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Fungal endophthalmitis: Analysis of 730 consecutive eyes from seven tertiary eye care centers in India

Published:September 18, 2021DOI:https://doi.org/10.1016/j.oret.2021.09.006

      Abstract

      Purpose

      To evaluate the clinical and microbiological features of a large cohort of culture-confirmed fungal endophthalmitis across India.

      Design

      Cross-sectional hospital-based retrospective medical records review.

      Participants

      Seven large tertiary eye care centers from different regions of India.

      Methods

      The patient data were pooled from the electronic/physical medical records of each participating center. Fellowship-trained vitreoretinal specialists clinically managed all patients, and in-house microbiology laboratories performed all microbiology work-ups. The clinical and microbiology procedures were broadly uniform across all participating centers. The essential treatment consisted of vitreous surgery and intravitreal and systemic therapy with antifungal agents.

      Main Outcome Measures

      Clinical outcome by the causative event and causative fungus.

      Results

      In the 2005-2020 period, seven centers treated 3830 cases of culture-proven endophthalmitis, and 19.1% (n=730) were culture-confirmed fungal endophthalmitis. It included 46.9% postoperative (87.4% post-cataract surgery), 35.6% traumatic and 17.5% endogenous endophthalmitis. The fungi included 39.0% Aspergillus (high in central, east and south zones), 15.1% Candida (high in west zone), 15.9% Fusarium (high in north and west zone). The time to symptoms was between 1w-4w in more than a third of patients except in traumatic endophthalmitis. Less than half of patients had hypopyon on presentation. Presenting visual acuity (PVA) in most patients was <20/400. Nearly all patients needed a vitrectomy and an average of two intravitreal injections of antifungal agents. At least 10% of eyes needed therapeutic keratoplasty, and up to 7% of eyes were eviscerated. Following treatment, the final (best corrected) visual acuity (FVA) was > 20/400 in 30.5% (n= 222) eyes; > 20/40 in 7.9% (n=58) eyes; and 12% (n=88) eyes lost light perception. Post-hoc analysis showed significantly more males in traumatic than post-operative (p<0.0001) and endogenous (p = 0.001) endophthalmitis; higher isolation of Candida species in endogenous than post-operative (p = 0.004) and traumatic (p<0.0001) endophthalmitis, better PVA in eyes with Candida species infection (p<0.0001) and poorer FVA in eyes with Aspergillus species infection.

      Conclusions

      Fungal endophthalmitis is not uncommon in India. The inclusion of antifungal agents with antibiotics as the first empirical intravitreal therapy before microbiological confirmation could be considered when fungal infection is suspected,

      Acronyms and Abbreviations:

      CFW (Calcofluor white), FVA (Final visual acuity), HM (Hand motions), KOH (Potassium hydroxide), LCB (Lactophenol cotton blue), LP (Light perception), PDA (Potato dextrose agar), PVA (Presenting visual acuity), SDA (Sabouraud’s dextrose agar), TPK (Therapeutic penetrating keratoplasty)
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