Diagnosis of Vitreoretinal Aspergillosis with Transvitreal Retinochoroidal Biopsy

Abstract

Diagnosing culture-proven endophthalmitis is complicated by the insufficient yield of intraocular samples and the variety of etiologies which mimic true endophthalmitis. In cases of impending vision loss where vitreous biopsy cannot provide a definitive diagnosis, transvitreal retinochoroidal biopsy can be an effective next step. Our case is a 48-year-old male with B-cell acute lymphoblastic leukemia that presented with counting fingers vision, redness, and tearing of the left eye. Exam showed cell and flare with hypopyon as well as dense vitritis. The patient underwent diagnostic pars plana vitrectomy and vitreous culture was negative at the time. Flow cytometry demonstrated no malignant cells. However, the patient's vision and mental status continued to clinically decline despite being started on intravitreal and systemic antibiotic and antifungal therapy. Neuroimaging revealed rim-enhancing brain lesions. Transvitreal retinochoroidal biopsy was performed in an elevated area of the retina. The biopsy helped rule out malignancy and showed acute-angle, septate, branching hyphae characteristic of Aspergillus fumigatus. Ultimately, the vitreous biopsy, cultures, and a biopsy from the left frontal lobe brain abscess all confirmed this diagnosis as well. Transvitreal retinochoroidal biopsy can play a role in the diagnosis of a case of posterior uveitis and can be particularly effective in diagnosing a fungal endophthalmitis.

Aspergillus Endophthalmitis: Epidemiology, Pathobiology, and Current Treatments

“…The aqueous and vitreous humors, which are typically obtained by pars plana vitrectomy (PPV) or a vitreous tap, are important specimens for the clinical diagnosis of endophthalmitis, as they can be used for either reverse transcription polymerase chain reaction (RT-PCR) or culturing [ 110 ]. It is pertinent to note that vitreous specimens are more reliable and sensitive than aqueous specimens in the process of fungal identification [ 111 , 112 , 113 ].…”

Acute lymphoblastic leukemia with central nervous system Aspergillus infection: A case report and literature review

“…NGS was only reported in the present study. The most frequently used drug was voriconazole, accounting for 22 cases and with the improvement of the drug, the disease improvement rate of patients significantly advanced compared with previous use, accounting for 19 cases (Table I) (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42).…”

Intraocular biopsy in uveitis

“…Minimally invasive 25-G trans-vitreal retinochoroidal (TVRC) biopsy to obtain larger samples for histopathological and immunohistochemical study has been described in selected situations. [ 57 ]…”