Academy guidelines for Candida-related endophthalmitis screening now available

The American Academy of Ophthalmology has published its recommendations against routine screening of patients for endophthalmitis caused by Candida septicemia.

Study design

The 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Management of Candidiasis recommends a dilated eye exam for all patients with candidemia; however, this recommendation was made from decades-old data without input of ophthalmologists and before the widespread use of systemic antifungals. This is a position paper from the Academy with a review of historical and recent data on the utility of routine screening for endophthalmitis in patients with Candida septicemia.

Outcomes

Recent data suggest that endophthalmitis from Candida septicemia is found in <1% of routinely screened patients. A 2003 study found that 19% of patients in hospital intensive care units had abnormal retinal findings regardless of candidemia status, which is comparable to the 16% cited in the IDSA candidemia screening guidelines. This suggests that incidental findings, such as Roth spots and cotton wool spots, found during screening may often be due to the underlying comorbidities in critically ill patients rather than from candidemia. Intraocular Candida lesions typically originate from the highly vascularized inner choroid, which is easily accessible by systemic antifungals. Overall, the Academy’s position is that an ophthalmic consultation is reasonable for a patient with clinical signs or symptoms concerning for ocular infection but recommends against routine evaluations after laboratory findings of Candida septicemia due to a lack of evidence supporting its value. The Academy suggests that any future recommendations be developed from collaboration between ophthalmologists and infectious disease specialists.

Limitations

The results of this paper summarize anecdotal experience from many ophthalmologists who provide hospital consultations. A similar paper should be published in a nationally recognized infectious disease journal and the recommendations disseminated by infectious disease professional societies to have a major change in practice.

Clinical significance

As an updated, evidence-based statement from the largest ophthalmic professional society, this position paper serves as a credible reference against routine ophthalmic screening for systemic Candida septicemia that can be used by hospitals across the country. Ophthalmologists can reference this paper with hospital infectious disease departments who continue to follow outdated recommendations.

Financial Disclosures: Dr. Xuejing Chen discloses no financial relationships.