The authors of this study from the January issue of the American Journal of Ophthalmology retrospectively reviewed microbiologic and medical records from a large case series of patients with endogenous fungal endophthalmitis. Yeasts were the most common cause of culture-proven endogenous fungal endophthalmitis. They found that the condition generally is associated with poor vision outcomes, especially when caused by molds, and retinal detachment is a frequent occurrence during follow-up.
Although this study has limitations, including its retrospective design, lack of uniform protocol for diagnosis or treatment, limited and variable follow-up, and limited use of newer antifungal treatments, such as voriconazole, I believe it provides valuable information for increasing our understanding of endogenous fungal endophthalmitis.
The study included 51 patients (65 eyes) with culture-positive endogenous fungal endophthalmitis seen at a single institution over a 20-year period. Time from onset of symptoms to presentation ranged from zero to 60 days (mean, 13 days). Follow-up was a mean of 18 months and ranged from two days to more than 15 years.
The causative organisms were yeasts in 38 patients (75 percent) and molds in 13 patients (25 percent). Retinal detachment occurred in 17 eyes (26 percent). At final follow-up 28 eyes (56 percent) with yeasts and five eyes (33 percent) with molds obtained a visual acuity of 20/200 or better. Final visual acuity of 20/50 or better was reached in 24 percent of eyes with retinal detachment.
The vast majority of patients (59 eyes) underwent pars plana vitrectomy during follow-up. When used as the initial diagnostic procedure, vitrectomy yielded positive culture results in 92 percent of eyes, anterior chamber paracentesis in 25 percent of eyes and vitreous tap in 44 percent of eyes.
The authors recommend a high index of clinical suspicion in patients with systemic risk factors for endogenous fungal endophthalmitis and clinical signs, such as diffuse vitreitis, chorioretinal inflammatory lesions with focal vitreous inflammation or subretinal chorioretinal lesions. In such patients, a diagnostic vitrectomy should be considered and appropriate intravitreal therapy given depending on clinical findings and culture results. Oral antifungal agents, such as fluconazole, can also be considered. Repeat intravitreal injections once or twice weekly may be required until infection subsides. They also recommend following patients for the possible development of retinal detachment.