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      News & Perspective Drugs & Diseases CME & Education Academy Video Decision Point
      Drugs & Diseases > Ophthalmology

      Fungal Endophthalmitis Clinical Presentation

      Updated: Mar 14, 2023
      • Author: Lihteh Wu, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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      Presentation

      History

      Patients with a history of recent COVID-19 hospitalization and/or systemic corticosteroid use, even without other known risk factors, should be considered to be at risk for endogenous fungal endophthalmitis. [18, 19, 20]

      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; [21] postpartum patients; premature infants; patients undergoing hyperalimentation; patients with a history of recent abdominal surgery; patients who have undergone genitourinary procedures; [22] and patients with debilitating diseases, such as diabetes mellitus, post–organ transplantation, or malignancies.

      Risk factors for Aspergillus endophthalmitis

      Patients with a history of renal transplantation who are receiving corticosteroids, leukemia and other hematologic 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

      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

      Next:

      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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      Next:

      Complications

      Potential complications include the following:

      • Choroidal neovascularization at the site of chorioretinal scars
      • Epiretinal membranes
      • Tractional retinal detachment
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      Differential Diagnoses
       
       
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