Fungal Endophthalmitis - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

Endophthalmitis, in general, is an inflammatory condition affecting the tissues and fluid of the eyeball. Fungal endophthalmitis suggests an ocular inflammation caused by a fungus. This condition is usually challenging to diagnose since the signs and symptoms resemble many other pathological conditions. This article will discuss the causes, signs and symptoms, risk factors, differential diagnosis, diagnosis, and treatment of fungal endophthalmitis in detail.

What Are the Causes of Fungal Endophthalmitis?

The causes of fungal endophthalmitis will fall into two categories - exogenous and endogenous sources.

• Exogenous - In general, an exogenous source means that the source is present in the outside environment and enters the human body during surgery, through a cut or injury, or as a spread from the infection of adjacent tissues and causes infection. Endophthalmitis infection spreads majorly during surgery, and the causative organism is rarely a fungus. However, the most common fungal organisms causing fungal endophthalmitis are Candida albicans and Aspergillus species. Spreading from the adjacent infected tissues is a rare exogenous cause; spreading through trauma is the common causative factor.

• Endogenous - Endogenous source or spread means an infection spreads through the blood (hematogenous spread). This is a very rare cause of fungal endophthalmitis. The hematogenous spread of fungal infection spreads (rarely) when an individual is immunocompromised and has fungemia (common with drug users). Spread through the urinary tract can also be seen. So, in short, a fungal infection in any part of the body spreads to the eyes and causes fungal endophthalmitis. The Candida albicans variety is the most common. However, few cases may show Candida tropicalis, Candida krusei, or Candida pelliculosa involvement. Aspergillus species may also cause this spread.

What Are the Symptoms of Fungal Endophthalmitis?

A few common signs and symptoms of fungal endophthalmitis are as follows.

• Floaters are commonly seen in the field of vision. It may cause disturbances while viewing things.

• Pain in the eye.

• Redness of the eye due to inflammation.

• Loss of vision is a common sign.

• Fever is a classic sign of fungal endophthalmitis.

• The infection caused by Aspergillus species may spread to the lungs and liver, and cause serious infections.

The signs and symptoms of fungal endophthalmitis may show up weeks to months after the initial exposure. It all depends on how the fungus spreads, the load of infection, and the types of fungus causing it.

What Are the Differential Diagnosis of Fungal Endophthalmitis?

• Sarcoidosis - Sarcoidosis is characterized by the presence of inflammatory cells in any body part. Sarcoidosis affecting the eyes will show signs like blurred vision and floaters and specks resembling fungal endophthalmitis.

• Behcet Syndrome - It is an inflammatory condition of the blood vessels, affecting the eyes, too. It can cause posterior uveitis, anterior uveitis, etc.

• Juvenile Idiopathic Arthritis - It tends to affect the eyes and cause uveitis. It may show signs mimicking fungal endophthalmitis.

• Retinoblastoma - Retinoblastoma is the cancerous condition of an important layer of the eye - the retina. It shows signs of eye redness and pain, and blurred or loss of vision.

• Toxoplasmosis Chorioretinitis - Caused by Toxoplasma gondii, affects the chorioretinal layer of the eyes and causes eye pain, redness, and permanent loss of vision.

• Bacterial Endophthalmitis - Bacteria causing endophthalmitis is known as bacterial endophthalmitis. Bacteria involved in causing the infection are syphilis, tuberculosis, Streptococcus, and Staphylococcus (especially Staphylococcus aureus).

• Viral endophthalmitis - Virus-causing endophthalmitis is called viral endophthalmitis, and the common viruses involved are Epstein-Barr virus, Herpes simplex virus, and Cytomegalovirus.

• Lymphoma (Intraocular) - Intraocular lymphoma is a rare malignancy that can cause blurred vision, light sensitivity, the presence of floaters, eye pain, and redness.

Who Is at Risk for Developing Fungal Endophthalmitis?

People who are at risk of developing fungal endophthalmitis are as follows:

• The ones with a weak immune system from human immunodeficiency virus infection (HIV) or AIDS (acquired immunodeficiency syndrome), diabetes, organ transplantation, cancer treatment (chemotherapy), and on drugs like corticosteroids for a longer time.

• Drug users (intravenous, predominantly).

• The ones admitted to an intensive care unit (ICU) for an extended period.

• Persistent lung diseases.

• The ones who have undergone gastrointestinal procedures.

• Women who have been pregnant underwent an abortion, or the ones in the postpartum phase.

• The ones who had intravenous catheters in the recent past.

• Those suffering from neutropenia (a decreased number of neutrophils, a type of white blood cell essential in fighting infections).

How to Diagnose Fungal Endophthalmitis?

Examining fungal endophthalmitis is a task. A complete examination of the eye is required to arrive at a diagnosis. Special instruments will be used to study the eye structures. A complete medical history of the patient, including recent hospitalization, surgeries, if any, drug usage, injury, or trauma, to determine if the cause is an exogenous or endogenous factor.

A few of the diagnostic studies recommended to confirm fungal endophthalmitis are,

• Ultrasound B-scan identifies any opacities and masses in the vitreous cavity that are not visible due to a cloudy cornea or lens.

• Intraocular fluid culture to identify specific organisms.

• Blood investigations to detect the presence of a fungal organism like Candida albicans.

• Polymerase Chain Reaction (PCR) detects fungal DNA in vitreous samples to rapidly identify the fungal species.

How to Treat Fungal Endophthalmitis?

Following are the drugs used in the mainline treatment of fungal endophthalmitis. Amphotericin B, Fluconazole, Ketoconazole, Miconazole, Flucytosine, Itraconazole, and Caspofungin. Amphotericin B is the primary drug of choice for treating fungal endophthalmitis. However, since Amphotericin B does not penetrate the vitreous cavity, Fluconazole will sometimes be used. The antifungal treatment will be continued for four to six weeks, and medications will be adjusted based on recovery.

What Are the Complications of Fungal Endophthalmitis?

The complications of fungal endophthalmitis are as follows:

• Retinal detachment.

• Cataracts.

• Scar formation of the chorioretinal layer.

• Opacification of the vitreous layer.

What Is the Prognosis of Fungal Endophthalmitis?

The prognosis is generally poor. Poor prognosis includes delay in healing, acceptance of medications, and other factors. The prognosis also greatly depends on the site and extent of the lesion.

Conclusion:

Fungal endophthalmitis, or endophthalmitis in general, is a serious condition, and the only way to prevent it from getting infected is to follow appropriate preventive measures. Measures like wearing protective glasses while working in hazardous conditions, cleaning the hands before touching the eyes, etc., will help.