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Endogenous Fungal Endophthalmitis: An Increasing Problem Among Intravenous Drug Users.

Endogenous fungal endophthalmitis is an uncommon disease caused by hematogenous spread of fungi to the posterior segment of the eye. Risk factors include intravenous drug use, immunosuppression, long-term indwelling catheters, chronic antimicrobial use, and other systemic diseases. Typical findings include focal white elevated lesions on the retina or on the vitreous, subretinal abscess formation, or retinal detachment (RD) with visible fungal lesions on the retina. In the June 2017 issue of JAMA Ophthalmology, Tirpack et al1 described a series of cases of endogenous fungal endophthalmitis involving young intravenous drug users in New England. All reported patients had unilateral involvement and the most common isolate was Candida albicans. When at-risk patients, such as intravenous drug users, report a history of acute or progressive loss of vision, endogenous fungal endophthalmitis should be considered. However, this diagnosis can be difficult to make for a variety of reasons. The clinical findings can be nonspecific and may mimic other types of intraocular inflammation such as toxoplasmosis, sarcoidosis, and Bartonellosis (cat scratch disease). If patients present to an ophthalmologist without a known history of fungemia, the correct diagnosis might not be considered. Alternatively, patients may present to primary care clinicians with other serious medical problems such as distant site infections (eg, involving the heart, brain, joints, or kidney) or mental status changes that may limit communication of visual symptoms. In this circumstance, the external eye may appear normal to penlight examination, making it unlikely that the correct diagnosis will be made unless a formal dilated fundus examination is performed. The diagnosis of endogenous fungal endophthalmitis is made based on clinical findings with subsequent laboratory confirmation. Obtaining intraocular cultures is desirable but may not be necessary in all patients. Many of these patients have a known positive fungal culture from an extraocular site or typical ocular features. Cultures may be obtained by needle aspiration or by pars plana vitrectomy (PPV), which has the advantages of clearing the visual axis and obtaining a larger specimen for culture. Growth of fungi on culture media may take several days, but special stains may allow earlier identification of the organism. Polymerase chain reaction testing is available at some centers for more rapid identification. Related article at jamaophthalmology.com JAMA OPHTHALMOLOGY