Exogenous Fungal Endophthalmitis: Microbiology and Clinical Outcomes

Objective: To report the fungal isolates, treatment strategies, and clinical outcomes for a large series of patients with exogenous fungal endophthalmitis. Design: Retrospective, single institution, consecutive case series. Participants: All patients treated at Bascom Palmer Eye Institute between January 1, 1990, and June 30, 2006, for culture-proven exogenous fungal endophthalmitis. Methods: Microbiologic and medical records were reviewed for all patients with intraocular cultures positive for fungal organisms and clinically diagnosed exogenous endophthalmitis. Main Outcome Measures: Fungal isolates, treatment strategies, visual acuity, and rate of enucleation. Results: Culture-positive exogenous fungal endophthalmitis occurred in 41 eyes, including 18 cases (44%) associated with fungal keratitis, 10 cases (24%) occurring after penetrating ocular trauma, and 13 cases (32%) after intraocular surgery. Filamentous fungi (molds) accounted for 35 cases (85%), and Candida species (yeasts) accounted for 6 cases (15%). Although most keratitis cases were caused by Fusarium (13 of 18; 72%), Aspergillus was the most common isolate in postoperative cases (5 of 13; 38%). Open-globe cases were caused by a broader spectrum of fungi. As initial treatment, 30 (73%) patients received intraocular amphotericin B, but at least 3 antifungal agents were used in 24 (59%) cases. At least 1 pars plana vitrectomy was performed in 25 (61%) eyes, and 29 (71%) eyes underwent 3 or more procedures, including surgeries and intraocular injections. Although a final vision of 20/400 or better was achieved in 22 (54%) eyes, all but 1 of these were either in the keratitis (11 of 18) or the postoperative (10 of 13) groups. Conversely, although 10 (24%) of 41 eyes were enucleated, 7 of these were among the open-globe patients. Conclusions: This report highlights the differences between the clinical categories of exogenous fungal endophthalmitis. Although 85% of all cases were caused by molds, most commonly Fusarium and Aspergillus, the most common fungal genera varied by clinical category. Amphotericin B was the most commonly used antifungal agent, but most cases were treated with at least 3 different antifungal agents. Final visual outcomes were variable, with the open-globe-associated patients having the poorest outcomes. Overall, 44% of patients achieved a final visual acuity of 20/80 or better. Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.