen YC, Kuo NW, et al. Endogenous cryptococcal endophthalmitis. Ophthalmology. 1998 Feb. 105(2):377-81. [Medline].
Smiddy WE. Treatment outcomes of endogenous fungal endophthalmitis. Curr Opin Ophthalmol. 1998 Jun. 9(3):66-70. [Medline].
Smith SR, Kroll AJ, Lou PL, Ryan EA. Endogenous bacterial and fungal endophthalmitis. Int Ophthalmol Clin. 2007. 47(2):173-83. [Medline].
Weishaar PD, Flynn HW, Murray TG, Davis JL, Barr CC, Gross JG, et al. Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes. Ophthalmology. 1998 Jan. 105(1):57-65. [Medline].
Weissgold DJ, Maguire AM, Brucker AJ. Management of postoperative acremonium endophthalmitis. Ophthalmology. 1996 May. 103(5):749-56. [Medline].
Zakka KA, Foos RY, Brown WJ. Intraocular coccidioidomycosis. Surv Ophthalmol. 1978 Mar-Apr. 22(5):313-21. [Medline].
Zhang YQ, Wang WJ. Treatment outcomes after pars plana vitrectomy for endogenous endophthalmitis. Retina. 2005 Sep. 25(6):746-50. [Medline].