What are the symptoms and signs of a fungal infection of the eye in a patient with a history of severe side effects to fluconazole (an antifungal medication)?

Clinical Presentation of Fungal Eye Infections

Fungal endophthalmitis presents with blurred vision as the most common manifestation, often accompanied by eye pain, redness, and inflammatory signs including white fluffy lesions in the vitreous or retina, hypopyon (layered white cells in the anterior chamber), and reduced red reflex. 1, 2

Key Clinical Features to Identify

Symptoms

• Progressive vision loss is the hallmark symptom, which may be painless initially but often becomes painful as inflammation advances 1, 3
• Blurred vision developing over days to weeks, particularly in patients with risk factors like candidemia or recent surgery 1, 2
• Eye pain and redness accompany more advanced disease 2

Physical Examination Findings

• Vitritis (inflammatory cells in the vitreous body) appears as white fluffy infiltrates or "cotton ball" lesions visible on dilated fundoscopic examination 4, 3
• Chorioretinitis manifests as white-yellow lesions on the retina and choroid, which may progress to involve the vitreous 4
• Hypopyon (layered white blood cells in the anterior chamber) is a classic sign of severe intraocular infection 2
• Fungal balls may be visible in the vitreous or on the retina during examination 3
• Reduced or absent red reflex due to dense vitritis obscuring visualization of the posterior segment 2
• Conjunctival hyperemia, lid edema, chemosis, and corneal edema indicate severe inflammation 2

Two Distinct Forms

Chorioretinitis (Early/Milder Form)

• Inflammation limited to the choroid and retina without vitreous involvement 4
• May be asymptomatic or cause minimal visual disturbance initially 5
• Can be detected only through dilated retinal examination before symptoms develop 5

Endophthalmitis (Advanced/Severe Form)

• Inflammation extends into the vitreous body, representing progression from chorioretinitis 4
• Associated with poor visual outcomes and potential permanent vision loss 4, 5
• Presents with dense vitritis that obscures fundoscopic visualization 3

Critical Diagnostic Timing

The most important clinical pitfall is waiting for symptoms before examining at-risk patients, as asymptomatic ocular candidiasis detected through screening has significantly better visual outcomes than symptomatic presentation. 5, 4

• All patients with candidemia require dilated retinal examination within the first week of antifungal therapy, regardless of visual symptoms 4, 5
• Up to 16% of candidemic patients develop ocular involvement, often without initial symptoms 4
• Examination should be performed by an ophthalmologist when possible to ensure adequate visualization and documentation 4, 5

Special Considerations for Fluconazole-Intolerant Patients

Given your history of severe fluconazole side effects, alternative treatment options exist but do not change the clinical appearance of the infection itself. The key is early detection through screening examination rather than waiting for symptoms, as liposomal amphotericin B with or without flucytosine provides effective alternative therapy for fluconazole-resistant or fluconazole-intolerant patients 4. Voriconazole represents another excellent alternative with superior ocular penetration 4.