Fungal Endophthalmitis Clinical Presentation

  • Author: Lihteh Wu, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Apr 30, 2012
 

History

  • 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.
    • Red eye
    • Photophobia
    • Pain
    • Floaters
    • Scotoma
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Physical

  • Candida endophthalmitis
    • 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.
  • Aspergillus endophthalmitis
    • 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 endophthalmitis
    • 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.
  • Coccidioides endophthalmitis
    • 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.
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Causes

  • C albicans is by far the most common cause of endogenous fungal endophthalmitis.
  • Other organisms that can cause fungal endophthalmitis include the following:
    • Aspergillus species
    • Cryptococcus neoformans
    • Coccidioides immitis
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Contributor Information and Disclosures
Author

Lihteh Wu, MD  Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica

Lihteh Wu, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Pan-American Association of Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Coauthor(s)

Teodoro Evans, MD  Retina Fellow, St Michael's Hospital, University of Toronto, Canada

Disclosure: Nothing to disclose.

Rafael Alberto García, MD  Chief of Outpatient Services, Department of Ophthalmology, Hospital México of San José, Costa Rica

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew A Dahl, MD  Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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