51.1 Features
Fungal endophthalmitis refers to intraocular inflammation involving the vitreous and anterior chamber of the eye due to endogenous or exogenous fungal infection. Clinical presentation of fungal endophthalmitis can vary depending on the source, particularly between endogenous and exogenous causes, as well as the causative organism. Endogenous fungal endophthalmitis occurs through hematogenous spread. Risk factors include a history of intravenous drug use, immunocompromised status, recent hospitalization, diabetes, malignancy, central lines, recent systemic surgery, organ transplantation, liver or renal disease, and ongoing parenteral nutrition. Exogenous fungal endophthalmitis typically occurs in immunocompetent patients after a history of ocular trauma, cataract surgery, or glaucoma filtering surgery. In some cases, fungal endophthalmitis can occur as a sequela of external ocular infection, such as fungal keratitis. Fungal endophthalmitis is uncommon after intravitreal injection or pars plana vitrectomy.
51.1.1 Common Symptoms
Commonly, redness of the eye, decreased vision, pain, photophobia, and floaters; often has a subacute presentation with symptoms worsening over days to weeks.
51.1.2 Exam Findings
Anterior segment exam can initially reveal minimal pathology. Eventually, patients can develop conjunctival injection, scleritis, keratic precipitates, and a hypopyon. Patients with endogenous fungal endophthalmitis often present with single or multiple chorioretinal lesions with overlying focal vitritis (“string of pearls”) unlike the commonly diffuse intraocular inflammation seen with bacterial endophthalmitis (▶ Fig. 51.1, ▶ Fig. 51.2). This likely occurs from the fungus spreading from the choroidal and/or retinal circulation into the vitreous. Patients with exogenous fungal endophthalmitis can have a similar presentation; however, findings are also often specific to the cause of the infection (e.g., a patient with fungal endophthalmitis related to fungal keratitis can have a dense anterior chamber reaction, while a patient with fungal endophthalmitis related to trauma may have more diffuse vitritis). Similarly, postcataract fungal endophthalmitis cases can occasionally present with an inflammatory plaque on the back of the intraocular lens implant.
Fig. 51.1 Montage fundus photograph of the left eye revealing peripapillary chorioretinal lesions with overlying focal areas of vitritis in the classic “string of pearls” configuration typical of endogenous fungal endophthalmitis.
Fig. 51.2 (a) Fundus photograph of the left eye with endogenous Candida endophthalmitis due to a colonoscopy, treated with oral voriconazole and a single intravitreal voriconazole injection (100 µg). A diffuse vitritis with more focal condensations of vitreous inflammation is seen. (b) Montage fundus photograph of the left eye 2 months after treatment shows significantly improved vitritis.
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