Candida Endophthalmitis: An Unusual Complication Of Prolonged Intravenous Access

Other species known to cause infections include A.

Baseline blood tests are indicated in all patients, but further investigations should be rationalized. Intraocular pressure OU was normal. This work was supported in part by funds from the National Natural Science Foundation of China (81400381 and 81570839). Intravitreal voriconazole for the treatment of endogenous Aspergillus endophthalmitis. Causative organisms are not present in all cases. Her right eye remained free of disease with normal visual acuity. Furthermore, as some of these mutations are inheritable, appropriate genetic counselling would also be beneficial and necessary.

In this case series study, 70.

(1999), where cultures were positive in 69% of anterior chamber taps and 66% of vitreous biopsies. As shown in Table 2, 30 eyes (27 patients) with initial and final VAs were available for the analysis of possible prognostic factors for the final visual outcome. The amended guidelines (Appendix 2) suggest that liver ultrasound be carried out only in the presence of abnormal liver function tests, and echocardiography only in the presence of suspicious clinical features. Oral voriconazole has been added to the guidelines as a treatment option (see Appendix 2). Schmid S, Martenet AC, Oelz O. Massey medicinals, children under 50 lbs. Endophthalmitis and Concurrent or Delayed-Onset Rhegmatogenous Retinal Detachment Managed With Pars Plana Vitrectomy, Intravitreal Antibiotics, and Silicone Oil. 2 months (range from 1 week to 2 years).

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2 years (range from 1 to 60 years). Boric acid, dO NOT USE BORIC ACID CAPSULES IF YOU ARE PREGNANT. Microbiology testing. Microbiological investigations confirmed the presence ofC albicans sensitive to fluconazole. They are ubiquitous organisms found in soil, decaying matter, water, and organic debris. Humans are ubiquitously exposed to conidia (spores) via inhalation. Our case highlights the importance of including Candida albicans infection in the differential diagnosis of sub-retinal abscesses, even in the immunocompetent.

A parsplana vitetrectony was done. Rao and Hidayat have suggested that Candida overgrowth in the gastrointestinal tract and the increased availability of glucose seen in diabetic patients promote the growth of Candida. 20/25 9 10 F OS Helminthosporium None HM Yes Yes FC 10 55 M OS Aspergillus nidulans TB HM No No HM 11 30 F OS Aspergillus nidulans None 0. Patients who have extraocular foci of bacterial infection have a reported mortality rate of 5 percentto 32 percent.

388 Because candidal endophthalmitis can lead to significant visual loss or blinding, it is reasonable to assess for this complication with fundoscopic examination in patients with disseminated candidiasis. This again emphasizes the role of vitrectomy in treating endophthalmitis, even for cases caused by endogenous fungal growth. A Cochrane Review sought to evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery. Most cases are endogenous, arising from hematogenous spread during candidemia. All 3 cases with bilateral disease were identified to have positive intraocular culture results in at least one eye. Abstract | Full Text | Full Text PDF | PubMed | Scopus (64) | Google ScholarSee all References, 6x6Lundstrom, M, Wejde, G, Stenevi, U et al.

  • 2%, leukocyte 13,600/mm(neutrophil 84.)
  • In conclusion, we assessed the clinical features and visual outcome of 29 patients with culture-proven endogenous fungal endophthalmitis.
  • Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study.
  • Molds were a common causative organism in 15 patients (51.)

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Examination of the fellow eye was completely normal. Though in most of the cases of endogenous endophthalmitis one or more risk factors are identified, a few cases among otherwise healthy and immunocompetent individuals have also been reported [11–13]. It is preferable this examination be done by an ophthalmologist, as small lesions are easily overlooked. The EVS randomized 420 patients into ‘tap' (needle aspirate or biopsy of vitreous humor) and vitrectomy groups, with both groups receiving intravitreal antibiotics after the procedures [14x14Endophthalmitis Vitrectomy Study Group. Right eye (OD): To report the causative organisms, management strategies, and visual outcomes of culture-proven endogenous fungal endophthalmitis in a case series from southern China.

Neutrophils are apparently important in the first-line defense against candidal organisms. In 1997, an international consensus conference recommended treatment guidelines for candidal infections including endophthalmitis (Edwards et al. )We reviewed the microbiological and medical records of patients with culture-positive endogenous fungal endophthalmitis visiting the Zhongshan Ophthalmic Center, Guangzhou, China, between January 1, 2020, and March 31, 2020. Data from North America and Europe showed an increasing percentage of gram negative organisms from 32 percent in 1986 to 52 percent in 2020. Endogenous endophthalmitis is a potentially devastating eye infection and needs to be diagnosed and managed promptly. Indian J Ophthalmol. In patients with acute endophthalmitis, combined steroid treatment with antibiotics have been found to improve visual outcomes, versus patients only treated with antibiotics, but any improvements on the resolution acute endophthalmitis is unknown.

Abstract | Full Text PDF | PubMed | Scopus (150) | Google ScholarSee all References]. Donahue SP, Greven CM, Zuravleff JJ, Eller AW, Nguyen MH, Peacock JE Jr, Wagener MM, Yu VL. Once in the bloodstream, Candida gains access to the eyes via the short posterior ciliary artery. This, combined with the limited systemic side effect profile when compared to other antifungals, often makes it the first-line when oral therapy is pursued. (Although spontaneous resolution of candida endophthalmitis has been reported, in the absence of effective treatment, retinal necrosis and vitreal organization occur with tractional retinal detachment leading to phthisis bulbi with complete loss of visual function 6 10 ). The epidemiology of acute endophthalmitis after cataract surgery in an Asian population. (DISCUSSION 1–3).


Of note, in a rabbit model of endogenous endophthalmitis ocular tissues were found to have increased resistance to hematogenous infections with species other than C. Ocular candidiasis: The visual outcome is highly correlated with the bacteriology. Blood-borne Candida endophthalmitis. Treatment must include intravitreal injection of an antifungal agent; vitrectomy is necessary in some cases, and adjunctive systemic azole therapy is given in most cases. Spectrum and clinical profile of post cataract surgery endophthalmitis in north India. This is consistent with our analysis, which suggests that good initial VA is an important predictor for visual outcome.

Abstract | Full Text | Full Text PDF | PubMed | Scopus (14) | Google ScholarSee all References22]. The 15 mold cultures included Aspergillus ( ), Fusarium ( ), Mucor ( ), Helminthosporium ( ), and Penicillium ( ); 2 molds could not be identified. Patients should be monitored daily for response to treatment. Mold endophthalmitis, however, showed worse visual prognosis than yeast cases. During the clinical course, her condition was complicated by unilateral candida endophthalmitis, which progressed despite the administration of systemic antifungal agents and ultimately required vitreous surgery. One month earlier, she swallowed acetic acid accidentally and corrosive esophagitis developed. Muhlschlegel F.

Candida Endophthalmitis

The fundus may be obscured because of vitreous haze or vitritis. Studies evaluating candidemic patients have reported widely varying rates for lesions consistent with candidal endophthalmitis. Recognition of such susceptibilities not only ensures prompt short-term and long-term treatments for patients, but also provides the opportunity for novel adjunctive therapy targeting specific mutations. (1%) and platelet 216,000/mm. For example, 56% of patients with EE caused by Candida achieved a visual acuity of 20/200 or better,3 compared with 41% who had bacterial EE1 and 33% who had EE caused by molds. Throughout this time, echography was used for serial monitoring given the poor view to the posterior pole due to the vitreous debris.

Recommended antibiotics are wide-spectrum antibiotics which cover most of gram positive and negative organisms.

Positive cultures from blood, cerebrospinal fluid or any extraocular site can be highly suggestive. In the absence of localizing symptoms the diagnostic yield from blood in endogenous Aspergillus endophthalmitis is reported to be very low. 2 Oude Lashof A. These cases manifest either as chorioretinitis alone or also with vitritis.

Up to 78{64e6c1a1710838655cc965f0e1ea13052e867597ac43370498029d1bc5831201} of cases of autopsy-proven invasive candidiasis show signs of retinal involvement [650]. Finally, this case emphasizes the importance of performing an in-depth workup and of screening for immunodeficiencies when managing atypical cases presenting with “spontaneous” deep Candida infections such as endophthalmitis. 4 Cerebral magnetic resonance imaging (T2, axial) demonstrating multiple right (R) parietal microabscesses as well as a left (L) frontal lesion suggesting previous infection.

  • All candidemic patients should receive antifungal therapy because of a high mortality rate and late complications of candidiasis.
  • Multiple genetic mutations, including CARD9, have been reported to cause impaired Th17 immunity against Candida species, predisposing to superficial and/or deep infections.
  • Furthermore, Candida endophthalmitis can occur after abdominal surgery or in diabetic patients without granulocytopenia.
  • J Ocul Pharmacol Ther.
  • 5% of all reported endophthalmitis cases [1–6].


These fungi are kept in check by the host's normal immune response. Campochiaro P. A systematic review of 342 cases of bacterial EE found that eyes treated with vitrectomy and intravitreal antibiotics were approximately 2 times more likely to have vision better than 20/200 and 3 times less likely to require evisceration or enucleation when compared with intravitreal antibiotics alone. In a study from France of 100 post-cataract endophthalmitis cases, the sensitivities of PCR and culture were similar with initial intra-ocular samples, before antibiotics had been injected [21x21Chiquet, C, Cornut, PL, Benito, Y et al. Fan’s abstract is featured here.

Mould Endophthalmitis

1 Jackson TL et al. The following aetiological factors were identified: The diagnosis was established as chronic mucocutaneous candidiasis (CMCC) complicated by invasive candidiasis, with the eye as the presenting infection site. 5% hourly was added. Whether the patient underwent surgical treatment and whether the tamponading agent (silicone oil) was used did not affect the final visual outcome ( and , resp.) Treatment and management decisions were made by the ophthalmologist in charge without a predefined study protocol. The patient's vision continued to decline in the right eye prompting referral for further evaluation. (Intraocular injection of amphotericin B, with or without vitrectomy, has been recommended in case of severe vitreitis17).

The latanoprost was withdrawn and the uveitis treated with topical dexamethasone hourly and atropine 1% bd.

Conversely, not all Candida endophthalmitis have proven candidemia at presentation. Anterior chamber aspiration was preformed and tissue plasminogen 25 μg/0. Ricca MD, Elaine M. The role of genetics in host reponses to mucosal and invasive candidiasis. Other samples sent for culture included a swab from a suspicious skin lesion (one case), a throat swab (one case) and a sample of the lemon juice used for dissolving intravenous drugs (from one patient).

  • J Cataract Refract Surg.
  • We will continue to audit our results and assess the effectiveness of treatment guidelines in 5‐yearly cycles.
  • The rarity of fungal endophthalmitis limits efforts to establish and review a treatment plan, compounding difficulties with the management of this condition.


Total parenteral nutrition (TPN) is being used increasingly for surgical patients and medical devastating patients. 5 (Ricci et al. )A clinical and pathologic study of 21 cases. Advances in the diagnosis and treatment of infectious endophthalmitis. On the basis of our experience, in such cases it is advisable to perform vitrectomy with amphotericin B intravitreal injection and silicone oil tamponade to prevent retinal detachment. 5 ways to get rid of a yeast infection at home. In some cases of endogenous endophthalmitis—particularly in immunocompromised patients or those with diabetes—the spread of infection may have been hematogenous (via the blood-stream). Intraocular candidiasis in patients with candidemia :

Kaburaki et el [14] reported a case of Candida albicans endophthalmitis complicated by sub-retinal abscess formation in a liver transplant patient.

The choroid is probably the first site of ocular infection. Systemic therapy alone is sufficient when the infection is isolated to the retina and choroid. No data is available to recommend with certainty which agent, procedure, or length of therapy is the best. Magnetic resonance imaging of the brain should be performed in all patients with neurological symptoms or evidence of meningeal irritation. Frozen samples were inoculated with 10,000 CFU/mL of yeast broth at a temperature of 350 C for 48 hours. Suspected EE should prompt a systemic workup for an occult infection; see Table 1 for tests that might be useful, depending on patient presentation and history. It is suggested that, the higher glucose concentration in vitreous supports the growth of Candida [11]. Treatment depends on the extent of infection.

TASS vs Infectious endophthalmitis. Control samples were positive by PCR in 6% of 50 patients with uveitis, although in none of 40 patients without intra-ocular inflammation. Candida endophthalmitis is typically seen in immunocompromised patients, but may also occur in association with intravenous access in the presence of a normal immune system. Amphotericin B (more toxic, particularly if administered intravenously) was reserved for fluconazole‐resistant organisms or C. Initial pars plana vitrectomy, intravitreal antifungal injection, and oral antifungal medications may not achieve resolution of the infection.

It can first present with the 'black dot sign' (Martin-Farina sign) where patients may report a small area of loss of vision that resembles a black dot or 'fly'.


The authors report no conflicts of interest. Endophthalmitis (intraocular infection) is a rare, potentially devastating condition with a poor visual prognosis. According to a review study, eyes undergoing pars plana vitrectomy are three times more likely to retain useful vision than those who did not undergo vitrectomy.

Differential Diagnosis

In three cases, treatment was delayed because clinical suspicion was not high enough to initiate treatment. In the USA and Europe, nearly all cases are caused by bacteria, whereas in tropical regions such as India, 10–20% of cases are caused by fungi [8x8Gupta, A, Gupta, V, Gupta, A et al. An independent sample t-test, and a chi-square test were used to analyze the difference between the two groups. However, culture from the aqueous was positive for Candida Galibrata, but the donor rim was negative.

8 Rabbit studies have shown that in inflamed eyes, ceftazidime reaches the mean inhibitory concentration threshold for Proteus, Haemophilus influenzae, and Neisseria but not for Pseudomonas or Acinetobacter when delivered through a systemic route only. However, despite multi-modal management, final visual acuity is often sub-optimal. In an outstanding review of 76 cases of Candida endophthalmitis, Edwards et al. Microbiological and clinical records were reviewed for all patients undergoing treatment at the Zhongshan Ophthalmic Center, Guangzhou, China, from January 1, 2020, to March 31, 2020, for intraocular culture-proven endogenous fungal endophthalmitis ( ). Endogenous endophthalmitis cases usually have a poor visual outcome. 2 The condition occurs very infrequently in children. Candida, if you are having abnormal vaginal discharge and are not sure whether you have a yeast infection, consult your health care professional. Edwards JE, Foos RY, Montgomerie JZ, Guze LB.

  • Treatment of opportunistic fungal infections.
  • This was followed by oral fluconazole (800 mg daily) for 1 year, leading to complete resolution of mucocutaneous symptoms and of the cerebral and spinal lesions on subsequent MRIs.
  • Most commonly, a full systemic workup is required to screen for other areas of infection or causes of immunodeficiency, to be coordinated with colleagues in internal medicine.
  • The clinical presentation of ocular candidiasis spans over a continuous spectrum.


Our previous regimen took into consideration the updated literature on antifungal agents to guide broad‐spectrum cover for common species causing fungal endophthalmitis and allowed the management to vary according to disease severity (Brod et al. )Her history was largely unremarkable except for occasional ingestion of beef tartar. Akler ME, Vellend H, McNeely DM, Walmsley SL, Gold WL. Injections of vancomycin (to kill Gram-positive bacteria) and ceftazidime (to kill Gram-negative bacteria) are routine. 8% (17/24) patients who had improved VA outcome underwent simple or combined PPV. Vitreous specimens were taken at a later date in four cases where the diagnosis was in question or pars plana vitrectomy was carried out.

Postinjection Endophthalmitis

6 Also these eyes are three times less likely to require evisceration or enucleation. The management guidelines introduced in 2020 provided an opportunity to assess treatment and outcome. In choosing systemic antibiotics, the clinician should keep in mind both breadth of coverage and intraocular penetration. In most patients, the inhalation of the spores leads to a self-limited respiratory disease. Diagnosis of fungal endophthalmitis was made at initial presentation in 21 cases (91%) on clinical grounds. Can thrush harm my baby during pregnancy?, vaginal douching is likely to make things worse, not better (NICE 2020) . No apparent benefit was seen in patients who presented with hand motion or better vision, although the study design may have obscured a possible benefit: Candida, Endophthalmiltis, Penetrating Keratoplasty, negative donner rim. It could be something as simple as a run away script or learning how to better use E-utilities, http:

PCR detection of Candida albicans was positive in the single vitreous sample where it was carried out. By the following day, vitreous biopsy cultures grew Aspergillus fumigatus and the intravenous medication was switched to voriconazole. Intraocular inflammation and uveitis. Blood cultures are positive in only a third of cases. When a breakdown in the host's immune system occurs, fungi may spread throughout the body. Occasionally embolic lesions can affect other eye structures producing conjunctivitis [650], episcleritis [2133], iritis [1529], or iris abscesses [1529].


Positive history of underlying medical conditions such as diabetes, cardiac disease and malignancy was reported in 90 percent of patients in a report by Annabelle A. Figure 3 Open in figure viewerPowerPoint Fundus photograph of ‘string of pearls’ appearance in endogenous fungal endophthalmitis. 1 ml given intracamerally in an attempt to disintegrate the hypopyon. Ocular manifestations of Candida septicemia:

In cases of endophthalmitis, one usually finds a history of recent intraocular surgery or penetrating ocular trauma. Evaluation of candida colonization and specific humoral responses against candida albicans in patients with atopic dermatitis. Cup-to-disc ratio: This finding agrees with other studies [10, 20], and the possible mechanism may be the invasive patterns of Aspergillus infection in the retina and choroid [26].

Management of a case of Candida albicans endogenous endophthalmitis with intravitreal caspofungin

The appropriate workup is patient dependent and based on the clinical picture at the time of presentation. 2020; Tarai et al. Other investigations such as chest X-ray, ultrasound abdomen, CT abdomen, echocardiography and Gallium-67 scans may help in identifying a systemic focus of infection. A detailed examination of immune function should be conducted for such cases to explore the underlying causes in future work.

Infection typically progresses, vertically, via chorioretinal infiltration and vitreous is a primary site of localisation. Cryptococci spores can survive up to 2 years in pigeon droppings. Candida endophthalmitis : 1 Amikacin (0. )This work is published under https: She was treated with intravitreal Amphotericin B. Computerized tomography scans of the orbit help to identify orbital involvement.

Endogenous endophthalmitis caused by Candida albicans in a healthy woman. Evaluation of the relationship between the total cost of treatment and final VA using Spearman’s rank correlation coefficient revealed a statistically insignificant corrected rho (ρ) value of 0. The correct diagnosis for our patient was made after a delay of almost 2 months requiring multiple visits. However, not all patients who underwent PPV showed improved VA after surgery, and chi-square analysis indicated that PPV did not influence the visual outcome significantly. However, because of the unspecificity of these retinal lesions and the overlap of underlying medical conditions (diabetes, hypertension, bacterial sepsis, retinopathy of AIDS, etc.) Three months later after discharge, there was no further improvement of visual acuity and no interval change of previously noted fundal lesions. Aspergillus fumigatus Endophthalmitis with Necrotizing Scleritis following Pars Plana Vitrectomy.