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Fungal endophthalmitis developing in asthmatic individuals treated with inhaled corticosteroids.

Candida albicans is a normal component of human microbial flora of the skin and gastrointestinal tract. When it gains access to the bloodstream, resulting in fungemia, susceptible patients may develop endogenous fungal endophthalmitis (EFE). A number of risk factors have been associated with Candida endophthalmitis and are shown in the Table. These include long-term intravenous therapy, intravenous drug abuse, and even lithotripsy. In this article, we propose another risk factor for EFE—the use of inhaled corticosteroids in the treatment of asthma. Oral candidiasis secondary to the treatment of asthma with inhaled corticosteroids has been welldocumented in the medical literature. We hypothesize that oral candidiasis may cause transient fungemia, which can seed the choroid and lead to EFE. Report of a Case. Case 1. The patient was a 68-year-old woman with a history of asthma and decreased, “cloudy” vision in both eyes for a period of 2 days. She had recently experienced an asthma exacerbation treated with inhaled corticosteroids and subsequently developed oral candidiasis treated with local application of nystatin. Examination revealed a visual acuity of counting fingers at 1 foot in both eyes, 1 conjunctival injection, and 4 cell in the anterior chamber with 1-mm hypopyon and posterior synechiae bilaterally (Figure). The anterior vitreous of the right eye was poorly visualized owing to a small pupil, while the left eye revealed vitreous cells. The media was hazy, and vitreous debris was seen on B-scan bilaterally. A clinical diagnosis of bilateral EFE was made, and she was treated with 200 mg of oral fluconazole twice daily for 1 month. In addition, she was given topical corticosteroids and cycloplegic eye drops. At the 1-month follow-up, her visual acuity was 20/25 in both eyes. As a result of fluconazole treatment, the patient resolved her infection and experienced a significant improvement in visual acuity, confirming our clinical diagnosis. Case 2. The patient was a 67-yearold woman with a history of steroiddependent asthma and chronic obstructive pulmonary disease who presented with 2 days of decreased visual acuity in the left eye and retroorbital and facial pain. In the 2 months prior, she had 3 hospital admissions for asthma exacerbations that were treated with inhaled corticosteroids. During these episodes, she developed oral candidiasis treated locally with nystatin. The patient’s left eye had a visual acuity of counting fingers at 6 inches, 2 conjunctival injection, 4 cell and flare in the anterior chamber with 0.5 mm hypopyon, 3 anterior vitreous cells, hazy fundus view with dull red reflex, and a “chalky white” lesion in the posterior pole. She was diagnosed clinically with EFE and treated with an intravitreal injection of 5 μg/0.1 mL of amphotericin B as well as corticosteroid and cycloplegic eye drops. At the 2-week follow-up, the patient had decreased vision and increased pain in the left eye. Exami-