Endogenous fungal endophthalmitis:risk factors,clinical course,and visual outcome in 13 patients

AIM:To analyze the risk factors,ophthalmological features,treatment modalities and their effect on the visual outcome in patients with endogenous fungal endophthalmitis(EFE).METHODS:Data retrieved from the medical files included age at presentation to the uveitis clinic,gender,ocular symptoms and their duration before presentation,history of fever,eye affected,anatomical diagnosis and laboratory evidence of fungal infection.Medical therapy recorded included systemic antifungal therapy and its duration,use of intravitreal antifungal agents and use of oral/intravitreal steroids.Surgical procedures and the data of ophthalmologic examination at presentation and at last follow-up were also collected.RESULTS:Included were 13 patients(20 eyes,mean age 58 y).Ten patients presented after gastrointestinal or urological interventions and two presented after organ transplantation.In one patient,there was no history of previous intervention.Diagnostic vitrectomy was performed in 16 eyes(80%)and vitreous cultures were positive in 10 of the vitrectomized eyes(62.5%).In only 4 patients(31%),blood cultures were positive.All patients received systemic antifungal therapy.Sixteen eyes(80%)received intravitreal antifungal agent with voriconazole being the most commonly used.Visual acuity(VA)improved from 0.9±0.9 at initial exam to 0.5±0.8 logMAR at last followup(P=0.03).A trend of greater visual improvement was noted in favor of eyes treated with oral steroids(±intravitreal dexamethasone)than eyes that were not treated with steroids.The most common complication was maculopathy.Twelve eyes(60%)showed no ocular complications.CONCLUSION:High index of suspicion in patients with inciting risk factors is essential because of the low yield of blood cultures and the good general condition of patients at presentation.Visual prognosis is improved with the prompt institution of systemic and intravitreal pharmacotherapy and the immediate surgical intervention.Oral±local steroids could be considered in cases of prolonged or marked inflammatory responses in order to hasten control of inflammation and limit ocular complications.

Surgical management of fungal endophthalmitis resulting from fungal keratitis

AIM： To report the fungal organisms, clinical features, surgical treatment strategies, and outcomes of patients with culture-proven exogenous fungal endophthalmitis （EFE） secondary to keratitis, and evaluate the role of surgery in the treatment. METHODS： The clinical records of 27 patients （27 eyes） with culture-proven EFE resulting from fungal keratitis treated at Shandong Eye Institute from January 2007 to January 2015 were retrospectively reviewed. Information about fungal culture results, clinical features, surgical procedures, and final visual acuity was obtained. RESULTS： There were 39 positive culture results from samples of cornea, hypopyon, vitreous and lens capsule, accounting for 56%, 26%, 15% and 2.5%, respectively. Fusarium was identified in 44% （12/27） of the eyes, followed by Aspergillus in 22% （6/27）. Posterior segment infection was involved in 78% （21127） of the patients. The corneal infection was larger than 3 mmx3 mm in 89% （24/ 27） of the patients, and 22% （6/27） of them had the entire cornea, and even the sclera involved. Three eyes had silicone oil tamponade, and two eyes had retinal detachment. Twenty-two eyes （81.5%） underwent penetrating keratoplasty （PKP）, and over half of them （545%） were operated within 3d from the onset of antifungal therapy. Fourteen eyes （52%） underwent intracameral antifungal drug injection, and three of them required repeated injections. Fifteen eyes （55.6%） underwent pars plana vitrectomy （PPV）. The rate of the eyes undergoing PPV as the initial surgical procedure was 60% （9/15）, lower than 77% in PKP. Intravitreal injection was given in 59% of the eyes （16/27）, and 75% of them required repeated injections. The final visual acuity was 20/100 or better in 37% of the eyes, and better than counting fingers in 55.6% of the eyes. Five eyes （18.5%） were eviscerated. In the two eyes with concurrent retinal detachment, one achieved retinal reattachment, and the other was eviscerated. In the three eyes with silicone oil tamponade, two eyes received silicone oil removal, and the other one was eviscerated. CONCLUSION： Fusarium and Aspergillus are the dominant pathogens in EFE resulting from keratitis. Aggressive antifungal surgeries including multiple intravitreal injections, PKP and core vitrectomy （especially in the initial surgery） are helpful procedures to improve prognosis of severe EFE secondary to keratitis.

A case of infectious endophthalmitis misdiagnosed as uveitis

Intraocular foreign body residue following ophthalmic surgery is rare but may cause severe postoperative occult inflammation.In some cases,small foreign bodies located in the anterior chamber angle may be missed by follow-up ultrasound biomicroscopy(UBM).We report the case of an elderly female whose right eye was injured by a nail and received corneal repair surgery in our hospital.Eleven days post-surgery,we found a mobile,short,translucent,rod-shaped foreign body in the upper corner of the right eye and another in the iris root at 7 o’clock.Two months post-surgery,the patient consulted a doctor due to right eye redness,pain,and vision loss,which was ultimately shown to be associated with foreign body residue resulting in a delayed postoperative inflammatory response.The patient was cured by surgeries and active anti-inflammatory and anti-infection treatments,but the final diagnosis of the patient was infectious endophthalmitis misdiagnosed as uveitis,which worths our consideration.We also review relevant literature on the differentiation of postoperative infectious endophthalmitis from noninfectious uveitis.It’s a reminder that patients with delayed endophthalmitis after open ocular trauma should not exclude the possibility of intraocular foreign bodies.As well clinicians can distinguish infectious endophthalmitis from uveitis by needle aspiration biopsy or vitrectomy for microbial culture in order to determine the need for antibiotic treatment.