1997 Jun. B-scan ultrasound findings for a patient with Candida endophthalmitis are shown in Figure 5. The investigators found 2 traits shared among the patients who developed endophthalmitis on ultrasound: vitreous opacifications and detachment of the posterior vitreous membrane. found that in 27 cases of post-cataract fungal endophthalmitis at a tertiary care hospital in India with a positive vitreous aspirate, 16 (59.3%) were A. flavus, 3 (11.1%) were A. fumigatus, and the rest included A. niger, Acremonium kiliense, Fonsecaea predosoi, Candida guilliermondii, C. albicans, and C. tropicalis [26]. She denied blurry vision, flashers, floaters, or changes in visual acuity; however, she could not see out of her left eye secondary to swelling. Pars plana vitrectomy also has a role in the treatment of retinal complications of infectious endophthalmitis. Surgery may be needed to remove infected tissue from inside the eye, which may improve the chances of stopping the infection. Early versus late removal of retained intraocular foreign bodies. Voriconazole against fluconazole-susceptible and resistant candida isolates: In-vitro efficacy compared with that of itraconazole and ketoconazole. [QxMD MEDLINE Link]. 1 similarly reported on a series of four cases of presumed endogenous fungal endophthalmitis in patients with COVID-19 pneumonia [57]. This review outlines the microbiological profile of endophthalmitis, current clinically used methods for organism identification, and the newer molecular techniques of polymerase chain reaction (PCR) and next-generation sequencing (NGS) technology as diagnostic tools for endophthalmitis. 2008; 115(9): 15011507.e15072 [17]. Shroff D., Narula R., Atri N., Chakravarti A., Gandhi A., Sapra N., Bhatia G., Pawar S.R., Narain S. Endogenous fungal endophthalmitis following intensive corticosteroid therapy in severe COVID-19 disease. Endophthalmitis refers to inflammation of the internal ocular structures with involvement of the vitreous and aqueous humors [1,2,3]. No high-powered studies have examined the relative incidence of bacterial versus fungal etiologies in exogenous endophthalmitis overall; data are generally limited to subclassifications of exogenous endophthalmitis, such as an overwhelming majority of bacterial sources in acute post-cataract surgery endophthalmitis (approaching 100% in the United States and Europe [1,2,17]) and a fungal majority (approximately 50% Aspergillus and Fusarium species) in keratitis-related exogenous endophthalmitis [2]. 53 (3):262-8. Endogenous bacterial endophthalmitis. You are being redirected to Noninfectious (sterile) endophthalmitis may result from various causes such as retained native lens material after an operation or from toxic agents. Ciulla TA, Beck AD, Topping TM, Baker AS. The most common incorrect initial diagnosis for endophthalmitis is non-infectious uveitis [2]. This might explain why the positive rate of VF samples was higher. Corneal perforation is not a sensitive finding for endophthalmitis: In Wan et al.s study, it was only present in 4 of 37 (10.8%) patients with fungal endophthalmitis in the setting of fungal keratitis. Gower EW, Keay LJ, Stare DE, Arora P, Cassard SD, Behrens A, et al. 0000012737 00000 n found that the most common infectious etiology was Gram-negative bacteria (31 cases, 54.4%), while C. albicans was the most common fungal etiology, present in 9 cases (15.8%) [12]. Diagnosis of endophthalmitis upon hospital admission was associated with a higher intraocular culture positivity (P = 0.040) and a shorter hospital stay (P = 0.035). Another group, Shen and Xu, reported that 11 of 20 (55.0%) vitreous specimens obtained via needle tap were negative in patients with endogenous endophthalmitis although PPV specimens later confirmed that all 11 were in fact fungi [74]. These CT findings suggested the presence of orbital cellulitis but did not offer clear evidence of vitreous involvement. The diagnosis of IOL-related inflammation was made by onset time, history of steroid treatment, and cytologic and microbiological examinations. Inflammation is caused by an infection. Am J Ophthalmol. The bacteria in anterior chambers are more easily cleared out than those in the vitreous body. Jambulingam M, Parameswaran SK, Lysa S, Selvaraj M, Madhavan HN. 2 The most common clinical manifestation of fungal endophthalmitis is vision loss, but other signs of inflammation and infection are frequently present. An important clue differentiating fungal endophthalmitis from bacterial endophthalmitis lies in the time course of clinical presentation. Intravitreal voriconazole: 100 g/0.1 mL. Eur J Ophthalmol. Though speciation information was not reported, Shah et al. Endophthalmitis is a medical emergency because vision prognosis is directly related to the time from onset to treatment. [QxMD MEDLINE Link]. Would you like email updates of new search results? 2020 Apr;212:34-42. doi: 10.1016/j.ajo.2019.11.026. performed a systematic review of endogenous Candida endophthalmitis cases and found that patients with chorioretinitis respond well to antifungal monotherapy, but in cases of vitreous involvement, drug penetration of amphotericin B is limited and pharmacologic management is insufficient [80]. Accessibility [QxMD MEDLINE Link]. The underlying etiology of infectious endophthalmitis is typically bacterial or fungal. 2014 May-Jun;59(3):286-303. doi: 10.1016/j.survophthal.2013.08.002. Possible complications of treatment modalities for fungal endophthalmitis are numerous. Ophthalmology. Miller JJ, Scott IU, Flynn HW Jr, Smiddy WE, Murray TG, Berrocal A, et al. Blood cultures may be used in the diagnostic workup for fungal endophthalmitis. Microbiological methods of microscopy (Gram's staining) and culture are the current gold standard for organism identification. Semin Ophthalmol. identified a retinal detachment rate of 26% following cases of endogenous fungal endophthalmitis [73]. Bethesda, MD 20894, Web Policies Fusarium Endophthalmitis following cataract Surgery: Successful Treatment with Intravitreal and Systemic Voriconazole. Systematic review of 342 cases of endogenous bacterial endophthalmitis, The emergence of Klebsiella pneumoniae endogenous endophthalmitis in the USA: basic and clinical advances. WB Saunders; 2013. Siddiqui M.Z., Gebhard G.M., Ahmad K.T., Sallam A.B., Rosenbaum E.R., Uwaydat S.H. Tanaka M., Kobayashi Y., Takebayashi H., Kiyokawa M., Qiu H. Analysis of predisposing clinical and laboratory findings for the development of endogenous fungal endophthalmitis. Keyhani K., Seedor J.A., Shah M.K., Terraciano A.J., Ritterband D.C. The link you have selected will take you to a third-party website. 8:2183-8. Endophthalmitis is a potential sight-threatening condition that leads to blindness. Wang L., Sun S., Jing Y., Han L., Zhang H., Yue J. o [teenager OR adolescent ], , MD, Boston University School of Medicine. There was no statistical difference between positive rates obtained between the smear and culture methods used to test all AH and VF specimens (Table 1). Modjtahedi BS, Finn AP, Papakostas TD, Durand M, Husain D, Eliott D. Intravenous Drug Use-Associated Endophthalmitis. If infection spreads from the globe to the neighboring soft tissues within the orbit, it is then classified as panophthalmitis [1]. . In this case, the strongly demarcated hyperechoic debris in the globe visualized on ultrasound significantly raised clinical suspicion for endophthalmitis in addition to orbital cellulitisa diagnosis that could not have been obtained by CT nor physical exam alone given the degree of periorbital swelling. Alfaro DV, Roth D, Liggett PE. The patient was unable to tolerate full visual acuity testing due to tenderness and swelling but reported blurry vision in her left eye compared to the right. Pulimood S., Ganesan L., Alangaden G., Chandrasekar P. Polymicrobial candidemia. Licensee MDPI, Basel, Switzerland. 0000010444 00000 n Epub 2019 Nov 23. It is caused by organisms that have entered the eye through a surgical incision or an injury to the eyeball or, less often, have traveled through the bloodstream into the eye. Endophthalmitis caused by Bacillus species. In fungal endophthalmitis, there are three levels of indications for the surgery-diagnostic vitrectomy, treatment of infection, and management of surgical complications that result from infection. 2009 Apr. This is not the procedure for patients with solely orbital cellulitis, as those patients can be managed at the initial presenting facility. 1994 May. FOIA In the last decade, there has been a two-fold increase in deaths secondary to drug dependence [53]. Liposomal amphotericin B: 35 mg/kg intravenously daily, with or without oral flucytosine 25 mg/kg four times daily. previously studied 43 intraocular specimens of known cases of fungal endophthalmitis and found culture positivity in 24 (55.8%) cases compared to PCR positivity in 32 (74.4%) [69]. Cultures are taken of eye fluids, and antibiotics are given as soon as possible. The .gov means its official. and transmitted securely. Please enable it to take advantage of the complete set of features! Ophthalmology. Figure 1. VF samples were collected from 24 of 36 infectious endophthalmitis patients as a therapeutic or diagnostic aspirate during pars plana vitrectomy. Previously, Silva et al. Similarly, while exceedingly rare, case reports have indicated the possibility of fungal endophthalmitis following Descemet stripping automated endothelial keratoplasty (DSAEK) surgery via the presence of surface venting incisions. reported that early PPV may be protective against development of retinal detachment in endogenous Candida endophthalmitis [8]. reported positivity of 75% [71]. reported a case of successful inflammatory resolution of Candida ciferri post-operative endophthalmitis using intravitreal capsofungin in the setting of C. ciferri resistance to fluconazole, voriconazole, and amphotericin B [97]. Overall, limited data in the literature suggest that both classes of drugs recommended by the ISDA are efficacious when used appropriately. the contents by NLM or the National Institutes of Health. If these, 9.8% had Candida infection and 1.8% had disseminated candidiasis [53]. An accurate clinical diagnosis for endophthalmitis confirmed by laboratory techniques is essential for early treatment with antifungal drugs, such as amphotericin B, imidazoles, and other antifungals. 2015. Richard Lavely, MD, JD, MS, MPH Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine Severe ocular inflammation with vitreous involvement following intraocular surgery should raise suspicion for post-operative endophthalmitis. who found 26 endophthalmitis cases amongst 448 open globe injuries (5.8%) [20]. Am J Ophthalmol. Binder M.I., Chua J., Kaiser P.K., Procop G.W., Isada C.M. Topical tetracaine drops were administered in bilateral eyes for comfort during intraocular pressures, which were measured bilaterally and elevated in the left eye to 35mm Hg whereas right eye pressure was 15mm Hg. 2021 Aug. 41 (8):2887-2895. Tan C.L., McGuinness M.B., Essex R., Dawkins R.C.H., Allen P.J. Mario J Castellanos, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Physicians, American Medical Association, Emergency Medicine Residents' Association, Gold Humanism Honor Society, Latino Medical Student AssociationDisclosure: Nothing to disclose. [CrossRef] [Google Scholar]. reported on a patient with endogenous Candida endophthalmitis who failed treatment with intravenous voriconazole and caspofungin and subsequently was successfully treated with intravitreal amphotericin B [92]. The https:// ensures that you are connecting to the [QxMD MEDLINE Link]. Kohanim S, Daniels AB, Huynh N, Eliott D, Chodosh J. Management of endogenous fungal endophthalmitis with voriconazole and caspofungin. Filler S.G., Crislip M.A., Mayer C.L., Edwards J.E., Jr. The site is secure. In more tropical locations such as India, a fungal predominance of pathogenesis is seen (21.5% compared to 10.0% confirmed bacterial positivity) in post-cataract endophthalmitis [25]. examined 12 eyes in 10 patients with endogenous Aspergillus endophthalmitis and found sustained vision loss in 8 of 12 (66.7%) of eyes, including 7 of 12 (58.3%) with vision worse than 20/200 [116]. Endophthalmitis; PCR; next-generation sequencing; polymerase chain reaction. One Gram-negative bacillus-Klebsiella oxytoca and 1 Gram-positive bacillus-Bacillus subtilis were also found in culture isolates from postoperative endophthalmitis patients. reported on seven eyes, which underwent PPV for endogenous fungal ophthalmitis and reported a flat retina in all post-surgical patients, and that no patients developed phthisis bulbi [102]. In both studies, the authors did not specify the percentage in fungal versus bacterial endophthalmitis. Parke DW 3rd, Pathengay A, Flynn HW Jr, Albini T, Schwartz SG. Other than floaters and decrease vision, the eye can be painful if there is significant iritis or keratitis. The causative agents of endophthalmitis mainly consist of bacteria, although a fungal etiology is not uncommon[3]. It happens inside the tissues or fluids of the eye due to a bacterial or fungal infection. It may occur with certain types of eye. Fungal endophthalmitis is a clinical diagnosis, which can be supported by vitreous, aqueous, or blood cultures. Davis J.L. Aspiration of vitreous fluid was cultured and grew Klebsiella Okada A.A., Johnson R.P., Liles W.C., DAmico D.J., Baker A.S. Endogenous bacterial endophthalmitis. Danielescu et al. If you log out, you will be required to enter your username and password the next time you visit. cultured vitreous fluid from vitrectomy biopsy and found fungal positivity in only 30 (38.0%) of 79 cases of known endogenous fungal endophthalmitis, suggesting that the diagnostic yield of culture may be even lower for fungal endophthalmitis compared to bacterial endophthalmitis [68]. A diagnosis of infectious endophthalmitis was made on the basis of clinical features, including periocular pain, loss of visual acuity, diffuse bulbar conjunctival hyperemia, chemosis, marked intraocular inflammation with fibrinopurulent reaction, and other signs suggestive of infectious etiology. Endogenous endophthalmitis: an 18-year review of culture-positive cases at a tertiary care center. Limited reports exist on treatment of other etiologies of fungal endophthalmitis. 0000004972 00000 n 0000019969 00000 n Rarely, untreated intraocular infections extend beyond the confines of the eye to involve the orbit and CNS. Candida endophthalmitis has been reported in premature infants with systemic candidiasis [55]. and transmitted securely. 11355 ; literature review, A.M.E. and A.A.H. It is a medical emergency. Amphotericin B has a well-studied side effect profile of nausea, vomiting, rigors, fever, hypertension or hypotension, hypoxia, and most notably nephrotoxicity [105,106]. Flushing official website and that any information you provide is encrypted New York, Microorganisms associated with this condition vary along a broad spectrum. One study examining 42 eyes with delayed (mean follow-up 48 weeks) consequences of infectious endophthalmitis included 22 (52.4%) with vitreous opacities, 9 (21.4%) with epiretinal membrane, and 11 (26.2%) with retinal detachment [104]. Chen et al. This number was similar (35 of 355, 9.9%) in cases of fungal keratitis without endophthalmitis. Fundoscopy was attempted, however, due to severe chemosis and swelling, findings were extremely limited and unhelpful in diagnosis of endophthalmitis. conducted a retrospective analysis of 81 patients who developed endophthalmitis following cataract surgery from 2000 to 2005 and searched for sonographic characteristics predictive of developing a future ocular infection. Int Ophthalmol. Amongst intravenous drug users, fungal pathogenesis has been identified in as high as 59% of cases, with C. albicans being the most common etiology [59,60]. Infectious endophthalmitis can be acquired by one of the following mechanisms: 1) surgical procedure (post- operative); 2) trauma caused by a penetrating foreign object (post-traumatic); 3) during metastasis of bacteria into the eye from a distant infection site (endogenous); 4) miscellaneous (e.g., secondary to keratitis) [2]. All the specimens were sent to the microbiology laboratory immediately. An outbreak of fungal endophthalmitis after intravitreal injection of compounded combined bevacizumab and triamcinolone. Taban M., Behrens A., Newcomb R.L., Nobe M.Y., McDonnell P.J. (C) OCT macula findings over the foveal chorioretinal lesion depicting infiltration from choroid through retinal layers into the vitreous with focal areas of traction. FOIA From Nov. 1999 to Dec. 2009, we evaluated intraocular specimens (aqueous humor-AH or vitreous fluid-VF) from 44 patients with a clinical diagnosis of endophthalmitis at Eye Centre of Tianjin Medical University. Results of the Endophthalmitis Vitrectomy Study. Although POCUS was found to be highly sensitive and specific for identifying retinal detachment (SN, 97%; SP, 96%), sensitivity was fair for vitreous hemorrhage (SN, 81.9%) and was poor for vitreous detachment (SN, 42.5%). Imaging findings for a 56-year-old patient with fungal chorioretinitis, showing characteristic fundus, autofluorescence, and optical coherence tomography (OCT) macula findings. A retrospective 12-year study of 79 eyes of 46 patients. Endophthalmitis is a severe complication of several possible ophthalmic insults. Thompson WS, Rubsamen PE, Flynn HW Jr, Schiffman J, Cousins SW. Endophthalmitis after penetrating trauma. Am J Ophthalmol. 0000018880 00000 n Ghoraba H.H., Ellakwa A.F., Elgemai E.M., Mansour H.O., Heikal M.A. A delay of even a few hours can result in irreversible vision loss in extreme cases. Any blood agar plate showing pathogens was tested by the minimum inhibitory concentration (MIC) method for drug sensitivity. Utility of ocular ultrasonography in diagnosing infectious endophthalmitis in patients with media opacities. examined susceptibilities to amphotericin B in 8 isolates and found that all isolates were resistant to intravenous amphotericin B and 7 of 8 (87.5%) were resistant to intravitreal amphotericin B [18]. reported on a case series of eight eyes of eight patients all developing fungal endophthalmitis secondary to injections contaminated with Exserohilum and Bipolaris hawaiiensis, underscoring the importance of using rigorously-protocolized injection samples [35]. Cultures may be taken from the aqueous humor (fluid inside the front of the eye, also called the aqueous) and the vitreous humor (the jellylike substance that fills the back of the eyeball, also . In 2003, Jackson etal The left orbit exhibited proptosis with significant fat stranding and edema, consistent with orbital cellulitis. Shroff et al. Eleven years later in 2014, Jackson etal Gonzales C.A., Scott I.U., Chaudhry N.A., Luu K.M., Miller D., Murray T.G., Davis J.L. Unauthorized use of these marks is strictly prohibited. One of the keys to success in treating this complication is to make an early clinical diagnosis and, if possible, an etiologic diagnosis that can guide treatment with antibiotic therapy. For azole-resistant strains, the ISDA recommends liposomal amphotericin B 35 mg/kg intravenously daily, with or without oral flucytosine 25 mg/kg four times daily [86]. 0000009930 00000 n Ophthalmology. Endophthalmitis is a serious vision-threatening condition, and knowledge of its diagnosis, clinical presentation, and management is essential for both ophthalmologists and physicians dealing with infectious disease. studied 41 cases of culture-positive exogenous fungal endophthalmitis and found that 18 cases (44%) were associated with fungal keratitis, 10 cases (24%) occurred secondary to penetrating ocular trauma, and 13 cases (32%) occurred after intraocular surgery [17]. Desilets J, Lee CS, Fang W, Hinkle DM. sharing sensitive information, make sure youre on a federal Epub 2013 Dec 18. Relhan N, Forster RK, Flynn HW Jr. Endophthalmitis: Then and Now. 1996 Jul. Eur J Ophthalmol. Endophthalmitis Vitrectomy Study Group. Department of Emergency Medicine, 2015 Aug. 43 (6):508-13. Two Gram-positive cocci, Staphylococcus epidermidis and Enterococcus faecalis, were also found in isolates from post-traumatic endophthalmitis patients. Ocul Immunol Inflamm. They found that although there was a statistically significant increase in vision in the immediate PPV group, there was no difference in the proportions of eyes reaching a postoperative acuity of 20/200 between the two groups [101]. Pain on extraocular movement without conjunctival Overview of Candida infections government site. It usually causes permanent loss of vision despite correct antibiotic treatment, and is associated with morbidity and mortality, especially if diagnosis and treatment is not early. In their study of 56,839 cases of endogenous endophthalmitis, Mir et al. Retina. Bacterial and Fungal Endophthalmitis. 2014. 0000018392 00000 n William A., Spitzer M.S., Deuter C., Blumenstock G., Partsch M., Voykov B., Ziemssen F., Bartz-Schmidt K.U., Doycheva D. Outcomes of Primary Transconjunctival 23-Gauge Vitrectomy in the Diagnosis and Treatment of Presumed Endogenous Fungal Endophthalmitis. Treatment of Candida endophthalmitis has not been documented in high-powered clinical trials, mainly due to the disease being uncommon. Based on the largest ophthalmic hospital in Australia, we highlight the key practical challenges faced by Australian diagnostic laboratories for their use in a clinical setting. Ness T, Pelz K, Hansen LL. The clinical presentation of fungal endophthalmitis is variable. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (. Elsewhere, Naoi and Sawada reported on fibrovascular membrane and thick preretinal membrane formation in three patients following PPV for endogenous fungal endophthalmitis [117]. Please confirm that you are not located inside the Russian Federation. Edwards et al. Am J Ophthalmol. Chakrabarti A., Shivaprakash M.R., Singh R., Tarai B., George V.K., Fomda B.A., Gupta A. Fungal endophthalmitis: Fourteen years experience from a center in India. Among these cases, 40%80% present as postocular procedural complications. 9 Although there was no association between duration of fungal endophthalmitis symptoms and development of detachment (OR = 0.77; 95% CI: 0.321.72), poor baseline visual acuity was associated with increased risk of detachment (OR = 5.86; 95% CI: 1.1382.02). Behera U.C., Budhwani M., Das T., Basu S., Padhi T.R., Barik M.R., Sharma S. Role of Early Vitrectomy in the Treatment of Fungal Endophthalmitis. Of 14 Candida isolates examined by Silva et al. 0000002640 00000 n Before 2011 Aug 1.
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