Fungal endophthalmitis following cataract surgery: clinical presentation, microbiological spectrum, and outcome

doi:10.1016/S0002-9394(01)01180-1

American Journal of Ophthalmology

Volume 132, Issue 5, November 2001, Pages 609-617

https://doi.org/10.1016/S0002-9394(01)01180-1 Get rights and content

Abstract

PURPOSE: To determine the clinical presentation, microbiological spectrum, and outcome in cases of fungal endophthalmitis following cataract surgery.

DESIGN: Observational case series.

METHODS: Setting: Tertiary referral hospital.

PATIENTS: Retrospective analysis of 27 cases of smear- and culture-proven fungal endophthalmitis.

INTERVENTION: Pars plana vitrectomy in 18 eyes, where the corneal condition did not preclude the same. All eyes received intravitreal amphotericin B and dexamethasone along with systemic antifungal agents.

MAIN OUTCOME MEASURES: Functional success: Final visual acuity of 3/60 or better with attached retina. Anatomical success: Final visual acuity of better than light perception with preserved anatomy of globe.

RESULTS: The majority of the eyes (22 of the 27) had early onset and diffuse presentation (that is, anterior segment as well as posterior vitreous exudates). Substantial corneal involvement was seen in 14 eyes (51.85%). Aspergillus sp. was the most common isolate. Multivariate analysis using forward stepwise logistic regression showed corneal involvement as the single most important risk factor in determining final visual outcome (P = .0429).

CONCLUSIONS: Early onset and diffuse presentation, which mimics bacterial endophthalmitis, stresses the importance of both bacterial and fungal cultures from intraocular fluids to reach a diagnosis apart from the clinical judgment. Corneal involvement was the most important predictor of outcome in cases of fungal endophthalmitis.

Section snippets

Patients and methods

This is a retrospective observational case series of 27 cases of fungal endophthalmitis that occurred after cataract surgery and presented to our institute, a tertiary eye care referral hospital, between December 1995 and December 1999. Included were cases of fungal endophthalmitis in the setting of postoperative infection following cataract surgery, if both smear and culture results from the intraocular fluids were positive for fungi. The records were retrieved from a computerized database of

Results

The study included 27 eyes with fungal endophthalmitis following cataract surgery, from 13 women and 14 men. Ages ranged from 25 years to 96 years (median 60 years). None of our patients were immunocompromised. None of the patients were suspected or diagnosed cases of immune-compromising diseases like HIV disease, blood dyscrasias, uncontrolled diabetes, or were on prolonged corticosteroids or immunosuppressant drugs. There was no evidence of systemic fungal infection in any of the patients.

Discussion

Exogenous fungal endophthalmitis has been previously described as having a prolonged latency period of weeks to months after intraocular inoculation.22, 23, 24 Pflugfelder reported mean latency period of 7 weeks in his cases of postoperative fungal endophthalmitis.22 Isolated cases of fungal endophthalmitis have been reported with prolonged latency period of several months,18, 25 however, in the present series, five cases of delayed endophthalmitis following cataract surgery were observed with

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To analyze intravitreal antifungal injections performed at a tertiary center to determine (1) risk factors increasing fungal endophthalmitis likelihood at the time of patient presentation, (2) prognostic factors at presentation, and (3) validity of American Academy of Ophthalmology (Academy) ophthalmologic Candida septicemia (candidemia) screening guidelines.
Single-center, retrospective clinical case-control study.
Clinical course, visual outcome, and final diagnosis were analyzed for 75 patients (81 eyes) receiving intravitreal antifungal injections between 2014 and 2021. Features were compared between fungal endophthalmitis and clinically similar diseases (masquerades).
Fungal endophthalmitis was more likely than masquerade based on injection in emergency department or inpatient setting (P = .0002) vs outpatient, greater visual acuity (P = .049), artificial indwelling line present (P = .0004), sepsis within past 6 months (P = .0002), prior/current hepatitis C diagnosis (P = .044), total parenteral nutrition (P = .0028), complicated diabetes mellitus (P = .035), actively treated cancer (P = .021), immunosuppressive medication within past year (P = .035), immunocompromising condition number (P = .031), and delayed pain (P = .0094) and vision loss (P = .020) onset. Visual acuity at presentation correlated with visual outcome (R² = 0.3524, P = 8.5 × 10^–7). No patients with fungal endophthalmitis were asymptomatic or identified by screening.
Many conditions can mimic fungal endophthalmitis, but certain risk factors should raise its suspicion. Regardless of diagnosis, presenting vision correlates with final vision. Lastly, no patients with fungal endophthalmitis were asymptomatic or identified by screening, further supporting current Academy candidemia screening guidelines.
Clinical Factors, Treatment Selection, and Outcomes in Postcataract Fungal Endophthalmitis from Contaminated Viscoelastics
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To investigate the factors associated with treatment outcomes of postcataract surgery fungal endophthalmitis outbreaks related to contaminated viscoelastics.
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This study included 228 eyes of 210 patients who were diagnosed with postcataract surgery fungal endophthalmitis related to the use of viscoelastic material (Unial, Unimed Pharmaceutical Inc); they were followed up for 6 months after the diagnosis.
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Baseline visual acuity (P < 0.01), age (P = 0.05), and the presence of corneal edema (P < 0.01) were closely associated with poor best-corrected visual acuity (BCVA) at 6 months. Patients who underwent immediate vitrectomy after diagnosis showed significantly better BCVA at 6 months (mean logarithm of minimum angle of resolution 0.26 ± 0.43 vs. 0.52 ± 0.52, P = 0.03) and greater degree of visual improvement (mean −0.17 ± 0.37 improvement vs. 0.10 ± 0.57 deterioration, P = 0.03) than those who underwent deferred vitrectomy. Patients who underwent IOL removal during vitrectomy required a lower number of intravitreal antifungal agent injections (mean 8.9 ± 9.1 vs. 16.7 ± 12.2, P < 0.01) and showed a lower incidence of repeated vitrectomy (20% vs. 82%, P < 0.01) than in those without IOL removal.
In postcataract fungal endophthalmitis, prompt vitrectomy at the time of diagnosis resulted in better treatment outcomes, and IOL removal reduced the treatment burden. Prompt and aggressive surgical intervention should be considered for postcataract fungal endophthalmitis.
Fungal Endophthalmitis: Analysis of 730 Consecutive Eyes from 7 Tertiary Eye Care Centers in India
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In the period from 2005 to 2020, 7 centers treated 3830 cases of culture-proven endophthalmitis, and of these, 19.1% (n = 730) were cases of culture-confirmed fungal endophthalmitis. It included 46.9% cases of postoperative (87.4% postcataract surgery), 35.6% of traumatic, and 17.5% of endogenous endophthalmitis. The fungi included 39.0% of Aspergillus (high prevalence in central, east, and south zones), 15.1% of Candida (high prevalence in west zone), and 15.9% of Fusarium (high prevalence in north and west zones). The time to symptom development was between 1 week and 4 weeks in more than one third of the patients, except in patients with traumatic endophthalmitis. Less than half of the patients had hypopyon on presentation. The presenting visual acuity (PVA) in most patients was <20/400. Nearly all patients needed vitrectomy and an average of 2 intravitreal injections of antifungal agents. At least 10% of eyes needed therapeutic keratoplasty, and up to 7% of eyes were eviscerated. After treatment, the final (best corrected) visual acuity (FVA) was >20/400 in 30.5% (n = 222) of eyes and >20/40 in 7.9% (n = 58) of eyes, and 12% (n = 88) of eyes lost light perception. A post hoc analysis showed the male sex to be significantly more associated with traumatic endophthalmitis than with postoperative (P < 0.0001) and endogenous (P = 0.001) endophthalmitis, more isolation of Candida species in patients with endogenous endophthalmitis than in those with postoperative (P = 0.004) and traumatic (P < 0.0001) endophthalmitis, better PVA in eyes with Candida species infection (P < 0.0001), and poorer FVA in eyes with Aspergillus species infection.
Fungal endophthalmitis is not uncommon in India. The inclusion of antifungal agents with antibiotics as the first empirical intravitreal therapy before microbiological confirmation should be considered when a fungal infection is suspected.
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Citation Excerpt :
This was evident in our patient, who had a delayed presentation at 6 weeks post cataract surgery with features of acute endophthalmitis: namely a painful eye, reduced vision; an anterior chamber hypopyon with vitreal cells on examination. Most patients present with visual acuities ranging from 20/80 on the Snellen chart to light perception only.3,4,13,14 Initial presenting visual acuities have not been an independent predictor of final visual outcomes.13
To present a case of fungal endophthalmitis with a novel organism and our management.
A 46 year old male presented with delayed-onset acute endophthalmitis 6 weeks after routine phacoemulsification and intraocular lens implantation. Initial treatment with intravitreal antibiotics did not improve his condition. With repeated vitreal taps, the causative organism was eventually identified as a fungus, Pseudozyma aphidis. Treatment with oral and intravitreal voriconazole, as well as pars plana vitrectomy, led to resolution of the endophthalmitis and recovery of vision to 20/25.
Fungal endophthalmitis is a rare, potentially blinding complication of cataract surgery. We report our approach to this previously unreported organism, that led to an excellent visual outcome. There are no specific guidelines for fungal endophthalmitis. The management approach has to be tailored to the clinical response and emerging laboratory data from the microbiologist. Identification of the organism will require specialist laboratory references that may not be available in all hospitals. Ophthalmologists must work closely with microbiologists in order to ensure an optimal outcome.

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View full text

Fungal endophthalmitis following cataract surgery: clinical presentation, microbiological spectrum, and outcome

Abstract

Section snippets

Patients and methods

Results

Discussion

Ophthalmology

Surv Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Am J Opthalmol

Ophthalmology

National outcomes of cataract extraction; endophthalmitis following inpatient surgery

Arch Ophthalmol

Endophthalmitis following cataract extractionA study of 24 cases in 4,498 operation

Acta Ophthalmol

Endopthalmitis

Fungal endophthalmitis following intraocular lens implantation; a surgical epidemic

Arch Ophthalmol

Etiology and diagnosis of fungal post operative endophthalmitis

Ophthalmology

Acremonium kiliense endophthalmitis that occurred after cataract extraction in an ambulatory surgical center and was traced to an environmental reservoir

Clin Infect Dis

Chronic Basidiomycetous endophthalmitis after extracapsular cataract extraction and intraocular lens implantation

Graefes Arch Clin Exp Ophthalmol

Surgical treatment for a case of post-operative Pseudallescheria boydii endophthalmitis

Ophthalmic Surg

Aspergillus terreus postoperative endophthalmitis

Br J Opthalmol

Pseudophakic Candida parapsilosis endophthalmitis with a consecutive keratitis

Cornea

Postoperative zygomycetes endophthalmitis

Opthalmic Surg

Exophiala jeanselmei causing late endophthalmitis after cataract surgery

Am J Ophthalmol