Treatment of endophthalmitis due to molds
- 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
Endophthalmitis due to molds is uncommon in temperate climates but is common in tropical regions such as India. Fusarium and Aspergillus spp account for most cases of mold endophthalmitis. Mold endophthalmitis often results in loss of vision.
The treatment of endophthalmitis due to molds will be reviewed here. The epidemiology, clinical features, and diagnosis of fungal endophthalmitis are discussed elsewhere. The treatment of endophthalmitis caused by Candida and bacterial species are also presented separately. Fusarium keratitis is also discussed elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of fungal endophthalmitis" and "Treatment of endogenous endophthalmitis due to Candida species" and "Treatment of exogenous endophthalmitis due to Candida species" and "Bacterial endophthalmitis" and "Treatment and prevention of Fusarium infection", section on 'Keratitis'.)
The term "endophthalmitis" means infection within the eye involving the vitreous and/or aqueous (figure 1).
Endogenous endophthalmitis results from bacterial or fungal seeding of the eye via the bloodstream. In most cases of endogenous mold endophthalmitis, the highly vascular choroid is seeded first, and the infection typically progresses from the "back" of the eye (posterior segment) anteriorly.
Exogenous endophthalmitis means the infection was introduced from the "outside," for example, following eye surgery, eye trauma, or extension of fungal infection of the cornea (termed "fungal keratitis" or "keratomycosis"). In exogenous endophthalmitis, the aqueous is typically infected first and, in some cases, the vitreous is not involved.
The treatment of mold endophthalmitis typically involves a combination of vitrectomy, intravitreal and/or intracameral (into the anterior chamber) injection of an antifungal agent, removal of foreign materials (eg, intraocular lens), and systemic antifungal therapy [1-3]. Corneal transplantation is indicated in some cases of mold keratitis (corneal infection) that have extended to the aqueous . No controlled trials of treatment regimens for mold endophthalmitis have been performed given its rarity. The evidence regarding the treatment of mold endophthalmitis comes from case reports and case series. Even with therapy, there is a high rate of loss of useful vision, but the prognosis may be improving with the availability of newer antifungal agents such as voriconazole. (See 'Prognosis' below.)
Vitrectomy and removal of foreign bodies — Surgical removal of the vitreous, or vitrectomy, is nearly always necessary in mold endophthalmitis [2-5]. Vitrectomy entails the use of a vitrector, an instrument inserted into the vitreous cavity that simultaneously cuts and aspirates some of the approximately 4 mL of gel-like vitreous into a canister (figure 2). During this process, a separate cannula infuses balanced salt solution into the vitreous cavity to maintain intraocular pressure. By the end of the case, the canister contains dilute vitreous "washings" (eg, 50 to 100 mL). Vitrectomy decreases the burden of fungi quickly by debriding the vitreous . Samples are obtained during vitrectomy for microbiologic studies, and intravitreal antibiotics are injected at the end of the case. A vitrectomy, which is typically performed with local anesthesia with sedation, may be difficult if there is so much inflammation that the retina surgeon cannot see the retina. In patients too ill for eye surgery, a needle aspiration of the vitreous (for stains and cultures) followed by an intravitreal antibiotic injection should be performed. If the aqueous is primarily involved, then needle aspiration of aqueous plus intracameral antibiotic injection should be performed.
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- Vitrectomy and removal of foreign bodies
- Corneal transplantation
- Intravitreal antifungal therapy
- Intracameral antifungal therapy
- Topical antifungal therapy
- Systemic antifungal therapy
- Approach to treatment
- - Exogenous mold endophthalmitis
- Anterior segment involvement only
- Vitreous involvement
- - Endogenous endophthalmitis
- - Duration of therapy
- SUMMARY AND RECOMMENDATIONS