Fig 1 - available via license: CC BY
Content may be subject to copyright.
![Imaging of endogenous Candida endophthalmitis (ECE) demonstrated by Zhuang et al. [1], now with labeling overlay (white markings). These examples of ECE (classified as "retinal" lesion types 1-4, respectively) demonstrate primary choroidal involvement (a), and shadowing that cannot establish a retinal origin or exclude choroidal origin (b-d). a Disrupted architecture of inner choroid (double arrow) extending into the overlying retinal pigment epithelium and neurosensory retina is consistent with a primarily choroidal infiltrative and inflammatory process. b Posterior shadowing (double arrow) is found approximate in size to the overlying, anterior aspect of a large hyperreflective structure (*). Lesion origin cannot be determined because the view of the choroid and outer retina is overshadowed (double arrows), but cystic changes are apparent in outer retina adjacent to the edges of shadowing (arrowheads) which suggest a possibly deep lesion origin. c Posterior extent of hyperreflectivity is seen extending at least into deep retina (arrowhead), surrounded by neurosensory retinal detachment and extensive shadowing that completely obscures underlying choroid (double arrows). d Large hyperreflective mass (*) with florid inner retinoschisis and secondary shadowing (double arrows) blocks choroidal visualization](publication/342901461/figure/fig1/AS:912888671772676@1594661028880/maging-of-endogenous-Candida-endophthalmitis-ECE-demonstrated-by-Zhuang-et-al-1-now.png)
Imaging of endogenous Candida endophthalmitis (ECE) demonstrated by Zhuang et al. [1], now with labeling overlay (white markings). These examples of ECE (classified as "retinal" lesion types 1-4, respectively) demonstrate primary choroidal involvement (a), and shadowing that cannot establish a retinal origin or exclude choroidal origin (b-d). a Disrupted architecture of inner choroid (double arrow) extending into the overlying retinal pigment epithelium and neurosensory retina is consistent with a primarily choroidal infiltrative and inflammatory process. b Posterior shadowing (double arrow) is found approximate in size to the overlying, anterior aspect of a large hyperreflective structure (*). Lesion origin cannot be determined because the view of the choroid and outer retina is overshadowed (double arrows), but cystic changes are apparent in outer retina adjacent to the edges of shadowing (arrowheads) which suggest a possibly deep lesion origin. c Posterior extent of hyperreflectivity is seen extending at least into deep retina (arrowhead), surrounded by neurosensory retinal detachment and extensive shadowing that completely obscures underlying choroid (double arrows). d Large hyperreflective mass (*) with florid inner retinoschisis and secondary shadowing (double arrows) blocks choroidal visualization
Source publication
Abstract Endogenous Candida endophthalmitis (ECE) has been established with microscopic histopathology, both by autopsy and experimentation, to primarily originate from and involve the choroid. Zhuang et al. examined a series of patients with ECE using spectral-domain optical coherence tomography (SD-OCT) imaging and present a new classification sc...
Contexts in source publication
Context 1
... in this study by Zhuang et al. [1]. The discrepancy here of SD-OCT interpretation with prior histopathology can be attributed to oversight of a crucial finding. Posterior shadowing is a well-established artifact for many OCT modalities [6][7][8], and accounts for the signal void posterior to the reflective, anterior surfaces of the ECE lesions ( Fig. 1). Without adequate visualization of the choroid from this artefactual shadowing, the subsequent classification of lesions based solely on retinal location dismisses this established, primary anatomical origin for these ECE lesions. Although the authors do mention their "type 1" retina lesion is similar to previously described ...
Context 2
... have not provided sufficient evidence [1]. Previous studies have demonstrated efficacy of systemic antifungal therapy alone (ideally with exchange of indwelling catheters) in many cases of ECE [2,10]. As ECE primarily emanates from the choroid (outside of the blood-outer retinal barrier), relatively mild lesions with minimal vitreous haze ( Fig. 1) are known to respond with this more conservative management without the risk of invasive intervention [2,10]. Surgical risk may be further compounded in this patient population, as multiple pre-existing comorbidities are often present ...
Citations
... Τα είδη Candida ενοχοποιούνται για τα περισσότερα περιστατικά ενδογενούς μυκητικής ενδοφθαλμίτιδας. Εδώ η αρχική εικόνα είναι συχνα χοριοαμφιβληστροειδίτιδα, χωρίς συμπτώματα, τα οποία εκδηλώνονται όταν η φλεγμονή έχει πλέον προσβάλλει και το υαλοειδές (Breazzano, 2020). Για το λόγο αυτό είναι απαραίτητο όλοι οι ασθενείς με καντινταιμία να υποβάλλονται τακτικά σε προληπτική βυθοσκόπηση. ...
... Endogenous fungal endophthalmitis (EFE) is a sightthreatening condition generally caused by fungemia and hematogenous seeding of fungal pathogens, most commonly Candida and Aspergillus species [1]. EFE sets off at and involves the inner choroid and the retina (chorioretinitis; indicated by fluffy, white chorioretinal lesions) and may 2 then expand into the vitreous cavity (vitritis) and aqueous humorous [2,3]. EFE, unlike endogenous bacterial endophthalmitis, more commonly presents subacutely, without systemic symptoms of infectionpatients may not seek ophthalmic care until a significant visual decline due to vitritis [3]. ...
Background:
Suboptimal response to conventional treatments in refractory diabetic macular edema (rDME) encourages efforts to identify new therapeutic options.
Purpose:
To evaluate the effect of three monthly intravitreal injections of a Rho-associated protein kinase (ROCK) inhibitor (Fasudil, Asahi Kasei Pharma Corporation, Tokyo, Japan) in eyes with rDME.
Methods:
Ten eyes of 10 patients with DME unresponsive to at least six previous intravitreal bevacizumab (IVB) injections were recruited and underwent 3 consecutive monthly intravitreal injection of 0.025mg/0.05mL Fasudil. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were evaluated as functional and anatomical response indicators, respectively.
Results:
The mean age was 60.1±5.1 years (range, 53-68). Five cases responded to treatment, two with both anatomical and functional responses (reduction of CMT from 521 to 395 and from 390 to 301 microns and improvement of BCVA from 0.3 to 0.1 LogMAR and 0.6 to 0.4 LogMAR, respectively) and three with only functional improvement (0.7 to 0.4; 0.7 to 0.4; and 0.3 to 0.1 LogMAR). Of note, cases with no significant change in CMT showed morphologic improvement of the retinal microstructure to some extent. No adverse event was observed during the study period.
Conclusion:
Monotherapy with intravitreal injection of ROCK inhibitors appears to have moderate visual benefits in eyes with DME refractory to IVB. Such effects may be functionally significant without obvious anatomical improvement.
... Endogenous fungal endophthalmitis (EFE) is a sightthreatening condition generally caused by fungemia and hematogenous seeding of fungal pathogens, most commonly Candida and Aspergillus species [1]. EFE sets off at and involves the inner choroid and the retina (chorioretinitis; indicated by fluffy, white chorioretinal lesions) and may 2 then expand into the vitreous cavity (vitritis) and aqueous humorous [2,3]. EFE, unlike endogenous bacterial endophthalmitis, more commonly presents subacutely, without systemic symptoms of infectionpatients may not seek ophthalmic care until a significant visual decline due to vitritis [3]. ...
Abstract
Purpose: To describe cases of endogenous fungal endophthalmitis (EFE) post-recovery from or hospitalization for coronavirus disease 2019 (COVID-19).
Methods: This prospective audit involved patients with suspected endophthalmitis referred to a tertiary eye care center over a one-year period. Comprehensive ocular examinations, laboratory studies, and imaging were performed. Confirmed cases of EFE with a recent history of COVID-19 hospitalization +/- intensive care unit admission were identified, documented, managed, followed up, and described.
Results: Seven eyes of six patients were reported; 5/6 were male, and the mean age was 55. The mean duration of hospitalization for COVID-19 was approximately 28 days (14-45); the mean time from discharge to onset of visual symptoms was 22 days (0-35). All patients had underlying conditions (5/6 hypertension; 3/6 diabetes mellitus; 2/6 asthma) and had received dexamethasone and remdesivir during their COVID-related hospitalization. All presented with decreased vision, and 4/6 complained of floaters. Baseline visual acuity ranged from light perception (LP) to counting fingers (CF). The fundus was not visible in 3 out of 7 eyes; the other 4 had “creamy-white fluffy lesions” at the posterior pole as well as significant vitritis. Vitreous taps were positive for Candida species in six and Aspergillus species in one eye. Anti-fungal treatment included intravenous amphotericin B followed by oral voriconazole and intravitreal amphotericin B. Three eyes underwent vitrectomy; the systemic health of two patients precluded surgery. One patient (with aspergillosis) died; the others were followed for 7-10 months – the final visual outcome improved from CF to 20/200-20/50 in 4 eyes and worsened (hand motion to LP) or did not change (LP), in two others.
Conclusion: Ophthalmologists should maintain a high index of clinical suspicion for EFE in cases with visual symptoms and a history of recent COVID-19 hospitalization and/or systemic corticosteroid use – even without other well-known risk factors.
... Physicians should have high clinical suspicion of endophthalmitis in the setting of a known mechanism for fungal penetration into the bloodstream, irrespective of a history of immunosuppression [7]. Due to an increased amount of blood flow directed to the choroidal space and ciliary body, endogenous endophthalmitis primarily affects these areas of the eye, beginning with the choroid and then progressing to secondary impact on the retina and vitreous spaces [4,48]. Endogenous endophthalmitis accounts for approximately 2-15% of all cases of endophthalmitis, including both bacterial and fungal etiologies [4,12]. ...
Endophthalmitis is a serious ophthalmologic condition involving purulent inflammation of the intraocular spaces. The underlying etiology of infectious endophthalmitis is typically bacterial or fungal. The mechanism of entry into the eye is either exogenous, involving seeding of an infectious source from outside the eye (e.g., trauma or surgical complications), or endogenous, involving transit of an infectious source to the eye via the bloodstream. The most common organism for fungal endophthalmitis is Candida albicans. The most common clinical manifestation of fungal endophthalmitis is vision loss, but other signs of inflammation and infection are frequently present. Fungal endophthalmitis is a clinical diagnosis, which can be supported by vitreous, aqueous, or blood cultures. Treatment involves systemic and intravitreal antifungal medications as well as possible pars plana vitrectomy. In this review, we examine these essential elements of understanding fungal endophthalmitis as a clinically relevant entity, which threatens patients' vision.
Zusammenfassung
Die endogene Candida -Endophthalmitis ist eine seltene, aber visusbedrohende Erkrankung. Eine durch Candida -Spezies hervorgerufene endogene Endophthalmitis hat in den meisten Fällen eine bessere Prognose als endogene Endophthalmitiden durch andere Pilzarten oder Bakterien, trotzdem ist die Prognose stark abhängig von der Zeitdauer bis zur Diagnostik und der anschließenden Therapie sowie dem initialen Visus. In der Vergangenheit wurden bereits Vorschläge für Therapiealgorithmen erstellt, verbindliche Leitlinien in der Ophthalmologie existieren aufgrund der Seltenheit der Erkrankung nur vereinzelt. In diesem Review soll auf die aktuellen Erkenntnisse zur endogenen Candida -Endophthalmitis eingegangen werden, und es werden Rückschlüsse aus der derzeitigen Studienlage gezogen.
The American Academy of Ophthalmology evaluated the practice of routine screening for intraocular infection from Candida septicemia. In the United States, ophthalmologists are consulted in the hospital to screen for intraocular infection routinely for patients with Candida bloodstream infections. This practice was established in the era prior to the utilization of systemic antifungal medication and to the establishment of definitions of ocular disease with candidemia. A recent study found a rate of less than 1% of routinely screened patients with endophthalmitis from Candida septicemia. Other studies found higher rates of endophthalmitis but had limitations in terms of classifications of ocular disease, lack of vitreous biopsies, selection biases and lack of longer-term visual outcomes. Some studies attributed ocular findings to Candida infections, rather than other comorbidities. Studies also have not demonstrated differences in medical management that are modified for eye disease treatment; therefore, therapy should be dictated by the underlying Candida infection, rather than be tailored based on ocular findings. In summary, the Academy does not recommend a routine ophthalmologic consultation following laboratory findings of systemic Candida septicemia, which appears to be a low-value practice. An ophthalmologic consultation is a reasonable practice for a patient with signs or symptoms suggestive of ocular infection along with candidemia.
