Postoperative cataract patient complains of irritated throat
A 62-year-old white female presented for her 1-week postoperative appointment following uneventful cataract surgery with concerns that her throat was irritated. She also reported a bitter taste after instilling her eye drops and that her mouth tasted bad all of the time. The patient was unsure of exactly when these symptoms had started. She had been seen 1 week prior for her 1-day postoperative appointment and reported no concerns at that time.
The patient’s ocular history was significant for cataract surgery via phacoemulsification with a posterior chamber intraocular lens (PCIOL) implant 2 weeks prior in the right eye and 1 week prior in the left eye. Current ocular medications included ketorolac 0.5%, prednisolone acetate 1% and moxifloxacin 0.5% four times per day in both eyes. She started the antibiotic 3 days before surgery and took it for 1 week postop. The family ocular history was significant for age-related macular degeneration in the patient’s mother.
The patient had a positive medical history of hypertension, hyperlipidemia, anxiety, insomnia and sleep apnea. Current systemic medications included trazodone, amlodipine, simvastatin, omeprazole, lorazepam and losartan. There had been no recent change in her systemic medications. A continuous positive airway pressure (CPAP) machine was not being used for her sleep apnea. Reported drug allergies included hydrochlorothiazide, promethazine and pramipexole. The patient denied tobacco or alcohol use.
Uncorrected visual acuities were 20/20+2 OD and 20/20 OS. The patient reported her habitual glasses no longer helped her see clearly in the distance and she was using +2.50 D over-the-counter reading glasses for near. The manifest refraction was plano in the right eye and plano-0.25 D x 005 OS. Visual acuity through the manifest refraction was 20/20 in each eye. Intraocular pressure was measured to be 17 mm Hg OD and 18 mm Hg OS by Goldmann applanation tonometry. Slit lamp examination of the anterior segment revealed clear corneas, flat irises, clean eyelids and eyelashes, and normal conjunctiva in both eyes. The anterior chamber of the right eye was deep and quiet, while that of the left was deep with rare cells. Both eyes had stable PCIOLs with clear posterior capsules. The incision from cataract surgery was sutureless with a negative Seidel’s sign in both eyes.
After removal of the patient’s dentures, examination of the mouth and oropharynx with a transilluminator revealed creamy white patches on the inner cheeks. Upon further questioning the patient reported one prior episode with similar symptoms after taking a course of high dosage oral antibiotics years earlier.
Oropharyngeal candidiasis, or thrush, is a local overgrowth of the fungus Candida albicans on the lining of the mouth. C. albicans is part of the normal oral flora, but under certain conditions it can overgrow and cause symptoms. Oral thrush results in slightly elevated, creamy white lesions typically on the tongue or inner cheeks. In more severe cases it may spread to the roof of the mouth, gums, tonsils or esophagus.
Thrush is seen most commonly in infants, older adults who wear dentures, patients undergoing certain treatments (chemotherapy or radiation to the head and neck), immunosuppressed patients (diabetes, cancer or HIV/AIDS) and patients taking certain medications (antibiotics and inhaled corticosteroids). Oral thrush is thought to result from any factor that disrupts the normal protective mechanisms preventing overgrowth of any one organism in the mouth.
Many patients with thrush are completely asymptomatic. If symptoms do occur they can develop slowly or come on acutely and can last from days to months. The most common symptoms are a cottony feeling in the mouth, irritation, loss of taste, bitter taste in the mouth, cracking and redness at the corners of the mouth (especially in denture wearers), and pain during eating or swallowing. For healthy patients, thrush is a minor problem. In immunosuppressed patients, it can be more severe and difficult to control, even spreading to the lungs, liver, digestive system and heart valves. Esophageal candidiasis is considered an AIDS-defining illness in patients with HIV due to its severity.
Making the diagnosis
Generally, thrush is diagnosed based upon history, symptoms and clinical examination. In some cases the diagnosis is confirmed by performing a Gram’s stain or potassium hydroxide preparation on scrapings from the lesions. Budding yeasts with or without pseudohyphae are seen under the microscope with Candida infection.
Scraping of the lesions is only indicated in recalcitrant or recurrent cases of thrush. In older children or teens with no obvious risk factors, a more extensive work-up may be completed to look for an underlying cause. In addition, if it is suspected that the thrush extends into the esophagus, a throat culture or endoscopic exam may be indicated because esophageal thrush requires more extensive treatment.
The goal of treatment of thrush is to stop the spread of the fungus. The treatment chosen depends upon the age and health of the patient as well as the severity and cause of the infection. Healthy adults and children are typically treated with local antifungal lozenges or solutions. Oral antifungal agents are often used in immunosuppressed patients or more severe cases. In patients with dentures, treatment of the dentures is required in order to completely resolve the infection.
Commonly used local antifungal medications include nystatin swish-and-swallow solutions and clotrimazole lozenges. Nystatin solution often requires four-times-per-day dosing and is not always palatable to patients. In addition, it contains sucrose, which can cause cavities when used for prolonged periods of time. Clotrimazole lozenges dissolve slowly in the mouth but must be used five times daily. The frequent dosing often makes adherence with this treatment modality difficult. Successful therapy with both of these topical agents depends on adequate contact time between the medication and the oral mucosa.
If the patient does not respond to local treatments, oral fluconazole is the preferred systemic therapy. Studies have shown that symptoms and signs resolve in more than 90% of patients taking fluconazole. The infection can recur in both healthy and immunosuppressed patients after treatment, especially if the underlying risk factors are still present. Prophylactic therapy with fluconazole daily can help prevent recurrence in patients requiring ongoing chemotherapy or other long-term treatments.
The occurrence of oral candidiasis infection secondary to topical ophthalmic medication use has only rarely been mentioned in the literature. However, it is relatively common for patients who wear dentures to get thrush as well as patients on oral antibiotics and oral or inhalational steroids. Our hypothesis is that the combination of dentures and topical antibiotics and steroids draining through the nasolacrimal system and into the throat resulted in an environment conducive to Candida overgrowth in our patient.
Management of this patient
We referred our patient to the hospital urgent care clinic for treatment of her thrush. Nystatin oral suspension (100,000 U/mL) was prescribed with instructions to swish and swallow 5 mL of the solution four times per day for 7 days. In addition, the patient was instructed to soak her dentures in nystatin solution (100,000 U/mL) twice per day for 7 days. We counseled the patient to begin manual punctal occlusion after instillation of her ocular medications to minimize passage of the drops through the nasal cavity and mouth.
A follow-up phone call was made to the patient 3 days after her visit to our office. She had not yet picked up her nystatin prescription. She reported concerns that if she started the 7-day course of nystatin immediately there would be a recurrence of the infection by the time she finished her prednisolone acetate 1% eye drops. Her tapering schedule indicated 2 more weeks of prednisolone acetate 1% in the right eye and 3 more weeks in the left eye at progressively lower doses. In addition, she noted that she still felt drops draining into her mouth despite doing manual punctal occlusion.
We decided the best course of action was to fit temporary collagen punctal plugs into the upper and lower punctum of both eyelids. This would provide at least 7 to 10 days of full punctal occlusion and reduce drainage of the drops into the throat. We considered fitting the patient with punctal plugs that would last up to 3 months. Unfortunately, she was moving out of town in a few days and would be unavailable for follow-up in case of epiphora or any other problems. We also instructed the patient to wait 1 week before starting the 7-day treatment with nystatin since her symptoms had not progressed and her mouth was not bothering her too much. This way she would only be on one drop of prednisolone acetate per day in the left eye by the time her punctal plugs dissolved and will have finished the course of nystatin treatment. It was our hope that this would reduce the risk of recurrence of the Candida infection.
A follow-up phone call was placed to the patient 1 day after insertion of the temporary punctal plugs. She reported that she could no longer taste the drops after instilling them. The plugs were successfully controlling the drainage of the drops into the throat, so we advised the patient to call with any additional problems or concerns.
Topical antibiotics and steroids are common after cataract surgery, and in many cases these drugs cannot be discontinued due to adverse side effects. This case highlights the significance of counseling patients regarding punctal occlusion, either manually or via punctal plugs, in situations where many types of drops and high dosages are being used. Although dentures are an independent risk factor for oral Candida infection, our patient’s symptoms may have been preventable if punctal occlusion was performed from the start of the drops. Although it would not help in the case of our patient, another consideration for when eye drops or their side effects need to be avoided is doing an intracameral injection of antibiotics and steroids during cataract surgery.
We feel that this is a useful case for all optometrists comanaging surgical patients. Thrush seems to be a rare complication of topical ocular antibiotic and steroid use, but it should be considered as a potential differential diagnosis when patients report oral symptoms with eye drop usage. Suspicion of thrush should elevate if the patient has additional risk factors such as dentures, a known immunocompromising condition, or is using systemic antibiotics or inhaled corticosteroids. Examination of the mouth with a transilluminator can easily identify thrush as a cause of these symptoms in such situations.
- Flach AJ. Trans Am Ophthalmol Soc. 2008;106:138-148. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646444/pdf/1545-6110_v106_p138.pdf.
- Hertel M, et al. Clin Oral Invest. 2015;doi:10.1007s00784-015-1631-0.
- Kauffman CA. Clinical manifestations of oropharyngeal and esophageal candidiasis. UpToDate website. http://www.uptodate.com/contents/clinical-manifestations-of-oropharyngeal-and-esophageal-candidiasis. January 27, 2016. Accessed February 11, 2016.
- Kauffman CA. Treatment of oropharyngeal and esophageal candidiasis. UpToDate website. http://www.uptodate.com/contents/treatment-of-oropharyngeal-and-esophageal-candidiasis. Updated February 8, 2016. Accessed February 11, 2016.
- Mayo clinic staff. Oral thrush. Mayo Clinic website. http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/definition/con-20022381. Updated August 12, 2014. Accessed February 11, 2016.
- Pappas PG, et al. Clin Infect Dis. 2009;doi:10.1086/596757.
- For more information:
- Kathryn Dailey is a fourth year optometry intern from Pacific University College of Optometry in Forest Grove, Ore. She can be reached at firstname.lastname@example.org. Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, practices at the Mayo Clinic Health System in Albert Lea, Minn., and is a member of the Primary Care Optometry News Editorial Board. He can be reached at Mayo Clinic Health System; email@example.com.
- Edited by Leo P. Semes, OD, a professor of optometry, University of Alabama at Birmingham, and a member of the Primary Care Optometry News Editorial Board. He may be reached at: firstname.lastname@example.org.
Disclosures: Dailey and Skorin report no relevant financial disclosures.