Endophthalmitis associated with fungal keratitis and penetrating injuries in North China

Abstract

Purpose: To report the laboratory findings, management strategies, and visual outcomes of culture-proven exogenous fungal endophthalmitis in North China. Methods: The microbiological and treatment records of patients with culture-positive exogenous fungal endophthalmitis who visited the Affiliated Hospital of Qingdao University from January 2012 to December 2016 were reviewed. Results: A total of 39 eyes (39 patients) were identified over a 5-year period. Exogenous fungal endophthalmitis was associated with penetrating trauma in 22 eyes (56.4%), fungal keratitis in 15 eyes (38.5%), and intraocular surgery in 2 eyes (5.1%). Hyphae were found in 29 of 37 smear samples (78.4%) by direct microscopic examination. Fungal pathogens cultured from 39 samples were identified as 10 genera and 15 species. Filamentous fungi (molds) accounted for 94.9% (37 samples), including Fusarium (19, 48.7%) and Aspergillus (11, 28.2%). Most keratitis cases were caused by Fusarium (11 of 15; 73.3 %). Aspergillus was isolated from nine penetrating ocular trauma cases (9 of 22; 40.9%). Three eyes receiving evisceration had fungal and bacteria coinfection (3 of 39, 7.7%) with Aspergillus and Bacillus. At least, one surgical intervention was performed in all 39 eyes and 28 (71.8%) eyes underwent two or more procedures, including surgeries and intraocular injections. Twenty-nine patients received intraocular antifungal therapy with amphotericin B and/or voriconazole. Visual acuity at discharge from the hospital was significantly better than the initial visual acuity ( p < 0.001). Final vision of 20/400 or better was achieved in 22 (56.4%) eyes. Conclusions: This study highlighted the differences between clinical categories of exogenous fungal endophthalmitis. Trauma was the major etiological factor. Molds were the most common pathogens, with Fusarium ranking first, followed by Aspergillus. Fungal and bacterial coinfection mostly occurred after metal penetrating trauma, and Bacillus was the primary bacterial pathogen. Coinfection may be one reason of evisceration. Immediate intravitreal antifungal therapy combined with vitrectomy was effective for exogenous fungal endophthalmitis. Amphotericin B and voriconazole were commonly used antifungal agents.

Vitrectomy combined with intravitreal antifungal therapy for posttraumatic fungal endophthalmitis in eastern China

“…Our results indicate that penetrating objects can cause fungal endophthalmitis, with plant material and iron objects being the predominant causes. As in previous studies [ 6 – 8 ], we observed a latent period of fungal endophthalmitis after a penetrating ocular trauma. The onset of fungal endophthalmitis after trauma was usually subacute or chronic.…”

“…The prevalence of posttraumatic fungal endophthalmitis varies in different countries. Fungal endophthalmitis after trauma predominantly occurs in developing countries, such as India and China [ 6 – 8 ], but it is rare in developed countries. A report from the USA retrospectively reviewed 41 cases of fungal endophthalmitis over 16 years, which included just 10 cases of posttraumatic fungal endophthalmitis [ 9 ].…”

Trends in Outpatient Prescribing Patterns for Ocular Topical Anti-Infectives in Six Major Areas of China, 2013–2019

“…Attention should be paid to the rational use of topical antiviral drugs. Anti-fungal drugs were seldom used, which was in accordance with the low prevalence of diagnosed ocular fungal infection [ 35 ]. Moreover, oral formulations and off-label use of injectable formulations are often used, but were not included for analysis in this study [ 36 ].…”

Fungal endophthalmitis: A 20‐year experience at a tertiary referral centre

“…Higher rates of evisceration and poor visual outcomes have been reported in cases with Aspergillus spp. growth 20,28,33 . Some of the risk factors associated with enucleation/evisceration include endophthalmitis secondary to corneal ulceration or endogenous endophthalmitis and initial poor VA 29 .…”