From the Department of Medicine (PSB), SUNY Upstate Medical University, Syracuse, New York; and the Department of Ophthalmology (JSC, TAA, ACS), Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.
Dr. Albini is a consultant for Alcon, Allergan, and Bausch & Lomb. The remaining authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Amy C. Schefler, MD, Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136. E-mail: firstname.lastname@example.org
Candida species are ubiquitous fungi representing the most common fungal pathogens affecting humans.1 They are unicellular yeast organisms that can form pseudohyphae. Candida species are commensal with the human body and are found normally in the female genital tract, the gastrointestinal tract, and the respiratory tract.2 Oropharyngeal colonization is found in 30% to 55% of healthy young adults and 40% to 65% of normal fecal florae.1
Endogenous endophthalmitis is rare, occurring in only 2% to 15% of all cases of endophthalmitis.3 Fungal organisms have been reported to cause up to 50% of all cases of endogenous endophthalmitis, with Candida albicans as the most common etiology (75% to 80%).4 Ocular involvement with Candida species typically presents as choroidal, retinal, and vitreal infiltrates. In the literature, three prior cases of endogenous endophthalmitis caused by C. albicans presenting as iridociliary abscesses have been reported.5–7 To our knowledge, this case represents the first case in an immunocompetent adult with lenticular involvement.
A 33-year-old man was referred to the Bascom Palmer Eye Institute with a complaint of 9 days of conjunctival erythema, pain, and worsening vision. His medical, ocular, and family history were non-contributory. He was recently incarcerated, had numerous tattoos, and had a 20 pack-year smoking history but denied intravenous drug abuse and alcohol use. Visual acuity was 20/25 in the right eye and hand motions in the left eye. Intraocular pressure was 9 mm Hg in the right eye and 28 mm Hg in the left eye. Anterior and posterior examination of the right eye was normal. In the left eye, slit-lamp examination revealed fibrin in the anterior chamber, 1+ cell and flare, posterior synechiae, a 0.5-mm hyphema, and a well-defined cream-colored iridociliary mass. There was iris neovascularization and no episcleral sentinel vessel was present (Fig. 1). Ultrasound biomicroscopy (UBM) demonstrated an iris mass with ciliary involvement, vitreous opacities, partial posterior vitreous detachment, and no retinal detachment (Fig. 2).
Figure 1. Slit-lamp photography at presentation demonstrating conjunctival injection, corneal edema, anterior chamber fibrin, and hyphema.
Figure 2. Ultrasound biomicroscopy demonstrating solid iris mass with ciliary involvement. The mass measured 2.1 mm in thickness and 4.0 by 4.5 mm in basal diameter. The mass wrapped around the posterior surface of the lens and appeared to infiltrate the lens capsule and lens.
Differential diagnosis included amelanotic iris melanoma, sarcoid granuloma, foreign body granuloma, and bacterial or fungal endophthalmitis. The patient began taking prednisolone and dorzolamide/timolol drops. Complete blood count demonstrated a white blood cell count of 14.5 × 103/μL with a left shift and an elevated sedimentation rate of 30 mm/h. The FTA-ABS test was reactive but the remainder of the initial work-up was normal, including angiotensin-converting-enzyme level, rapid plasma reagin, human immunodeficiency virus, HLA-B27, basic metabolic panel, purified protein derivative, and chest x-ray.
Several days later the inflammation and hyphema had resolved, but repeat UBM revealed that the iris mass was unchanged. Anterior chamber paracentesis was performed and then sent for cytology, bacterial, viral, and fungal cultures, all of which were negative. Two weeks after the paracentesis, the patient returned with increasing eye pain. Slit-lamp examination revealed an extensive pupillary membrane and UBM showed an increase in size of the iris mass with lenticular involvement (Fig. 3). At this time, we performed a pars plana vitrectomy, lensectomy, and iris biopsy. Culture of the vitreous cassette and iris mass yielded a diagnosis of C. albicans. The patient then received intravitreal amphotericin injections three times weekly and was admitted for intravenous amphotericin.
Figure 3. Slit-lamp photography taken several days after Figure 1 demonstrating increased conjunctival injection, extensive pupillary membrane, and anterior chamber shallowed by iris mass.
Systemic work-up for an endogenous fungal source, including blood cultures and echocardiogram, was negative. He was discharged with oral fluconazole and received intravitreal amphotericin three times per week in addition to topical natamycin for 14 days. Two months after the initial presentation, the patient’s visual acuity in the left eye with aphakic correction was 20/50. Slit-lamp examination demonstrated a quiet anterior chamber and clear vitreous cavity. The patient was subsequently lost to follow-up despite repeated attempts to contact him.
The greatest risk factor for the development of endogenous Candida endophthalmitis is intravenous drug abuse. Other risk factors include long-standing indwelling catheters, postpartum status, prematurity, hyper-alimentation, recent abdominal surgery, diabetes mellitus, post-organ transplantation, or malignancies.8
Clinical symptoms are dependent on the location of the inflammatory focus. Peripheral lesions may cause few or no visual symptoms, whereas central lesions or those resulting in severe vitritis will manifest earlier. The progression is much slower than in bacterial endophthalmitis and bilateral involvement is frequent. Anterior uveitis is uncommon in the early stages but may become prominent later. Creamy white chorioretinal lesions with overlying vitritis and floating “cotton-ball” colonies are characteristic. Chronic endophthalmitis is characterized by severe vitreous infiltration and abscess formation. The disease is progressive and can result in the development of retinal necrosis and retinal detachment associated with severe proliferative vitreoretinopathy if left untreated.
Diagnostic work-up often includes vitreous biopsy with smears and cultures to confirm the diagnosis. Treatment includes intravitreal, topical, and systemic antifungals. Pars plana vitrectomy is often indicated in cases with vitreous involvement.
Our differential diagnosis in this case included amelonotic iris melanoma, sarcoid granuloma, foreign body granuloma, and infectious endophthalmitis. Ultimately this presentation was atypical because the patient presented with hyphema and a discrete iris mass that progressed to involve the lens.
A Medline review using the key words iris granulomas, iris nodules, iris mass, iris abscess, endophthalmitis and lenticular involvement, endophthalmitis and lens involvement, Candida endophthalmitis and nodules, or Candida endophthalmitis and iris resulted in only three reports of iris involvement with C. albicans endophthalmitis.5–7 In these three cases, iris nodules representing presumed Candida abscesses were reported, but UBM was not performed and limited diagnostic imaging was provided. Lens involvement (anterior lens capsule only) was reported in just one case7 and no UBM imaging was performed to confirm this suspicion. Although rare, ocular fungal infections other than Candida have involved the lens.9,10 Most of these cases have been reported in premature infants.11,12
Our patient responded well to traditional treatment of Candida endophthalmitis. Although he never admitted to intravenous drug abuse, our clinical suspicion was high given the lack of other infectious foci. The predilection of Candida for the posterior segment makes it an uncommon diagnosis for anterior segment pathology. Clinicians should consider a C. albicans abscess, especially when a discrete iris mass demonstrates lenticular involvement associated with hyphema.
- Pappas PG, Rex JH, Lee J, et al. A prospective observational study of candidemia: epidemiology, therapy, and influences on mortality in hospitalized adult and pediatric patients. Clin Infect Dis. 2003;37:634–643. doi:10.1086/376906 [CrossRef]
- Schiedler V, Scott IU, Flynn HW, Davis JL, Benz MS, Miller D. Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. Am J Ophthalmol. 2004;137:725–731.
- Lundstrom M, Wejde G, Stenevi U, Thorburn W, Montan P. Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology. 2007;114:866–870.
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- Binder MI, Chua J, Kaiser PK, Procop GW, Isada CM. Endogenous endophthalmitis: an 18-year review of culture-positive cases at a tertiary care center. Medicine. 2003;82:97–105. doi:10.1097/00005792-200303000-00004 [CrossRef]
- Jones BR. Principles in the management of oculomycosis. Am J Ophthalmol. 1975;79:719–751.
- Kuriakose T, Thomas PA. Keratomycotic malignant glaucoma. Indian J Ophthalmol. 1991;39:118–121.
- Shah GK, Vander J. Intralenticular Candida species abscess in a premature infant. Am J Ophthalmol. 2000;129:390–391. doi:10.1016/S0002-9394(99)00404-3 [CrossRef]
- Clinch TE, Duker JS, Eagle RC Jr, Calhoun JH, Augsburger JJ, Fischer DH. Infantile endogenous Candida endophthalmitis presenting as a cataract. Surv Ophthalmol. 1989;34:107–112. doi:10.1016/0039-6257(89)90038-6 [CrossRef]