Epidemiology, clinical manifestations, and diagnosis of fungal endophthalmitis
- Marlene L Durand, MD
Marlene L Durand, MD
- Associate Professor of Medicine
- Harvard Medical School
- Carol A Kauffman, MD
Carol A Kauffman, MD
- Section Editor — Fungal Infections
- Professor of Internal Medicine
- University of Michigan Medical School
- Veterans Affairs Ann Arbor Healthcare System
- Section Editors
- Stephen B Calderwood, MD
Stephen B Calderwood, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine (Microbiology and Immunobiology)
- Harvard Medical School
- Jonathan Trobe, MD
Jonathan Trobe, MD
- Section Editor — Ophthalmology
- Professor of Ophthalmology and Visual Sciences
- Professor of Neurology
- University of Michigan Kellogg Eye Center
Fungal endophthalmitis due to yeasts (eg, Candida albicans) differs from that due to molds (eg, Aspergillus or Fusarium spp). Yeast-associated endophthalmitis is usually endogenous (secondary to fungemia), and treatment is often successful, whereas mold endophthalmitis is usually exogenous (occurring after trauma, surgery, or keratomycosis) and often results in permanent loss of vision.
The epidemiology, pathogenesis, clinical features, and diagnosis of fungal endophthalmitis will be reviewed here. The management of fungal endophthalmitis is discussed separately; bacterial endophthalmitis, Fusarium keratitis, and candidemia and other types of Candida infections are also presented elsewhere. (See "Treatment of endogenous endophthalmitis due to Candida species" and "Treatment of exogenous endophthalmitis due to Candida species" and "Treatment of endophthalmitis due to molds" and "Bacterial endophthalmitis" and "Mycology, pathogenesis, and epidemiology of Fusarium infection", section on 'Keratitis' and "Treatment of candidemia and invasive candidiasis in adults" and "Overview of Candida infections".)
The term "endophthalmitis" means bacterial or fungal infection within the eye and usually implies infection of the vitreous and/or aqueous (figure 1).
Endogenous fungal endophthalmitis — Endogenous fungal endophthalmitis results from fungal seeding of the eye via the bloodstream. In most cases, the highly vascular choroid is seeded first. As a consequence, endogenous fungal endophthalmitis often presents with choroiditis or chorioretinitis (infection localized to the choroid or the choroid and retina), with minimal inflammation in the vitreous or aqueous. As the infection worsens, marked vitritis develops and the aqueous may also become involved.
The distinction between fungal choroiditis or chorioretinitis and endophthalmitis (ie, with marked vitritis) is important for making decisions about treatment, and we will specify the degree of involvement in the discussion below.
- Durand ML. Endophthalmitis. In: Principles and Practice of Infectious Diseases, 8th, Bennett JE, Dolin R, Blaser MJ (Eds), Churchill Livingstone Elsevier, Philadelphia 2015. Vol 1, p.1415.
- Lingappan A, Wykoff CC, Albini TA, et al. Endogenous fungal endophthalmitis: causative organisms, management strategies, and visual acuity outcomes. Am J Ophthalmol 2012; 153:162.
- Sheu SJ, Chen YC, Kuo NW, et al. Endogenous cryptococcal endophthalmitis. Ophthalmology 1998; 105:377.
- Cunningham ET Jr, Seiff SR, Berger TG, et al. Intraocular coccidioidomycosis diagnosed by skin biopsy. Arch Ophthalmol 1998; 116:674.
- Gonzales CA, Scott IU, Chaudhry NA, et al. Endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum: a case report and literature review. Ophthalmology 2000; 107:725.
- Joshi N, Hamory BH. Endophthalmitis caused by non-albicans species of Candida. Rev Infect Dis 1991; 13:281.
- Oude Lashof AM, Rothova A, Sobel JD, et al. Ocular manifestations of candidemia. Clin Infect Dis 2011; 53:262.
- Griffin JR, Pettit TH, Fishman LS, Foos RY. Blood-borne Candida endophthalmitis. A clinical and pathologic study of 21 cases. Arch Ophthalmol 1973; 89:450.
- Edwards JE Jr, Foos RY, Montgomerie JZ, Guze LB. Ocular manifestations of Candida septicemia: review of seventy-six cases of hematogenous Candida endophthalmitis. Medicine (Baltimore) 1974; 53:47.
- Henderson DK, Edwards JE Jr, Montgomerie JZ. Hematogenous candida endophthalmitis in patients receiving parenteral hyperalimentation fluids. J Infect Dis 1981; 143:655.
- Donahue SP, Greven CM, Zuravleff JJ, et al. Intraocular candidiasis in patients with candidemia. Clinical implications derived from a prospective multicenter study. Ophthalmology 1994; 101:1302.
- Tanaka M, Kobayashi Y, Takebayashi H, et al. Analysis of predisposing clinical and laboratory findings for the development of endogenous fungal endophthalmitis. A retrospective 12-year study of 79 eyes of 46 patients. Retina 2001; 21:203.
- Popovich K, Malani PN, Kauffman CA, et al. Compliance with Infectious Diseases Society of America guidelines for ophthalmologic evaluation of patients with candidemia. Infect Dis Clin Pract 2007; 15:254.
- Krishna R, Amuh D, Lowder CY, et al. Should all patients with candidaemia have an ophthalmic examination to rule out ocular candidiasis? Eye (Lond) 2000; 14 ( Pt 1):30.
- Kannangara S, Shindler D, Kunimoto DY, et al. Candidemia complicated by endophthalmitis: a prospective analysis. Eur J Clin Microbiol Infect Dis 2007; 26:839.
- Rodríguez-Adrián LJ, King RT, Tamayo-Derat LG, et al. Retinal lesions as clues to disseminated bacterial and candidal infections: frequency, natural history, and etiology. Medicine (Baltimore) 2003; 82:187.
- Connell PP, O'Neill EC, Amirul Islam FM, et al. Endogenous endophthalmitis associated with intravenous drug abuse: seven-year experience at a tertiary referral center. Retina 2010; 30:1721.
- Tirpack AR, Duker JS, Baumal CR. An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England. JAMA Ophthalmol 2017; 135:534.
- Moratti E, Kashanpour H, Lombardelli T, Maisto M. Intravenous misuse of buprenorphine: characteristics and extent among patients undergoing drug maintenance therapy. Clin Drug Investig 2010; 30 Suppl 1:3.
- Aboltins CA, Allen P, Daffy JR. Fungal endophthalmitis in intravenous drug users injecting buprenorphine contaminated with oral Candida species. Med J Aust 2005; 182:427.
- Deutscher M, Perlman DC. Why some injection drug users lick their needles: a preliminary survey. Int J Drug Policy 2008; 19:342.
- Bisbe J, Miro JM, Latorre X, et al. Disseminated candidiasis in addicts who use brown heroin: report of 83 cases and review. Clin Infect Dis 1992; 15:910.
- Martínez-Vázquez C, Fernández-Ulloa J, Bordón J, et al. Candida albicans endophthalmitis in brown heroin addicts: response to early vitrectomy preceded and followed by antifungal therapy. Clin Infect Dis 1998; 27:1130.
- Newton-John HF, Wise K, Looke DF. Role of the lemon in disseminated candidiasis of heroin abusers. Med J Aust 1984; 140:780.
- Wykoff CC, Flynn HW Jr, Miller D, et al. Exogenous fungal endophthalmitis: microbiology and clinical outcomes. Ophthalmology 2008; 115:1501.
- Merchant A, Zacks CM, Wilhelmus K, et al. Candidal endophthalmitis after keratoplasty. Cornea 2001; 20:226.
- Tappeiner C, Goldblum D, Zimmerli S, et al. Donor-to-host transmission of Candida glabrata to both recipients of corneal transplants from the same donor. Cornea 2009; 28:228.
- Chakrabarti A, Shivaprakash MR, Singh R, et al. Fungal endophthalmitis: fourteen years' experience from a center in India. Retina 2008; 28:1400.
- Stern WH, Tamura E, Jacobs RA, et al. Epidemic postsurgical Candida parapsilosis endophthalmitis. Clinical findings and management of 15 consecutive cases. Ophthalmology 1985; 92:1701.
- McCray E, Rampell N, Solomon SL, et al. Outbreak of Candida parapsilosis endophthalmitis after cataract extraction and intraocular lens implantation. J Clin Microbiol 1986; 24:625.
- Kauffman CA, Bradley SF, Vine AK. Candida endophthalmitis associated with intraocular lens implantation: efficacy of fluconazole therapy. Mycoses 1993; 36:13.
- Weems JJ Jr. Candida parapsilosis: epidemiology, pathogenicity, clinical manifestations, and antimicrobial susceptibility. Clin Infect Dis 1992; 14:756.
- Benz MS, Scott IU, Flynn HW Jr, et al. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol 2004; 137:38.
- Weishaar PD, Flynn HW Jr, Murray TG, et al. Endogenous Aspergillus endophthalmitis. Clinical features and treatment outcomes. Ophthalmology 1998; 105:57.
- Young LH, Bazari H, Durand ML, Branda JA. Case records of the Massachusetts General Hospital. Case 33-2010. A 22-year-old woman with blurred vision and renal failure. N Engl J Med 2010; 363:1749.
- Lamaris GA, Esmaeli B, Chamilos G, et al. Fungal endophthalmitis in a tertiary care cancer center: a review of 23 cases. Eur J Clin Microbiol Infect Dis 2008; 27:343.
- Riddell Iv J, McNeil SA, Johnson TM, et al. Endogenous Aspergillus endophthalmitis: report of 3 cases and review of the literature. Medicine (Baltimore) 2002; 81:311.
- Epstein AB. In the aftermath of the Fusarium keratitis outbreak: What have we learned? Clin Ophthalmol 2007; 1:355.
- Rosenberg KD, Flynn HW Jr, Alfonso EC, Miller D. Fusarium endophthalmitis following keratitis associated with contact lenses. Ophthalmic Surg Lasers Imaging 2006; 37:310.
- Cornut PL, Thuret G, Creuzot-Garcher C, et al. Relationship between baseline clinical data and microbiologic spectrum in 100 patients with acute postcataract endophthalmitis. Retina 2012; 32:549.
- Lalwani GA, Flynn HW Jr, Scott IU, et al. Acute-onset endophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology 2008; 115:473.
- Gupta A, Gupta V, Gupta A, et al. Spectrum and clinical profile of post cataract surgery endophthalmitis in north India. Indian J Ophthalmol 2003; 51:139.
- Anand AR, Therese KL, Madhavan HN. Spectrum of aetiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol 2000; 48:123.
- Mikosz CA, Smith RM, Kim M, et al. Fungal endophthalmitis associated with compounded products. Emerg Infect Dis 2014; 20:248.
- Tabbara KF, al Jabarti AL. Hospital construction-associated outbreak of ocular aspergillosis after cataract surgery. Ophthalmology 1998; 105:522.
- Güngel H, Eren MH, Pınarcı EY, et al. An outbreak of Fusarium solani endophthalmitis after cataract surgery in an eye training and research hospital in Istanbul. Mycoses 2011; 54:e767.
- Omuta J, Uchida K, Yamaguchi H, Shibuya K. Histopathological study on experimental endophthalmitis induced by bloodstream infection with Candida albicans. Jpn J Infect Dis 2007; 60:33.
- Aziz AA, Bullock JD, McGuire TW, et al. Aspergillus endophthalmitis: a clinical and experimental study. Trans Am Ophthalmol Soc 1992; 90:317.
- Essman TF, Flynn HW Jr, Smiddy WE, et al. Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis. Ophthalmic Surg Lasers 1997; 28:185.
- Hunt KE, Glasgow BJ. Aspergillus endophthalmitis. An unrecognized endemic disease in orthotopic liver transplantation. Ophthalmology 1996; 103:757.
- Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:503.
- Tarai B, Gupta A, Ray P, et al. Polymerase chain reaction for early diagnosis of post-operative fungal endophthalmitis. Indian J Med Res 2006; 123:671.
- Endogenous fungal endophthalmitis
- Exogenous fungal endophthalmitis
- EPIDEMIOLOGY AND RISK FACTORS
- Candida endophthalmitis
- - Endogenous Candida endophthalmitis
- - Exogenous Candida endophthalmitis
- Mold endophthalmitis
- - Endogenous mold endophthalmitis
- - Exogenous mold endophthalmitis
- Endogenous endophthalmitis
- Exogenous endophthalmitis
- CLINICAL MANIFESTATIONS
- Endogenous fungal endophthalmitis
- Exogenous fungal endophthalmitis
- OPHTHALMIC EXAMINATION
- Approach to diagnosis
- Microbiology studies
- Blood cultures
- Polymerase chain reaction
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS