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Fadi Shaya, Ben Cohen, Thomas Walsh, Alan Sheyman, David Eppenstein, Kent W Small; Final Outcomes of an Outbreak of Fungal Endophthalmitis Caused by Contaminated Intravitreal Triamcinolone from a Compounding Pharmacy. Invest. Ophthalmol. Vis. Sci. 2016;57(12):6374.
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To report the final outcomes of an outbreak of fungal endophthalmitis caused by intravitreal triamcinolone contaminated by a compounding pharmacy. We had previously reported the initial findings within the first several months of the outbreak. However, because the long-term outcomes are substantially different, the final outcomes need to be reported with 4-year's follow up data.
A retrospective chart review from two retina practices (in CA and NY) was performed for 25 eyes that received contaminated intravitreal triamcinolone obtained from a single compounding pharmacy (Frank's Compounding Pharmacy). IRB consent was obtained for this review. Medical records were reviewed from December 2011 through 2015. Pertinent clinical data were collected. Visual acuity, intraocular pressure, fundus photography, fluorescein angiography, ultrasonography; presence of vitreous cell, anterior chamber cell; and fungal detection obtained by vitreous needle aspiration or vitreous biopsy were obtained for each subject.
There were 25 eyes injected with the contaminated triamcinilone in California and New York. The causative organism was identified by genotyping to be Bipolaris hawaiienis. Three of these eyes showed no evidence of infection, 5 eyes were enucleated, eight eyes had visual acuity of 20/50 or better, three eyes had visual acuity at count fingers, and six eyes resulted in light perception or no light perception. The enucleated eyes showed evidence of persistent organisms despite aggressive local and chronic (1 year) systemic therapy.
The final clinical outcomes were highly variable; 3 eyes never showed any signs of infection while 5 resulted in enucleation. We suspect this is likely due to variable fungal load in the triamcinolone. Despite long-term aggressive local and systemic treatment utilizing voriconazole and amphotericin-B intravitreal injections, fungal elements were still found in the enucleated eyes. Diagnostic techniques such as fungal cultures were extremely insensitive and PCR was completely worthless. Vitreous tap was inadequate as well. Direct vitreous biopsy by PPV with cytospin was only 50% sensitive.The patients that seemed to have the best outcome were treated with long term (1 year or more) high dose (300 mg PO BID) voriconazole rather than frequent PPV and intravitreal injection of Amphoptericin B and voriconazole.
This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.
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