Why does a patient with candidemia require an eye examination?

From the Guidelines

Patients with candidemia should undergo a dilated eye examination by an ophthalmologist to check for endophthalmitis, a serious intraocular infection, within the first week of diagnosis of candidemia. This examination is crucial to detect endophthalmitis, which may initially be asymptomatic but can lead to vision loss if untreated. The prevalence of ocular involvement in candidemia ranges from 2-16%, making screening essential even in asymptomatic patients 1. If endophthalmitis is detected, treatment typically involves systemic antifungal therapy with agents like fluconazole (usually 400-800 mg daily), voriconazole, or an echinocandin, often for a prolonged course of 4-6 weeks. Severe cases may require intravitreal antifungal injections (such as amphotericin B 5-10 μg) or even vitrectomy. Early detection through routine ophthalmologic examination allows for appropriate treatment modifications and duration adjustments, potentially preventing permanent vision damage. This recommendation applies to all candidemic patients, including those who are critically ill or neutropenic.

Some key points to consider:

• The examination should be performed by an ophthalmologist to ensure accurate detection of endophthalmitis 1.
• The examination should be done within the first week of diagnosis of candidemia in nonneutropenic patients, and delayed until neutrophil recovery in neutropenic patients 1.
• Decisions regarding antifungal treatment and surgical intervention should be made jointly by an ophthalmologist and an infectious diseases physician 1.
• The duration of treatment should be at least 4–6 weeks, with the final duration dependent on resolution of the lesions 1.

Overall, a dilated eye examination is a crucial component of the management of candidemia, and should be performed promptly to prevent vision loss and improve patient outcomes.

From the Research

Importance of Eye Examination in Patients with Candidemia

• Patients with candidemia are at risk of developing endogenous Candida endophthalmitis, a sight-threatening manifestation of disseminated candidiasis 2.
• The occurrence of endogenous candida endophthalmitis in patients with candidemia has ranged from 0-45% in the published literature 2.
• The Infectious Disease Society of America recommends that all patients with candidemia undergo a dilated retinal exam to exclude endogenous Candida endophthalmitis 3.

Risk Factors for Developing Candida Endophthalmitis

• Central venous catheter presence, intravenous drug use, immunosuppression, total parenteral nutrition recipient, race, age, and gender are risk factors for developing Candida endophthalmitis 3.
• Candida albicans is more likely to result in Candida endophthalmitis 3.
• The presence of these risk factors can help clinicians develop targeted and cost-effective strategies for endophthalmitis screening 3.

Diagnosis and Treatment of Candida Endophthalmitis

• Fluconazole has been shown to be effective in the management of candidal endophthalmitis, with a cure rate of 94% in 16 eyes 4.
• Pars plana vitrectomy with or without intravitreal amphotericin B injections has been advocated for patients with moderate-to-severe vitritis and substantial vision loss 2.
• The current treatment options for candida endophthalmitis are not well-established, and more research is needed to determine the best course of treatment 2.

Screening for Ocular Candidiasis

• The American Academy of Ophthalmology recommends against routine screening in patients with candidemia without symptoms, while the Infectious Diseases Society of America recommends a screening dilated retinal examination by an ophthalmologist for all patients with candidemia 5.
• Ocular candidiasis was found in 26% of patients with candidemia, with all cases manifesting as chorioretinitis 6.
• The number needed to screen to detect presumed Candida chorioretinitis among asymptomatic patients was 20, highlighting the importance of continued ophthalmological screens 5.