April 2014
Volume 55, Issue 13
ARVO Annual Meeting Abstract  |   April 2014
Histopathology of enucleation specimens of fungal endophthalmitis secondary to a compounding pharmacy
Author Affiliations & Notes
  • Fadi Salim Shaya
    Macula & Retina Institute, Glendale, CA
  • Thomas J Walsh
    Pediatrics and Microbiology and Immunology, Weill Cornell Medical College, New York, NY
  • Kent W Small
    Macula & Retina Institute, Glendale, CA
  • Don Minckler
    Ophthalmology and Laboratory Medicine, University of California, Irvine, Irvine, CA
  • Footnotes
    Commercial Relationships Fadi Shaya, None; Thomas Walsh, None; Kent Small, None; Don Minckler, None
  • Footnotes
    Support None
Investigative Ophthalmology & Visual Science April 2014, Vol.55, 3863. doi:
  • Views
  • Share
  • Tools
    • Alerts
      This feature is available to authenticated users only.
      Sign In or Create an Account ×
    • Get Citation

      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.

      Download citation file:

      © ARVO (1962-2015); The Authors (2016-present)

  • Supplements

Purpose: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Keywords: 513 endophthalmitis • 530 fungal disease • 638 pathology: human  

This PDF is available to Subscribers Only

Sign in or purchase a subscription to access this content. ×

You must be signed into an individual account to use this feature.