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Fadi Salim Shaya, Thomas J Walsh, Kent W Small, Don Minckler; Histopathology of enucleation specimens of fungal endophthalmitis secondary to a compounding pharmacy. Invest. Ophthalmol. Vis. Sci. 2014;55(13):3863.
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Compounded medications are frequently used in routine management of many retinal diseases. Franck's Compounding Pharmacy had distributed several preloaded syringes of preservative free triamcinilone which was later found to be contaminated with the rice mold Bipolaris hawaiienese. This resulted in fungal endophthalmitis in most of those receiving this medication intravitreally. Five of these eyes resulted in enucleation. We report pathologic and clinical data from 5 eyes with endophthalmitis due to Bipolaris hawaiiensis contaminated triamcinolone.
From a solo retina practice, we reviewed the histopathology of 5 enucleated eyes.These eyes were being treated for retinal vascular disease and diabetic retinopathy with preservative free intravitreal triamcinolone from a single lot prepared by Franck's Compounding Pharmacy.
Endophthalmitis occurred in 14 of 17 injected eyes. Onset of signs and symptoms of endophthalmitis (decreased vision, anterior chamber or vitreous cells) in the five cases presented here varied from 5 to174 days. Vitreous biopsy with cytospin and PAS stain for hyphae was the most sensitive method for proving fungus present, positive in 3 of 5 of our cases. PCR was not positive in any of the specimens. Five of the 5 enucleation specimens from the whole series of 14 clinical cases were confirmed as positive for Bipolaris hawaiiensis by genotyping at the Center for Disease Control. Three of the removed eyes were cultured and were negative, however all 5 demonstrated organisms with fungal stains (PAS) despite extensive intravitreal and systemic treatments.
The important clinical messages are that symptoms of fungal endophthalmitis can be minimal and delayed up to 10 months. More worrisome is that apparently viable organisms persist in ocular tissues despite prolonged exposure to high dose anti-fungal agents intravitreally and systmeically. This suggests that this organism may not be able to be eradicated with currently available agents. Bipolaris, a plant mold, is also frighteningly similar to the fungus involved in meningitis outbreak also due to contaminated triamcinilone from another compounding pharmacy, New England Compounding. Lessons learned from our cases may need to be extrapolated to the meningitis cases. This suggests that the fungal meningitis cases may require prolonged systemic anti-fungal therapy.
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