What are the ophthalmic complications of fungal infection?

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Ophthalmic Complications of Fungal Infection

Fungal endophthalmitis is the most devastating ophthalmic complication of fungal infection, resulting in severe vision loss or blindness if not promptly treated, and can occur through exogenous routes (keratitis, trauma, surgery) or endogenous hematogenous spread. 1, 2, 3

Primary Ophthalmic Complications

Fungal Endophthalmitis

Endophthalmitis represents purulent inflammation of the intraocular spaces and is the most serious fungal complication affecting the eye. 3

  • Endogenous fungal endophthalmitis occurs via hematogenous spread, most commonly from Candida albicans in candidemic patients, initially manifesting as chorioretinitis with potential extension into the vitreous causing vitritis 1, 2, 3

  • Exogenous fungal endophthalmitis results from direct inoculation through three mechanisms: progression from fungal keratitis (44% of cases), penetrating ocular trauma (24%), or post-intraocular surgery (32%) 4, 5

  • Macular involvement is a critical prognostic indicator—outcomes for visual acuity depend heavily on whether the macula is affected at presentation, with macular involvement predicting poor visual recovery 1, 6

Fungal Keratitis

Fungal keratitis serves as both a primary complication and a pathway to endophthalmitis, with Fusarium species being the predominant pathogen (72-73% of keratitis cases). 4, 5, 7

  • Fungal keratitis presents with corneal infiltrates, ulcerations, and stromal involvement that can progress to intraocular infection 1, 7

  • Topical natamycin is the first-line treatment for filamentous fungal keratitis, while topical amphotericin B is preferred for yeast keratitis 7

  • Corticosteroids must be avoided in fungal keratitis as they worsen outcomes 1

Post-Transplant Fungal Infections

Fungal infections following endothelial keratoplasty (EK) have increased significantly, rising from 0.014% in 2013 to 0.023% in 2016, representing a serious complication of corneal transplantation. 1

  • Fungal pathogens may originate from donor tissue, storage media, or periocular sources 1

  • Lamellar interface infection is a specific complication unique to EK procedures 1

  • Positive fungal cultures from donor rims have predictive value, with three-quarters of mate tissues also showing fungal growth 1

Causative Organisms by Clinical Category

Endogenous Endophthalmitis

  • Candida albicans is the predominant species, though all Candida species causing candidemia can cause endophthalmitis 1, 2, 3

Exogenous Endophthalmitis from Keratitis

  • Fusarium species account for 72-73% of keratitis-associated cases 4, 5

Exogenous Endophthalmitis from Trauma

  • Aspergillus species predominate in penetrating trauma cases (40.9% of trauma-related endophthalmitis) 5
  • A broader spectrum of fungi causes open-globe injuries compared to other categories 4

Post-Surgical Endophthalmitis

  • Aspergillus is the most common isolate in postoperative cases (38% of surgical endophthalmitis) 4

Polymicrobial Infections

  • Fungal-bacterial coinfection occurs in 7.7% of cases, most commonly with Aspergillus and Bacillus following metal penetrating trauma, and carries the worst prognosis often requiring evisceration 5

Clinical Manifestations

Vision Loss Patterns

  • Vision loss is the most common clinical manifestation of fungal endophthalmitis 3
  • Outcomes vary dramatically by mechanism: keratitis-associated cases achieve 20/400 or better vision in 61% of cases, while open-globe trauma cases have the poorest outcomes with 70% of enucleations occurring in this group 4

Inflammatory Signs

  • Chorioretinitis with or without vitritis characterizes endogenous infection 1
  • Anterior chamber inflammation accompanies most cases of exogenous fungal endophthalmitis 4, 5

Management Principles

Diagnostic Approach

All candidemic patients require dilated ophthalmologic examination by an ophthalmologist to detect endophthalmitis, as waiting for ocular symptoms results in worse visual outcomes. 1

  • Culture of vitreous and/or aqueous humor is the gold standard for definitive diagnosis and must be performed before initiating therapy 6
  • Direct microscopic examination detects hyphae in 78.4% of smear samples 5

Treatment Strategies

Treatment decisions for fungal endophthalmitis must be made jointly by an ophthalmologist and infectious diseases physician. 1

For Fluconazole/Voriconazole-Susceptible Isolates:

  • Fluconazole loading dose 800 mg (12 mg/kg), then 400-800 mg (6-12 mg/kg) daily OR voriconazole loading dose 400 mg (6 mg/kg) IV twice daily for 2 doses, then 300 mg (4 mg/kg) IV or oral twice daily 1
  • These azoles achieve adequate concentrations in the posterior segment including the vitreous 1

For Fluconazole/Voriconazole-Resistant Isolates:

  • Liposomal amphotericin B 3-5 mg/kg IV daily 1

Intravitreal Therapy:

  • Sight-threatening lesions near the macula or vitreous invasion require intravitreal injection of amphotericin B deoxycholate or voriconazole 1, 6
  • Amphotericin B was used in 73% of exogenous cases as initial treatment, though most cases ultimately required at least 3 different antifungal agents 4

Surgical Intervention:

  • At least one pars plana vitrectomy is performed in 61-71% of cases to remove inflammatory debris 6, 4, 5
  • Most eyes undergo 3 or more procedures including surgeries and intraocular injections (71% of cases) 4
  • Medical therapy alone does not suffice for invasive fungal infections, particularly those caused by Fusarium species—surgical debridement is essential 7

Critical Pitfalls and Caveats

Timing Is Critical

Fungal endophthalmitis is a medical emergency—delayed therapy results in permanent vision loss. 6

Corticosteroid Contraindication

Corticosteroids are contraindicated in fungal infections and should be avoided in cases of suspected fungal keratitis or endophthalmitis. 1, 7

Contact Lens-Related Risk

  • Contact lens wear increases risk of fungal keratitis, which can progress to endophthalmitis 1
  • Extended overnight wear carries 10-15 times greater risk of microbial keratitis compared to daily wear 1

Geographic and Environmental Factors

  • Fungal infections show geographic variation, with gram-negative organisms and fungi more prevalent in southern climates 1
  • Trauma remains the major etiological factor for exogenous fungal endophthalmitis in many regions (56.4% of cases) 5

Prognosis Determinants

  • Final visual outcomes depend on virulence of the organism, extent of intraocular involvement, macular involvement, and timing of interventions 2, 3
  • Overall, 44-54% of patients achieve final visual acuity of 20/80 or better, but this varies dramatically by clinical category 4, 5

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Fungal endophthalmitis.

Expert review of anti-infective therapy, 2011

3
Research

Fungal Endophthalmitis: A Comprehensive Review.

Journal of fungi (Basel, Switzerland), 2021

6
Guideline

Endophthalmitis Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

7
Research

Current perspectives on ophthalmic mycoses.

Clinical microbiology reviews, 2003

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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