**19. Exogenous fungal endophthalmitis**

**18. Risks of endophthalmitis with retained IOFB and prevention**

Intraocular penetration of a dirty or soil-contaminated foreign body requires an emergent intervention. Delayed removal of IOFB following trauma may result in a significant increase in the development of clinical endophthalmitis. Risk factors for poor visual outcome may in‐ clude poor initial presenting VA, posterior location of IOFB and the lack of vitrectomy at the time of initial IOFB removal. [27, 28, 59] A retrospective study of a 20-year review found that 8% of patients with an IOFB developed endophthalmitis, of whom half lost all light percep‐ tion. [1, 6] One of the largest study of penetrating eye trauma and retained IOFB in eyes of 565 patients managed at a large tertiary eye care center over a 22 year period revealed that 7.5% of them developed clinical evidence of endophthalmitis at some point after trauma. [31] In these patients, the initial presenting VA of 20/200 or better was recorded in only 18.1% of eyes and the remaining 81.9% had VA ranging from 20/400 to light perception. On‐

**Figure 11.** External photographs of a 13-years-old male who presented one week after trauma to his right eye (a and b). He was found to have no light perception vision and evidence of pus filled right eye which required evisceration (c).

(c)

(a)

190 Common Eye Infections

(b)

Exogenous fungal endophthalmitis has been reported more often from countries in the trop‐ ical region. Most common causes of exogenous fungal endophthalmitis include Aspergillus and Fusarium species. [3] These infections are usually associated with trauma, but can fol‐ low intraocular surgery especially in the rural settings. [61] The filamentous fungus especial‐ ly Aspergillus as well as Fusarium cause infection following trauma with soil contaminated 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 Ketoconazole, Fluconazole, or Voriconazole. [64]

**Figure 13.** External photograph of left eye of an elderly female who developed fungal keratitis and endophthalmitis requiring surgical as well as systemic antifungal treatment.

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 with minimal systemic side effect profile as compared with amphotericin B. In general in vi‐ tro susceptibility of Candida, Aspergillus, and Fusarium species appears to be almost 100% to the administered Voriconazole. [63] Candida endophthalmitis seems to result in better outcome than Aspergillus endoophthalmitis. Caspofungin appears to have a very good ac‐ tivity against Candida and Aspergillus species and when administered systemically along with Voriconazole, it has been found to be very effective in treating endophthalmitis caused by these organisms. Due to its unique mechanism of action and high activity against yeast and molds, Caspofungin may show more promise in future treatment strategies for fungal endophthalmitis. Fusarium endophthalmitis is particularly difficult to treat, requiring both surgical removal of the inoculums along with Amphotericin and Imidazoles therapy. Gener‐ ally, Voriconazole or Fluconazole (to cover Candida albicans) or Itraconazole (to cover other Candida species, Aspergillus or Cryptococcus) can be considered. [65, 66]

**Figure 14.** Post-operative delayed fungal endophthalmitis; photograph (a) showing sectoral iris infiltration with As‐ pergillus niger requiring pars-plana vitrectomy, total capsulectomy, total iridectomy and removal of intraocular lens, photograph (b) showing white plaque extending from the upper capsule equator caused by Aspergillus terreus re‐ quiring 3 PPVs and intra-viteal Amphotericin B injections and eventual enucleation because of recurrent fungal infec‐ tion. (Figures reproduced with permission: Al-Mezaine HS, Al-Assiri A, Al-Rajhi AA. Incidence, clinical features, causative organisms, and visual outcomes of delayed-onset pseudophakic endophthalmitis. Eur J Ophthalmol 2009;19:804-811).
