Grand RoundsGrand RoundsJanuary 5, 2007January 5, 2007

Jeffrey D. Colburn, M.D., PGY-2Jeffrey D. Colburn, M.D., PGY-2

Vanderbilt Eye InstituteVanderbilt Eye Institute

The Case…The Case…

• CC: New onset blurry vision (x2 days)

• HPI: 70 yo WF admitted 10 days prior for N/V/failure to thrive s/p Abd surgery– Pain in OS transiently 2 days ago– Like “looking through a dirty windshield”– New floaters OU

HistoryHistory• Past Ocular Hx

– Wears glasses– CEIOL OD

• Past Med/Surg Hx– Insulinoma, s/p pancreatic

enucleation, 8/29/06– Ventral hernia, 8/06– CT guided drainage of fluid

collection surrounding pancreas (9/21/06)

– Home TPN since 10/2/06– HTN– CAD, s/p MI & CABG– Depression

Meds: ASA, Imdur, Cartia, Coreg, Lasix, HCTZ, KCl, Protonix, Pravachol, Naproxen, MVI, Nitro, Ca+D, Lopid, Prozac, Reglan, Vancomycin

• Allergies: Theodur, Demerol

• Family Hx– Father – Colon CA– Mother – CHF– Son – DM– Daughter – SLE

• Social Hx– No Tobacco– Occasional EtOH

• ROS+ Nausea, Vomiting, Fatigue, chronic

SOB

ExamExam

• BCVA: 20/200-1 OU

• IOP: 15 OD, 16 OS

• CVF: full OD, superonasal deficit OS

• Pupils: 4 → 2 OU, no RAPD

• Motility: Full OU

• External: WNL

ExamExam• SLE

LLL: quiet OU

Conj: quiet OU

K: clear OU

A/C: D&Q OU, no cell/flare

Iris: Intact

Lens: PCIOL OD, 2-3+ NSC OS

VA now 20/400 OUVA now 20/400 OU

Further Images from OSFurther Images from OS

ExamExam• DFE:

Vitreous: vitritis OD>OS

Disks: hazy view

C/D: small cups OU

Macula: round white lesion with well defined

edges near fovea OD

Periphery: similar lesions superiorly & nasally OS

Vascular: wnl

Differential DiagnosisDifferential Diagnosis

Differential DiagnosisDifferential Diagnosis• Infectious

– Bacterial endophthalmitis– Fungal endophthalmitis– Toxoplasmosis– Syphilis– CMV retinitis– HZV/HSV retinitis– Nocardia– Tuberculosis

• Inflammatory/Infiltrative– Sarcoid– Wegener’s– PAN

• Neoplastic– Large cell lymphoma

Additional HistoryAdditional History• Fever spike of 102.7 with tachycardia 4

days prior

• PICC line removed

• Cultures grew out Coag Negative Staph and Candida albicans

• On IV Vancomycin & Diflucan

Diagnosis:Diagnosis:Endogenous Multifocal Infectious Endogenous Multifocal Infectious

Chorioretinitis – likely staphylococcal Chorioretinitis – likely staphylococcal due to due to

multifocal nature, recent fever spike, multifocal nature, recent fever spike, diffuse vitritisdiffuse vitritis

CourseCourse– Tx with IV Vancomycin, PO Diflucan– Day 3 – Minimal improvement, added PF 1% QID for

AC reaction– Week 2 – PF not started, Posterior Synechiae

developed OS– Week 4 – No better, new lesions OS, increased vitritis

with “string of pearl appearance” VA= 6’/200 E OU

→ Revised diagnosis:

Endogenous Fungal Endophthalmitis

CourseCourse

– Week 4 – Intravitreal injection of amphotericin OU• Switched to IV caspofungin and PO voriconazole

– Week 5 – PPV, intravitreal inj of Amphotericin OS– Week 6 – PPV, intravitreal inj of Amphotericin OD

– Vitreal cultures – no growth OU

• Candida – most common• History of risk factors• Mild/Mod inflammation, focal/multifocal yellow-

white chorioretinal lesions– May coalesce, forming mushroom shaped nodules

extending into vitreous– Classic: “string of pearls” appearance

• Dx: systemic/intraocular cultures, PPV• Relatively favorable outcome for Candida if

treated aggressively early.

Endogenous fungal endophthalmitisEndogenous fungal endophthalmitis

CandidemiaCandidemia

• Rare before 1950• Incidence in patients with candidemia reported from 28%

to 45%• Donahue, et al, showed in 1992 that Candida

endophthalmitis was rare when properly defined– 118 patients, no endophthalmitis, 9.3% chorioretinitis

only– Risk factors: visual symptoms, C. albicans species,

immunosuppression, multiple + blood cultures• Feman, et al (2002): incidence of <2%

TreatmentTreatment

• Intravenous amphotericin B – first used in 1960– Significant systemic side effects– Poor intraocular penetration

• Systemic fluconazole– Better side effect profile– O’Day, et al: Better intraocular penetration– May be effective monotherapy for chorioretinitis– Fungistatic

TreatmentTreatment• Vitrectomy

– First reported in 1976– Provides specimen for diagnosis– Removes pathogen load– Improves ocular penetration of systemic tx

• Intraocular amphotericin B– Potential retinal toxicity, but rarely seen clinically– Used commonly for advanced cases

TreatmentTreatment

• Vitrectomy with oral fluconazole alone may be an effective option– Christmas & Smiddy (1996): Case series 6 of

six eyes• PPV and 4-weeks of oral fluconazole• Five achieved final VA of 20/40 or better

TreatmentTreatment• Intraocular corticosteroid injection is controversial

– Theoretically should not alter host defense as no affect on neutrophils

– If used, must assure appropriate antimicrobial coverage

• Intraocular imidazoles may be useful in cases of resistance to therapy, or for Aspergillus

• PO/IV voriconazole and caspofungin for tx failure

Update on our patientUpdate on our patient

– Last visit (1/2/07 – Week 10)– VA: 6/200 OD, 20/60 with correction OS– Inactive punched out scars in both eyes.– Resolved vitritis

To RememberTo Remember

• Relatively favorable prognosis

• Keep this diagnosis in mind

• Early and aggressive therapy

• Treatment options are expanding

ReferencesReferences• Donahue SP, et al. Intraocular candidiasis in patients with candidemia.

Ophthalmology 1994;101:1302-1309.• Flynn, HW. The Clinical challenge of endogenous endophthalmitis. Retina

2001;21:572-574.• Gupta A, et al. Fungal endophthalmitis after a single intravenous administration of

presumably contaminated dextrose infusion fluid. Retina 2000;20:262-268.• O’Day DM. Ocular uptake of fluconazole following oral administration. Arch

Ophthalmol 1990;108:1006-1008.• Smiddy, WE. Treatment outcomes of endogenous fungal endophthalmitis. Current

Opinions in Ophthalmology 1998;9:66-70.• Snip RC, Michels RG. Pars plana vitrectomy in the management of endogenous

Candida endophthalmitis.• Williams, MA, et al. Diagnosis and treatment of endogenous endophthalmitis.

Ophthalmologica 2006;220:134-136.

Thank youThank you