Treatment of endogenous endophthalmitis due to Candida species
- 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
- Marlene L Durand, MD
Marlene L Durand, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Kieren A Marr, MD
Kieren A Marr, MD
- Section Editor — Compromised Host Infections; Fungal Infections
- Professor of Medicine and Oncology
- Johns Hopkins University School of Medicine
- Jonathan Trobe, MD
Jonathan Trobe, MD
- Section Editor — Ophthalmology
- Professor of Ophthalmology and Visual Sciences
- Professor of Neurology
- University of Michigan Kellogg Eye Center
Candida species are a common cause of fungal endophthalmitis. This infection arises in two distinct ways:
●The endogenous form follows candidemia, with hematogenous seeding of the eye. Fungi usually first seed the highly vascular choroid, then infection typically progresses through the retina into the vitreous. The aqueous is sometimes involved as well.
●The exogenous form follows trauma, eye surgery, or progression of fungal keratitis (corneal infection). Fungi are directly inoculated into the aqueous and/or vitreous. (See "Treatment of exogenous endophthalmitis due to Candida species".)
The management of endogenous endophthalmitis due to Candida species will be reviewed here. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of fungal endophthalmitis are discussed separately. The management of exogenous endophthalmitis due to Candida species and endophthalmitis due to molds are also presented elsewhere. Bacterial endophthalmitis, Fusarium keratitis, and candidemia and other types of Candida infection are also discussed elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of fungal endophthalmitis" and "Treatment of exogenous endophthalmitis due to Candida species" and "Treatment of endophthalmitis due to molds" and "Bacterial endophthalmitis" and "Treatment and prevention of Fusarium infection", section on 'Keratitis' and "Treatment of candidemia and invasive candidiasis in adults" and "Overview of Candida infections".)
The terminology of Candida endophthalmitis may be confusing. The term "endophthalmitis" means infection within the eye and in general implies infection of the vitreous and/or aqueous (figure 1). Endogenous Candida endophthalmitis often presents first as chorioretinitis with minimal vitritis (vitreous inflammation) then later progresses to produce vitreous and sometimes aqueous infection. The term "ocular candidiasis" is used to describe this spectrum of infection, and some articles in the literature reserve the term "Candida endophthalmitis" only for cases in which the vitreous and/or aqueous are involved. However, the majority of publications include the entire spectrum, including chorioretinitis, in the term "Candida endophthalmitis," so we will follow this convention. We will note the distinction between chorioretinitis alone and Candida infection that extends to involve the vitreous throughout this topic because the approach to therapy differs between these two conditions.
- Barza M. Treatment options for candidal endophthalmitis [editoria; comment]. Clin Infect Dis 1998; 27:1134.
- GREEN WR, BENNETT JE, GOOS RD. OCULAR PENETRATION OF AMPHOTERICIN B: A REPORT OF LABORATORY STUDIES AND A CASE REPORT OF POSTSURGICAL CEPHALOSPORIUM ENDOPHTHALMITIS. Arch Ophthalmol 1965; 73:769.
- Savani DV, Perfect JR, Cobo LM, Durack DT. Penetration of new azole compounds into the eye and efficacy in experimental Candida endophthalmitis. Antimicrob Agents Chemother 1987; 31:6.
- Scherer WJ, Lee K. Implications of early systemic therapy on the incidence of endogenous fungal endophthalmitis. Ophthalmology 1997; 104:1593.
- 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.
- Goldblum D, Rohrer K, Frueh BE, et al. Ocular distribution of intravenously administered lipid formulations of amphotericin B in a rabbit model. Antimicrob Agents Chemother 2002; 46:3719.
- Tod M, Lortholary O, Padoin C, Chaine G. Intravenous penetration of fluconazole during endophthalmitis. Clin Microbiol Infect 1997; 3:143.
- Urbak SF, Degn T. Fluconazole in the management of fungal ocular infections. Ophthalmologica 1994; 208:147.
- 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.
- del Palacio A, Cuétara MS, Ferro M, et al. Fluconazole in the management of endophthalmitis in disseminated candidosis of heroin addicts. Mycoses 1993; 36:193.
- Luttrull JK, Wan WL, Kubak BM, et al. Treatment of ocular fungal infections with oral fluconazole. Am J Ophthalmol 1995; 119:477.
- Akler ME, Vellend H, McNeely DM, et al. Use of fluconazole in the treatment of candidal endophthalmitis. Clin Infect Dis 1995; 20:657.
- Nomura J, Ruskin J. Failure of therapy with fluconazole for candidal endophthalmitis. Clin Infect Dis 1993; 17:888.
- Filler SG, Crislip MA, Mayer CL, Edwards JE Jr. Comparison of fluconazole and amphotericin B for treatment of disseminated candidiasis and endophthalmitis in rabbits. Antimicrob Agents Chemother 1991; 35:288.
- Louie A, Liu W, Miller DA, et al. Efficacies of high-dose fluconazole plus amphotericin B and high-dose fluconazole plus 5-fluorocytosine versus amphotericin B, fluconazole, and 5-fluorocytosine monotherapies in treatment of experimental endocarditis, endophthalmitis, and pyelonephritis due to Candida albicans. Antimicrob Agents Chemother 1999; 43:2831.
- Breit SM, Hariprasad SM, Mieler WF, et al. Management of endogenous fungal endophthalmitis with voriconazole and caspofungin. Am J Ophthalmol 2005; 139:135.
- Hariprasad SM, Mieler WF, Lin TK, et al. Voriconazole in the treatment of fungal eye infections: a review of current literature. Br J Ophthalmol 2008; 92:871.
- Riddell J 4th, Comer GM, Kauffman CA. Treatment of endogenous fungal endophthalmitis: focus on new antifungal agents. Clin Infect Dis 2011; 52:648.
- Oude Lashof AM, Rothova A, Sobel JD, et al. Ocular manifestations of candidemia. Clin Infect Dis 2011; 53:262.
- Hariprasad SM, Mieler WF, Holz ER, et al. Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans. Arch Ophthalmol 2004; 122:42.
- Kim JE, Perkins SL, Harris GJ. Voriconazole treatment of fungal scleritis and epibulbar abscess resulting from scleral buckle infection. Arch Ophthalmol 2003; 121:735.
- Reis A, Sundmacher R, Tintelnot K, et al. Successful treatment of ocular invasive mould infection (fusariosis) with the new antifungal agent voriconazole. Br J Ophthalmol 2000; 84:932.
- Garbino J, Ondrusova A, Baglivo E, et al. Successful treatment of Paecilomyces lilacinus endophthalmitis with voriconazole. Scand J Infect Dis 2002; 34:701.
- 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.
- Sarria JC, Bradley JC, Habash R, et al. Candida glabrata endophthalmitis treated successfully with caspofungin. Clin Infect Dis 2005; 40:e46.
- Gauthier GM, Nork TM, Prince R, Andes D. Subtherapeutic ocular penetration of caspofungin and associated treatment failure in Candida albicans endophthalmitis. Clin Infect Dis 2005; 41:e27.
- Mochizuki K, Sawada A, Suemori S, et al. Intraocular penetration of intravenous micafungin in inflamed human eyes. Antimicrob Agents Chemother 2013; 57:4027.
- Mora-Duarte J, Betts R, Rotstein C, et al. Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med 2002; 347:2020.
- Reboli AC, Rotstein C, Pappas PG, et al. Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med 2007; 356:2472.
- Pappas PG, Rotstein CM, Betts RF, et al. Micafungin versus caspofungin for treatment of candidemia and other forms of invasive candidiasis. Clin Infect Dis 2007; 45:883.
- Betts RF, Nucci M, Talwar D, et al. A Multicenter, double-blind trial of a high-dose caspofungin treatment regimen versus a standard caspofungin treatment regimen for adult patients with invasive candidiasis. Clin Infect Dis 2009; 48:1676.
- Kuse ER, Chetchotisakd P, da Cunha CA, et al. Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: a phase III randomised double-blind trial. Lancet 2007; 369:1519.
- Tabbara KF, al Jabarti AL. Hospital construction-associated outbreak of ocular aspergillosis after cataract surgery. Ophthalmology 1998; 105:522.
- Durand ML. Endophthalmitis. In: Principles and Practice of Infectious Diseases, 7th edition, Mandell GL, Bennett JE, Dolin R. (Eds), Churchill Livingstone Elsevier, Philadelphia 2010. Vol 1, p.1553.
- Binder MI, Chua J, Kaiser PK, et al. Endogenous endophthalmitis: an 18-year review of culture-positive cases at a tertiary care center. Medicine (Baltimore) 2003; 82:97.
- Systemic antifungal therapy
- - Choice of agent
- Amphotericin B and flucytosine
- Intravitreal antifungal agents and vitrectomy
- Approach to treatment
- - Endogenous endophthalmitis without vitritis
- - Endogenous endophthalmitis with vitritis
- - Duration of systemic therapy
- SUMMARY AND RECOMMENDATIONS
- Endogenous endophthalmitis without vitritis
- Endogenous endophthalmitis with vitritis
- Exogenous endophthalmitis