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Kent Small; Fungal Endophthalmitis Onset Due To Intravitreal Triamcinilone Contaminated by a Compounding Pharmacy. Invest. Ophthalmol. Vis. Sci. 2013;54(15):1123.
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A retrospective chart review of the onset and presentation of fungal endophthalmitis was undertaken to assist the ophthalmic, epidemiologic and infectious disease communities in detecting and managing outbreaks from compounding pharmacies. These ophthalmic data may be useful in managing the meningitis outbreak.
A retrospective chart review was performed of 14 patients who received intravitreal injections of preservative-free triamcinolone pre-loaded syringes obtained from Franck's pharmacy which were subsequently found to be contaminated with the fungus Bipolaris hawaiiensis. Sixteen eyes were injected (one twice) with this preservative-free triamcinilone . Two patients received bilateral sequential injections. The data extracted from the charts were: time to onset of signs and symptoms of infection, visual acuity, intraocular pressure, fundus photos, fluorescein angiography, ultrasounds, vitreous culture and biopsy results.
Of the sixteen eyes injected, 10 (62%) eventually developed fungal endophthalmitis. The time onset of signs and / or symptoms ranged from 2 weeks to 7 months, median 3 months. The typical presenting signs and symptoms were painless loss of vision in an eye which was white and quiet appearing except for cell in the anterior chamber or the vitreous. Vitreous biopsy (cyto-spin for hyphae) obtained by pars plana vitrectomy was more sensitive in making the diagnosis of fungal endophthalmitis than was vitreous culture or in office "vitreous taps" (including cyto-spin)
Fungal endophthalmitis is rare and can have an insidious and much delayed onset. Initially making the diagnosis without the context of a documented "outbreak" is extremely difficult. Endophthalmitis due to Bipolaris hawaiiensis, a plant mold, has only been reported twice before. One was in a patient who had a scleral laceration from a rice branch and the other was endogenously in an immuno-compromised patient. Our Bipolaris endophthalmitis cases have many similarities with the Exserohilum meningitis cases. Both are ubiquitous airborne black molds which had contaminated triamcinilone by different compounding pharmacies. The markedly delayed onset of Bipolaris hawaiiensis infections is a potentially ominous warning for the patients and doctors involved with the 17,000 patients exposed to Exserohilum meningitis
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