Abstract
Purpose :
Although current Infectious Diseases Society of America guidelines recommend the use of systemic antifungal in patients with endogenous fungal endophthalmitis (EFE), there is no robust evidence to support the use of intravenous (IV) versus oral antifungal therapy. The purpose of this study is to describe treatment strategies and outcomes in patients with EFE, including considerations that inform systemic antifungal therapeutic choices.
Methods :
This is a retrospective chart review at a single institution. Charts of patients diagnosed with EFE between 2010 and 2023 were reviewed for inclusion. Patients who received systemic treatment for EFE with a minimum of 14 days of follow-up were included. Outcome measures include time to improvement in vitritis or chorioretinitis, change in systemic therapy, and need for surgical intervention.
Results :
Twenty eyes of 16 patients were included. Candida species were the most common pathogen (43.8%), followed by culture negative EFE (37.5%), and Aspergillus species (18.8%). Ninety percent of eyes had either vitritis and/or macula-involving chorioretinitis.
Most patients with Candida infections (60%) or culture negative EFE (75%) were treated initially with oral antifungals. Patients with a history of immune compromise, known positive fungal culture, or positive Fungitell assay were more likely to be treated with early IV antifungal therapy. Two cases required systemic antifungal therapy modification despite early initiation of intravitreal antifungal injections. In one case of rare voriconazole-resistant Aspergillosis, ongoing chorioretinal lesion growth despite intravitreal amphotericin B injections was an early sign of drug resistance; in the second case, a patient with C. dubliniensis demonstrated chorioretinal lesions regression only after switching from oral to IV fluconazole.
Conclusions :
Initial systemic treatment decisions were driven primarily by systemic culture positivity, perceived systemic illness secondary to fungal infection, or the presence of comorbidities. Intravitreal antifungal therapy is an effective adjunct for the treatment of vitreous involvement but is not sufficient to arrest progression of chorioretinal lesions. In some cases, visible end-organ damage in the form of chorioretinitis may indicate the need for a change in systemic therapy and may serve as a surrogate for culture sensitivities.
This abstract was presented at the 2024 ARVO Annual Meeting, held in Seattle, WA, May 5-9, 2024.