From the Marmara University, School of Medicine, Department of Ophthalmology, Istanbul, Turkey.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Sumru Onal, MD, FEBOphth, Associate Professor of Ophthalmology, Marmara University, School of Medicine, Tophanelioglu Cad. 13/15, 34660 Üsküdar, Istanbul Turkey.
Endogenous endophthalmitis is an intraocular inflammation in which the causative organism reaches to the eye through the blood circulation. It is estimated that about 2 to 10% of endophthalmitis cases are endogenous.1Candida albicans is the most common causative organism in patients with endogenous endophthalmitis.2 Candida endophthalmitis has been described in both immunosuppressed and immunocompetent patients with candidemia.3 Predisposing risk factors for endogenous candida endophthalmitis are the same as for the development of candidemia, and include the presence of central venous catheters, hyperalimentation, the use of broad-spectrum antibiotics, history of gastrointestinal trauma and/or surgery, neutropenia, corticosteroid therapy, intravenous drug abuse, and diabetes mellitus.4 It should be remembered that any patient with candidemia is at risk to develop endophthalmitis.3
We report the clinical manifestations, treatment and prognosis of a patient with bilateral endogenous candida endophthalmitis. In addition to administration of systemic medication, both eyes were treated with vitrectomy and intravitreal liposomal amphotericin B one week apart. The initially vitrectomized left eye received a second injection of liposomal amphotericin B.
A 77-year-old man was seen at the Ophthalmology Clinic of Marmara University with a history of gradual loss of vision over several weeks. He initially presented to an emergency room elsewhere with flank pain, and a regimen of antibiotics and pain killers was given. He also received an unknown intravenous fluid supplement to be used at home. During his outpatient treatment, the patient realized that he developed blurred vision bilaterally over a period of 1 month.
At the presentation to the eye clinic, the best corrected visual acuity was 0.2 in each eye. Biomicroscopy revealed 3(+) cells in the anterior chamber and nuclear sclerosing cataracts bilaterally. Intraocular pressure was 12 mmHg in the right and 11 mmHg in the left eye. The vitreous of both eyes was infiltrated with inflammatory cells; vitreous opacities connected by strands producing a “string-of-pearls” appearance, and multiple abscesses were seen (Figs. 1A to C). The details of the posterior pole could not be seen clearly in both eyes but the vitreous haze and infiltration were more prominent in the left eye. The patient appeared in good general health. To rule out candidemia, he was worked up with complete blood cell count, serum biochemistry, serological tests including human immunodeficiency (HIV) and hepatitis viruses, peripheral blood smear and echocardiography with normal results. The patient was started on intravenous fluconazole (400 mg/day) treatment for 15 days. On the second day of systemic therapy a 3-port pars plana vitrectomy and intravitreal liposomal amphotericin B (5 μg/0.1 cc) injection was given into the left eye. Vitreous material was sent for microbiological examination and the culture was positive for Candida albicans. 1 week later, the vitrectomy and intravitreal liposomal amphotericin B (5 μg/0.1 cc) injection were performed in the right eye and at the same session intravitreal injection of the liposomal amphotericin B (5 μg/0.1 cc) was repeated in the left eye. Vitrectomy aspiration fluid cultures of the right eye yielded Candida albicans as well.
Figure 1. (A) Preoperative Fundus Photographs Showing Vitreous Haze Due to Severe Vitritis and Abscess Formation in the Right Eye. (B) “string-of-Pearls” Appearance in the Peripheral Fundus of the Right Eye. (C) Preoperative Fundus Photograph of the Left Eye Reveals Severe Vitreous Opacification Obscuring Details of the Posterior Pole Along with Vitreous Abscesses. (D) Fundus Photograph of the Left Eye Shows Marked Decrease of Vitreous Inflammation Two Days After Vitrectomy and Intravitreal Liposomal Amphotericin B Injection.
During the first few postoperative days, a remarkable resolution in inflammation was observed in both eyes with resorption of abscesses (Fig. 1D). Visual acuity in the left eye improved from 0.2 to 0.4. The visual acuity of the right eye remained 0.2 because of the development of secondary cataract. No clinical toxicity was noted after intravitreal injection of liposomal amphotericin B. After 15 days of intravenous fluconazole therapy, the patient was discharged from the hospital; the drug regimen was changed to oral fluconazole 400 mg/day.
The salient clinical manifestations and the medical and surgical treatment modalities of a patient who was affected with bilateral endogenous candida endophthalmitis are presented. Prompt vitrectomies and intraocular liposomal amphoterisin B injections were combined with systemic antifungal therapy. Intravitreal liposomal amphotericin B injection was repeated in the left eye in which the vision improved better but the degrees of vitritis resolution were similar in both eyes.
Vitrectomy indications in the treatment of candida endophthalmitis include significant loss of vision and the presence of moderate to severe vitritis. Apart from these, it is also known that the laboratory diagnostic yield is higher with vitrectomy than with vitreous taps.5 Indeed, in our case, both vitreous samples obtained from vitrectomy materials were positive for Candida albicans although one eye (right eye) underwent surgery 9 days after the initiation of systemic fluconazole treatment.
To the best of our knowledge, this is the first report of the use of liposomal amphotericin B intravitreally for the treatment of candida endophthalmitis. We used amphotericin B in the liposomal form because the other form is no more available in Turkey. In animal studies both amphotericin B and liposomal amphotericin B directly injected into the vitreous were reported to be well tolerated; the liposomal form appeared to be less toxic.6 We also did not observe any clinical ocular toxicity with liposomal form of amphotericin B injections.
We would like to emphasize that even in the absence of confirmed candidemia, endogenous endophthalmitis caused by Candida albicans can be diagnosed clinically and that liposomal amphotericin B can be used safely along with pars plana vitrectomy. Needless to say, generalizations cannot be made with one case and randomized studies are urgently needed to understand the efficacy and safety of this new form of amphotericin B.
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- Donahue SP, Greven CM, Zuravleff JJ, Eller AW, Nguyen MH, Peacock JE Jr, Wagener MW, Yu VL. Intraocular candidiasis in patients with candidemia. Ophthalmology. 1994;101:1302–1309.
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