Defining Risk Factors for Fungal Endophthalmitis

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Diagnosis of fungal endophthalmitis remains a clinical challenge, but researchers at the Wilmer Eye Institute in Baltimore have identified specific factors that should raise a clini­cian’s index of suspicion.¹

Study goals. The researchers’ pri­mary objective was “to determine risk factors [for fungal endophthalmitis] at presentation that might help clinicians with diagnosis and prognosis,” said Mark P. Breazzano, MD, now at Retina-Vitreous Surgeons of Central New York in Syracuse.

UNCLEAR CAUSE. Vitreous cells, haze, and debris in a patient with a history of IV drug use. Treatment involved broad-spectrum antimicrobial treatment and systemic steroids. No ocular tissue sample confirmed a fungal cause for this inflammation.

Study design. For this retrospective study, the researchers assessed patients (age, 58.1 ± 16.9 years) who received antifungal injections at Johns Hopkins from 2014 to 2021. All told, 75 patients (81 eyes) were included. The patients’ clinical courses, visual outcomes, and final diagnoses were reviewed, and case features were compared between fungal endophthalmitis and clinically similar diseases.

Outcomes. Eleven patients (12 eyes) had confirmed fungal endophthalmi­tis, 13 (16 eyes) had presumed fungal endophthalmitis, and 38 (40 eyes) were diagnosed with another condition. The following factors were more likely to occur in cases of fungal endophthalmi­tis than in masquerade syndromes:

Systemic: Diagnosis of hepatitis C; diagnosis of complicated diabetes; can­cer under active treatment; diagnosis of sepsis within the previous six months; or any other immunocompromising condition, including HIV and chronic kidney disease.

Drugs and devices: Intravitreal administration of an antifungal agent in the emergency department or in an inpatient setting; presence of an artificial indwelling line; total parenter­al nutrition within the previous week; or an immunosuppressant medication within the last year.

Ophthalmic: Relatively greater preserved VA; longer duration of vision loss prior to presentation; or longer du­ration of ocular pain prior to presenta­tion. Of note, presenting VA correlated with final vision.

Common masquerades. Other observed conditions included bacterial endophthalmitis (n = 16), nonfungal infectious endophthalmitis (n = 13), presumed syphilis (two eyes of one patient), and undifferentiated interme­diate uveitis (two eyes of one patient).

Putting it all together. “Interestingly, the clinical presentations overall were nonspecific across other causes of infection and inflammation, including bacterial and viral,” Dr. Breazzano said. Moreover, he said, “None of the pa­tients were captured by routine ocular screening for a fungal bloodstream in­fection over all seven years of the study.”

A note on screening guidelines. The findings add “to the body of knowledge that systemic medical management for fungal infection should not change based on a routine ocular screening examination,” Dr. Breazzano said.

The issue of screening has been somewhat controversial recently, he added. For instance, the Infectious Diseases Society of America (IDSA) published guidelines recommending a dilated retinal exam, preferably by an ophthalmologist, within a week after a diagnosis of candidemia, regardless of eye symptoms.² However, according to guidelines issued by the Academy, routine eye exams in candidemia are a “low-value practice.”³ Other interna­tional societies also disagree with the IDSA position.⁴

What’s next? More research needs to be done to elucidate presumed fungal endophthalmitis, Dr. Breazza­no said. “Endophthalmitis can be a devastating disease and is, fortunately, rare. It is important that we continue to consider not only fungus as a cause but also other etiologies, even if we are confident or potentially biased [in favor of] a particular diagnosis.”

—Patricia Weiser, PharmD

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1 Priluck AZ et al. Am J Ophthalmol. Published online Feb. 21, 2023.

2 Pappas PG et al. Clin Infect Dis. 2016;62(4):e1-e50.

3 Breazzano MP et al. Ophthalmology. 2022;129(1):73-76.

4 www.rcophth.ac.uk/wp-content/uploads/2021/01/Intensive-Care-Unit.pdf. Accessed March 17, 2023.

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Relevant financial disclosures: Dr. Breazzano—None.

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