Mycoses of the eye

Ref ID: 19446

Author:

C. A. Kauffman

Author address:

University of Michigan, Ann Arbor, USA

Full conference title:

6th Trends in Medical Mycology 2013

Date: 11 October 2014

Abstract:

Fungal eye infections originate either endogenously from hematoge-
nous spread or exogenously as a result of penetrating trauma or fol-
lowing an operation. Endogenous infections encompass isolated
chorioretinitis as well as chorioretinitis with extension into the vitre-
ous (vitritis). Endogenous fungal endophthalmitis is seen most often
as a complication of candidemia and is frequently linked to the pres-
ence of a central venous catheter. In outpatients, intravenous drug
use is a leading risk factor for endogenous Candida endophthalmitis.
Candida albicans is the most common cause of endogenous endoph-
thalmitis, but all species have been implicated in this infection.
Endogenous mold endophthalmitis occurs rarely and is usually asso-
ciated with intravenous drug use or immunosuppression. The pre-
dominant species is Aspergillus fumigatus, but Aspergillus flavus is
especially common among intravenous drug users.
Molds are more common than Candida species as a cause of exoge-
nous endophthalmitis, accounting for 80-90% of cases. Exogenous
mold endophthalmitis is more common in tropical climates than in
temperate climates and often begins as keratitis. Aspergillus, Fusari-
um, and a variety of other molds have been implicated. An outbreak
of over 250 cases of Fusarium keratitis, some of which progressed to
endophthalmitis, was linked to the use of a specific lens solution and
poor contact lens care several years ago. Although uncommon, exog-
enous endophthalmitis due to Candida species is usually associated
with cataract or corneal surgery. Candida parapsilosis has been com-
monly reported in this circumstance and has been linked to contami-
nated irrigation fluids or prosthetic materials, such as intra-ocular
lens implants.
Because of the sight-threatening nature of fungal endophthalmitis,
treatment should be initiated as quickly as possible. Penetration of
systemically administered antifungal agents into the various com-
partment of the eye is highly variable. In the posterior segment of
the eye, amphotericin B, all the echinocandins, and posaconazole
achieve only very low concentrations. Fluconazole, flucytosine, and
voriconazole concentrations are much higher, achieving concentra-
tions above the MIC for most Candida species and for some molds,
such as Aspergillus, in the case of voriconazole. Voriconazole is
increasingly used to treat fungal endophthalmitis because of its abil-
ity to achieve excellent intra-ocular concentrations, its availability as
an oral formulation, and its activity against both molds and many
Candida species.
For endogenous Candida chorioretinitis without vitritis, systemic
antifungal therapy is usually adequate provided the agent achieves
reasonable posterior compartment concentrations; fluconazole or vo-
riconazole are recommended, and treatment should continue until
the lesions have resolved. For sight-threatening macular involvement
and vitritis, intravitreal injection of either amphotericin B or vorico-
nazole, in addition to systemic antifungal therapy, is helpful in order
to achieve high local antifungal activity as quickly as possible. Vitrec-
tomy also is recommended for sight-threatening Candida and Aspergil-
lus endophthalmitis with vitritis. Vitrectomy allows removal of
loculated areas of infection that likely would not respond to systemic
antifungal agents, and it decreases the overall burden of organisms.
It also is the most sensitive method to obtain material for culture.
For patients with exogenous mold endophthalmitis, in addition to
systemic antifungal therapy with oral voriconazole, amphotericin B
or voriconazole is usually injected into the aqueous humor. If the vit-
reous is also involved, vitrectomy and intravitreal injection of
amphotericin B or voriconazole also is required. For Candida exoge-
nous endophthalmitis, oral fluconazole or voriconazole is given,
along with injection of voriconazole into the aqueous humor. Intravi-
treal injection of voriconazole or amphotericin B is needed only if
there is extension into the vitreous. Foreign material, including intra-
ocular lens implants, should be removed, if at all possible.
Outcomes of endogenous Candida endophthalmitis have improved
in recent years. Treatment for chorioretinitis is successful in most
patients unless the macula is involved. Vitritis carries a worse prog-
nosis; with aggressive management and use of appropriate antifungal
agents, normal visual acuity can be restored in some patients, but
many never have return to their baseline vision. In contrast, endoge-
nous mold endophthalmitis has a poor outcome; even with aggres-
sive management, few eyes return to functional vision, and many
require enucleation. Treatment of Candida exogenous endophthalmitis
associated with an intra-ocular lens implant usually requires lens
removal for cure, and visual acuity depends on whether another lens
can be implanted. Outcomes for exogenous mold endophthalmitis
depend on the extent of trauma and the infecting mold, but often
result in loss of visual acuity.

Abstract Number: w03-1

Conference Year: 2013

Link to conference website: NULL

New link: NULL

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