What is the recommended treatment for Candida infection of the eye (Candida keratitis/endophthalmitis)?

Treatment of Candida Eye Infection

For azole-susceptible Candida ocular infections, initiate systemic fluconazole (loading dose 800 mg, then 400-800 mg daily) or voriconazole (loading dose 400 mg IV twice daily for 2 doses, then 300 mg IV/oral twice daily) for at least 4-6 weeks, with treatment decisions made jointly by ophthalmology and infectious diseases. 1

Initial Assessment and Diagnosis

All patients with candidemia require dilated fundoscopic examination by an ophthalmologist within the first week to detect ocular involvement 2. The ophthalmologist must determine the extent of infection:

• Chorioretinitis alone (retinal involvement without vitreous involvement)
• Chorioretinitis with macular involvement
• Endophthalmitis (vitreous involvement)

This distinction is critical because it determines whether intravitreal injections and vitrectomy are needed 2.

Treatment Algorithm Based on Disease Severity

For Chorioretinitis WITHOUT Vitritis or Macular Involvement

Systemic therapy alone:

• First-line (azole-susceptible isolates): Fluconazole 800 mg loading dose, then 400-800 mg daily OR voriconazole 400 mg IV twice daily × 2 doses, then 300 mg IV/oral twice daily 2
• Alternative (azole-resistant isolates): Liposomal amphotericin B 3-5 mg/kg IV daily ± flucytosine 25 mg/kg four times daily 2

Critical caveat: Echinocandins have poor penetration into the posterior chamber and should be avoided for endophthalmitis 1. They may only be considered for asymptomatic, well-localized chorioretinitis if the isolate is echinocandin-susceptible 1.

For Chorioretinitis WITH Macular Involvement

Systemic therapy PLUS intravitreal injection:

• Same systemic regimen as above
• PLUS intravitreal injection: Amphotericin B deoxycholate 5-10 μg/0.1 mL sterile water OR voriconazole 100 μg/0.1 mL sterile water/normal saline 2

The intravitreal injection ensures prompt high-level antifungal activity at the macula to prevent vision loss 2.

For Endophthalmitis (Vitritis Present)

Systemic therapy PLUS intravitreal injection PLUS consider vitrectomy:

• Same systemic regimen as chorioretinitis
• Intravitreal injection: Amphotericin B deoxycholate 5-10 μg/0.1 mL sterile water OR voriconazole 100 μg/0.1 mL sterile water/normal saline 2
• Vitrectomy: Should be considered to decrease organism burden and remove fungal abscesses inaccessible to systemic agents 2

The 2025 ECMM/ISHAM/ASM guideline emphasizes that intravitreal therapy and vitrectomy decisions must be evaluated case-by-case jointly by infectious disease and ophthalmology 1.

Drug Selection Rationale

Why fluconazole/voriconazole are preferred:

• Fluconazole achieves vitreous concentrations ~70% of serum levels 2
• Voriconazole achieves vitreous concentrations ~40% of serum levels 2
• Both can be given orally for step-down therapy
• Extensive clinical experience demonstrates efficacy 3, 4

Why echinocandins should be avoided:

• Poor pharmacokinetics in the posterior chamber 1
• Inadequate vitreous penetration 2
• Only acceptable for isolated chorioretinitis without vitritis in select cases 1

When to use liposomal amphotericin B:

• Azole-resistant isolates (C. glabrata, C. krusei) 1, 2
• Achieves higher intraocular concentrations than conventional amphotericin B in animal models 2
• Alternative when resistance to other agents is encountered 1

Treatment Duration and Monitoring

• Minimum duration: 4-6 weeks 2
• Final duration: Based on resolution of lesions determined by repeated ophthalmological examinations 2
• Follow-up: Serial dilated fundoscopic exams to assess treatment response 2

Common Pitfalls to Avoid

1. Do not use echinocandins for endophthalmitis - Despite being first-line for candidemia, they fail in ocular infections due to poor penetration 1

2. Do not delay ophthalmology consultation - Joint decision-making between infectious disease and ophthalmology is essential from the outset 2

3. Do not skip intravitreal therapy for macular involvement or vitritis - Systemic therapy alone is insufficient when the macula is threatened or vitreous is involved 2

4. Monitor voriconazole levels - Serum trough levels should be 2-5 μg/mL to enhance efficacy and avoid toxicity due to variable pharmacokinetics 2

5. Verify susceptibility testing - Treatment decisions should be reviewed based on susceptibility results, particularly for non-albicans species 1

The most recent 2025 global guideline 1 aligns with the 2016 IDSA recommendations 2 but provides updated emphasis on avoiding echinocandins and the importance of multidisciplinary management for optimal visual outcomes.