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 very difficult to diagnose, since the signs and symptoms resemble a lot of 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 exogenous source means that these sources are present in the outside environment and enter the human body during surgery, through a cut or an 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. But the most common fungal organisms causing fungal endophthalmitis are Candida albicans and Aspergillus species. Spread from the adjacent infected tissues is a rare exogenous cause; spreading through trauma is the second most 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. But 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 disturbance 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 start showing up weeks to months after the initial exposure. It all depends on how the fungus spreads, 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 parts. Sarcoidosis affecting the eyes will show signs like blurred vision, presence of 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 - 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 and can cause blurred vision, light sensitivity, presence of floaters, eye pain, and redness.

Who Is at Risk for Developing Fungal Endophthalmitis?

• The ones with a weak immune system from Human Immunodeficiency Virus infection (HIV) or AIDS, diabetes, organ transplantation, cancer treatment (chemotherapy), and on drugs like corticosteroids for a longer period of 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 abortion, or the ones in postpartum phase.

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

• The ones suffering from neutropenia (decreased number of neutrophils, a type of white blood cells, which is essential in fighting infections).

How to Diagnose Fungal Endophthalmitis?

Examining fungal endophthalmitis is a bit of a task. 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 a trauma, to finalize if the cause is an exogenous or endogenous factor.

Few of the diagnostic studies recommended confirming fungal endophthalmitis are,

• Ultrasound B-scan.

• Intraocular fluid culture.

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

• Polymerase Chain Reaction (PCR).

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. Of these, Amphotericin B is the main drug of choice in treating fungal endophthalmitis. But since Amphotericin B does not penetrate the vitreous cavity, Fluconazole will be used in some cases.

The antifungal treatment will be continued for four to six weeks and based on recovery, medications will be adjusted.

What Are the Complications of Fungal Endophthalmitis?

• Retinal detachment.

• Cataracts.

• Scar formation of the chorioretinal layer.

• Opacification of the vitreous layer.

How Is the Prognosis of Fungal Endophthalmitis?

Prognosis is generally poor. Poor prognosis includes delay in healing, acceptance of medications, etc. Also, prognosis 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 is to prevent ourselves from getting infected. Appropriate preventive measures have to be followed. Measures like wearing protective glasses while working in hazardous conditions, cleaning the hands before touching the eyes, etc., will help.