February 2007

 

CATARACT/ IOL

 

Investigating Aspergillus-related endophthalmitis


by Maxine Lipner EyeWorld Senior Contributing Editor

 

 

 

Fungal endophthalmitis infections need to be on practitioners’ “radar screens.” Here’s what to watch for

These days, bacterial endophthalmitis is a rare occurrence in cataract surgery, and the fungal variety rarer still—yet practitioners still need to keep the latter cases prominently in mind when faced with mysterious infections. In a series recently published in the American Journal of Ophthalmology, investigators reported on five cases of Aspergillus-related endophthalmitis that left 60% patients enucleated.

Spurred by the severe outcomes associated with such cases, investigators felt that it was important to take a closer look, noted Timothy G. Murray, M.D., professor of ophthalmology, Bascom Palmer Eye Institute, Miami. “Because of the outcomes being so poor and because of the rarity of this condition, we wanted physicians to have a better understanding of how this disease presented, how we treated these patients, and what we thought might be options for monitoring patients presenting with this condition,” Dr. Murray said.

Five Aspergillus cases

Aspergillus endophthalmitis seven weeks after phacoemulsification surgery with posterior chamber intraocular lens insertion. Note clump of fungal elements in the superior portion of the anterior chamber adjacent to the scleral tunnel wound.

Source: Timothy Murray, M.D.

When investigators reviewed the records of the five patients who were diagnosed with Aspergillus–related endophthalmitis at their practices between 1992 and 2005, they found that the cases differed from what would have been expected with the bacterial variety. “First of all, 40% of the patients we took care of were immunosuppressed, so that their normal immune response to organisms in the eye was altered,” Dr. Murray said. “All of the patients had what was felt to be relatively uncomplicated cataract surgery, and they typically presented around one month after surgery.” This timeline is later than that expected for the classic post-cataract endophthalmitis, which typically presents around one week after the procedure.

Patients with Aspergillus-related endophthalmitis usually present with non-specific complaints such as decreased vision, eye pain, and ocular irritation, resulting in red eyes. “So, there is not one thing that screams that this is an atypical infection,” Dr. Murray said. In reviewing the cases, Dr. Murray found that the infection tended to take a more indolent course before progressing significantly. With the Aspergillus-related infection there also tends to be a lot of flocculent material in the anterior chamber, also differing from that of a bacterial infection. “The appearance of the material in the eye is different, where it tends to be clumpy and flocculent as opposed to bacterial endophthalmitis, where it tends to have a cellular response and a layering called a hypopyon,” he said. “Patients can also often have involvement of the sclera where they can then have an infectious scleritis that then goes on to necrosis.”

For three of the five initially-treated patients in the study, doctors used a tap-and-inject approach, in which a needle was placed in the eye to aspirate the intraocular contents and the material then cultured. “We used the tap-and-inject approach for 60% of the eyes and then two of the eyes, 40%, had a pars plana vitrectomy,” Dr. Murray said. “All of the eyes were treated with broad spectrum antibiotics.” In three of the cases, this treatment was not sufficient to control the infection, and the eyes needed to be removed. However, two of the other eyes did reasonably well with this approach. One patient ultimately attained 20/30 acuity and the other 20/200. Dr. Murray found that there seemed to be no correlation between time to treatment and visual results. “Patients presented with involvement from 10 to 62 days after their surgery and there did not seem to be an association between their presentation and their outcome,” he said. The patient who showed up the earliest, at just seven days, required enucleation, as did the one who showed up the latest.

Stomping out Aspergillus

If practitioners suspect that they are facing a potential case, Dr. Murray recommended obtaining an excellent sample and initially covering the patient with broad spectrum antibiotics. He also urges practitioners not to overlook fungal treatment initially. “Consider an antifungal coverage at the time of the antibiotic coverage,” he said. “Then be aggressive about your follow-up on your culture results, and tailor your therapy based upon these results.” While historically the gold standard for treatment has been amphotericin there has been some recent interest in an alternative antifungal agent known as Vfend (voriconazole, Pfizer, New York). “There has also been a suggestion that intravitreal amphotericin, and oral voriconizole may be a good combined therapy for these patients,” Dr. Murray said. The biggest mistake that practitioners could make would be to discount the presence of a fungal infection when a patient presents with an atypical inflammatory response. Dr. Murray urged practitioners to obtain a culture and make sure that the culture is aggressively followed. “The mistake would be to see this, not be concerned about it, not culture this eye, and not cover this patient with an antibiotic,” he said. “I think that that would be something that would be hard to defend for the clinician.”

Though serious, these Aspergillus–related endophthalmitis infections are fortunately rare. “I think that the key is to have a high suspicion for these unusual infections and then to treat them aggressively,” Dr. Murray said.

Editors’ note: Dr. Murray has no financial interests related to his comments.

Contact Information

Murray: 305-326-6166, tmurray@med.miami.edu

Investigating Aspergillus-related endophthalmitis Investigating Aspergillus-related endophthalmitis
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