**20. Endogenous endophthalmitis**

objects. [61]According to some studies, up to 50% of central corneal ulcers may be caused by fungi and almost 50% of these cases may be associated with fungal endophthalmitis. [62] The fungal endophthalmits can also occur due to the failed treatment of contact lens-associ‐ ated keratitis. Exogenous fungal endophthalmitis is mostly sight threatening unless aggres‐ sive intervention by antifungal therapy and surgery initiated. Effective therapy requires proper identification of the causative organisms and their sensitivity to the desired antifun‐ gal agents (Figure 13). Currently, some of the effective antifungal drugs include Amphoteri‐ cin B, Natamycin, Flucytosine, Thiabendazole, Miconazole, Ketoconazole, Clotrimazole, Econazole, Fluconazole, Itraconazole, Voriconazole, and Posaconazole. Amphotericin B is the only fungicidal depending on concentration achieved, and is active against a wide range of fungi including Aspergillus species, Fusarium species and Candida species. It may be giv‐ en topically, sub-conjunctivaly, and intra-vitreally. [63] In addition to intra-vitreal therapy, Amphotericin B is given systemically by a slow intravenous infusion for the treatment of fungal endophthalmitis. For fungal endophthalmitis, Amphotericin or Miconazole is usually used following vitrectomy. Amphotericin B can be administered intravenously combined with oral Flucytosine for severe Candida endophthalmitis associated with retino-choroiditis. For Candida retinochoroiditis without endophthalmitis, treatment is effective with systemic

**Figure 13.** External photograph of left eye of an elderly female who developed fungal keratitis and endophthalmitis

Treatment for minimal fungal chorioretinitis and vitritis include systemic antifungal therapy along with serial ophthalmic evaluations. [3, 61, 64] In cases of moderate to severe vitritis due to fungal endophthalmitis, intra-ocular antifungal therapy along-with systemic as well as surgical intervention may be necessary to treat fungal endophthalmitis (Figure 14). Rec‐ ommended treatment protocols include, Amphotericin B and Voriconazole as primary ther‐ apeutic options. [61, 64] Both can be given systemically and intra-vitreally. Since the intraocular penetration of Amphotericin B after topical or systemic treatment is limited, and many fungal pathogens are not susceptible to these agents, Voriconazole seem to be promis‐ ing alternative. Systemically administrated Voriconazole has a good intraocular penetration

Ketoconazole, Fluconazole, or Voriconazole. [64]

192 Common Eye Infections

requiring surgical as well as systemic antifungal treatment.

Endogenous endophthalmitis is a severe vision-threatening intraocular infection that spreads through bloodstream from a concurrent infection somewhere else in the body. Endogenous endophthalmitis is relatively uncommon, accounting for 2% to 8% of all reported cases of en‐ dophthalmitis. [67] The outcome of endogenous bacterial endophthalmitis has not improved over the last several decades and clinicians need to have a high level of suspicion of this com‐ monly misdiagnosed condition. [67, 68] The majority of patients with endogenous endoph‐ thalmitis are initially misdiagnosed and many have an underlying disease known to predispose to infection. Blood cultures may be the most frequent means for establishing the infective cause. Endogenous bacterial endophthalmitis usually leads to total loss of vision. Al‐ though most cases of endogenous endophthalmitis present as unilateral, bilateral cases have also been reported. [69, 70] In a large study of endophthalmitis from a major center over a 10year period, 86 cases were reported; 10 of these were due to endogenous causes. [71] The poor visual outcome in these patients has been related to the delay in the early diagnosis and ap‐ propriate timely treatment. [72] Systemic symptoms rather than acute ocular symptoms may be the most common reasons for a patient to present to a physician and many of these cases may be initially misdiagnosed. Jackson et al. reviewed 267 reported cases of endogenous bac‐ terial endophthalmitis and also presented a 17-year prospective series. [67]
