Home Print this page Email this page Users Online: 788
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 87-96

Management of postoperative fungal endophthalmitis with section infiltrates: Our experience


1 Department of Ophthalmology, GITAM Institute of Medical Sciences, Visakhapatnam, Andhra Pradesh, India
2 Retina Consultant, Sankar Foundation Eye Hospital, Visakhapatnam, Andhra Pradesh, India
3 GMR Care, Rajam, Andhra Pradesh, India

Date of Submission31-Mar-2017
Date of Acceptance13-Mar-2019
Date of Web Publication11-Dec-2019

Correspondence Address:
P Veena
GITAM Institute of Medical Sciences, 7-1-73/A, Srija Plaza-401, Chinna Waltair, Visakhapatnam - 530 017, Andhra Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_29_17

Rights and Permissions
  Abstract 


Aim: The aim of the study is to report the management of postoperative fungal endophthalmitis (POFE with corneoscleral infiltrates) after the cataract surgery. Settings and Design: The study was conducted at a tertiary care referral center in North Andhra. This was a retrospective, single-institution, interventional case series. Materials and Methods: Ten cases were microbiologically proven POFE, out of which eight cases having sclera-corneal infiltrates and two cases having corneal infiltrates, refractory to conventional management, were included in this study. Four cases were managed with intraocular lens (IOL) explantation, pars plana vitrectomy (PPV), intravitreal vancomycin, ceftazidime, and voriconazole, followed by the excision of corneoscleral infiltrate and therapeutic patch graft/therapeutic penetrating keratoplasty (TPK) as a secondary procedure. Six cases were managed with IOL explantation, excision of infected corneoscleral tissue, therapeutic corneoscleral patch graft/TPK, and anterior vitrectomy with intravitreal voriconazole. “Anatomical success” was defined as preserved anatomy of the globe and absence of signs of inflammation. “Functional success” was defined as an attached retina and a best-corrected visual acuity of better than 20/400. Results: Of the ten cases, the duration between cataract surgery and the diagnosis of endophthalmitis was 2–10 weeks in nine cases and 3 days in one case. Five cases were culture and potassium hydroxide (KOH) positive for fungus (Aspergillus fumigatus – 3, Aspergillus flavus – 1, and Aspergillus niger – 1), and five cases were KOH positive for fungus. No recurrences were observed after corneal patch graft/TPK with PPV and IOL explantation (Median follow-up – 12 months). Prestudy defined the criteria for successful “anatomical” and “functional” outcomes were achieved in 90% and 50%, respectively. Conclusion: This report highlights the effective role of combined IOL explantation, excision of infected tissue, therapeutic patch graft with PPV, and intravitreal voriconazole in managing POFE with corneoscleral infiltrates.

Keywords: Corneal patch graft, intraocular lens explantation, postoperative endophthalmitis


How to cite this article:
Veena P, Sharma A, Peri G. Management of postoperative fungal endophthalmitis with section infiltrates: Our experience. J Clin Ophthalmol Res 2019;7:87-96

How to cite this URL:
Veena P, Sharma A, Peri G. Management of postoperative fungal endophthalmitis with section infiltrates: Our experience. J Clin Ophthalmol Res [serial online] 2019 [cited 2020 Jan 25];7:87-96. Available from: http://www.jcor.in/text.asp?2019/7/3/87/272706



Postoperative fungal endophthalmitis (POFE) following intraocular surgery is usually uncommon, but has been reported[1],[2],[4],[5],[6],[7],[8],[9],[10] more frequently from India.[1],[2],[4]

Experience in managing POFE remains limited.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Intraocular lens (IOL) explantation has been reported anecdotally with corneal recurrence needing additional surgery.[11] Compared to older reports[4],[6],[7],[8] with poor outcome, recently, newer antifungal agents such as voriconazole/liposomal amphotericin B/caspofungin have shown promise.[1],[2] The experience with these drugs in developing countries is limited due to economic reasons.[12]

We report our experience in managing postcataract surgery fungal endophthalmitis with corneoscleral infiltrate, with IOL explantation, excision of infected corneoscleral tissue and therapeutic corneoscleral patch graft and parsplana vitrectomy (PPV) and intravitreal antibiotics.


  Materials and Methods Top


This study is a retrospective analysis of ten consecutive cases (ten eyes) of microbiologically proven POFE presenting to a tertiary care center in North Andhra Pradesh. Our center serves as a tertiary eye care referral hospital for North Andhra, costal Andhra, part of Orissa, and part of Chhattisgarh. The records were reviewed for details including the demographic details, interval between cataract surgery and presenting vision, anterior and posterior segment signs of inflammation, microbiological survey, interventions, and final outcome.

Seven cases were operated elsewhere in the same month; three isolated cases out of 40,000 cataract surgeries were operated at our institute over a period of 3 years. All cases were postcataract surgery, one case was aphakic small incision cataract surgery (SICS), eight cases underwent SICS with IOL implantation, and one case underwent phacoemulsification with IOL implantation. The latent period ranged from 3 days to 10 weeks [Table 1].
Table 1: Demographic details of patients with recurrent fungal endophthalmitis

Click here to view


Patients at presentation were subjected to “tap and inject” regime, involving intravitreal antibiotics and antifungal (vancomycin and ceftazidime, 1 and 2.25 mg in 0.1 ml each, respectively, and voriconazole 0.05 mg in 0.1 ml). The intraocular fluid was sent for Gram's Stain, potassium hydroxide 10% (KOH) mount, implanted in blood agar, nutrient agar, and Sabouraud's Dextrose Agar (SDA) for fungal culture. One portion of the sample was transported for bacterial culture in blood agar and nutrient agar. The second portion was directly inoculated on one plate of the SDA and incubated at 30°–37° for a period of 6 weeks.

Following injections, in four cases initially PPV, IOL explantation with removal of bag done by retinal surgeon, and then referred to cornea specialist for the management of corneal infiltrate. In these four cases, as endophthalmitis did not responded, after 2 days therapeutic corneoscleral patch graft performed along with repeat intravitreal injection of voriconazole 0.05 mg in 0.1 ml.

In remaining six cases, combined IOL explantation, therapeutic (corneoscleral/corneal) patch graft and PPV performed in the same sitting along with intravitreal injection of voriconazole 0.05 mg/0.1 ml on the same day.

All these patients also received topical antifungal eye drops (natamycin 5% and voriconazole 20% hourly) along with topical nepaflam 0.3% eye drops 2 times for 16 weeks, and topical ofloxacin 0.3% eye drops 4 times a day for 10 days, cyclopentolate 1% eye drops 2 times a day for 1 month, and tear substitutes 4–6 times a day for 16 weeks. Patients were given oral ciprofloxacin 500 mg twice a day for 5 days, topical steroid loteprednisolone 0.5% eye drops 4 times a day starting on the 7th-postoperative day and continued for 4 weeks in a tapering dose. The topical antifungal therapy (5% natamycin and 20% voriconazole) was continued for a minimum of 16 weeks, initially hourly for the first 7 days, 2 hourly for the next 2 weeks, followed by 4 times a day for the next 12 weeks. Natamycin 5% eye drops were continued for months, voriconazole 20% eye drops, and nepaflam 0.3% eye drops continued for the next 4 weeks and monitored for possible side effects and recurrence.

Surgical steps of excision of infected tissue IOL explantation and corneoscleral patch graft [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h.
Figure 1: (a–g) Surgical steps of corneoscleral patch graft and, (h) 1 wk post operative

Click here to view


Surgical steps included painting of eye with betadine, eye was draped, lids were separated with speculum, conjunctival resection was done at the site of infiltrate, the size of the infiltrate was measured with calipers, and 2 mm infiltrate-free area was marked. In six cases, 6 mm trephine was used for marking infected corneoscleral zone; host cornea, limbus, and sclera were marked with gentian violet, side port was made to introduce anterior chamber maintenance, full-thickness trephination was done on corneal side, and hand-fashioned excision was done on sclera along the marking. Infected tissue with 2-mm infiltrate-free area was excised, anterior chamber wash was done to remove hypopyon and exudates, later IOL along with capsular bag was removed. After keeping anterior chamber maintainer, peripheral iridectomy was done, donor button was prepared using 6.5-mm trephine at corneoscleral junction depending on the amount of sclera involved and sutured with interrupted 10–0 nylon on corneal side; 6–0 vicryl and 9–0 nylon alternatively on the sclera side. Later, 23-G PPVt was performed by the retinal surgeon. Intravitreal antibiotics and antifungal (vancomycin and ceftazidime, 1 and 2.25 mg in 0.1 ml each, respectively, and voriconazole 0.05 mg in 0.1 ml) were given.

After a minimum follow-up of 12 months for the last intervention, the outcome was defined in terms of “anatomical” and “functional” success. “Anatomical success” was defined as a preserved anatomy of the globe with the absence of signs of inflammation. “Functional success” was defined as an attached retina and a best-corrected visual acuity of better than 20/400.

Institutional ethical committee approval was obtained for the retrospective analysis for this study.


  Results Top


The study included ten eyes of ten patients with fungal endophthalmitis with corneoscleral/corneal infiltrate following the cataract surgery. There were six males and four females. The mean age was 60.6 years (range, 50–70 years). One patient was hepatitis B surface antigen positive. One patient was diabetic. One patient had postcataract surgery trauma. The demographic details of the patients are summarized in [Table 1].

First seven patients were referred from elsewhere and had undergone cataract surgery in the same month (case 1, 2, and 7 on 1 day; case 5 and 6 on 1 day; and case 3 and 4 on 2 different days), three cases in Sankar Foundation (cases 8, 9, and 10 underwent surgery on 3 isolated months in 2 years). The type of cataract surgery and the duration of presentation with initial endophthalmitis are indicated in [Table 1]. The mean time interval between cataract surgery and diagnosis of endophthalmitis was 4.24 weeks (median 4 weeks; range 3 days–10 weeks).

Clinical features of each patient at the time of initial presentation including visual acuity, anterior and posterior segment findings, and microbiological results are summarized in [Table 2]. The initial visual acuity ranged from light perception (PL) to 20/80. All eyes except one (case no 10) presented with section infiltrates (corneoscleral), significant anterior chamber cells, hypopyon, and intense flare (100%), and fibrin coating the IOL surface (100%). On B-Scan, multiple vitreous opacities were seen with an attached retina. Of the ten cases, the duration between cataract surgery and the diagnosis of endophthalmitis. Five were culture and smear positive (Aspergillusfumigatus-3[Figure 2], Aspergillusflavus-1 [Figure 3], and Aspergillusniger-1 [Figure 4]) and five were smear positive for fungus [Table 2].
Table 2: Clinical features at the presentation of patients with fungal endophthalmitis

Click here to view
Figure 2: (a) Aspergillus fumigatus on culture plate (b) Aspergillus conidia under electron microscope

Click here to view
Figure 3: (a) Aspergillus flavus in culture plate (b and c) Aspergillus flavus conidia under electron microscope

Click here to view
Figure 4: (a) Aspergillus niger in culture plate (b) Aspergillus conidia under electron microscope

Click here to view


Case 1

As shown in [Figure 5]a and [Figure 5]b, 4-week-old postcataract surgery (SICS with IOL implantation) presented with corneoscleral infiltrate at section, on presentation with vitreous tap, intravitreal vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1 were given. Two days later, excision of necrozed corneal tissue, IOL was explained, corneal suturing and intravitreal injections (vancomycin, ceftazidime, and voriconazole) were given. As infection was increasing with the presence of vitreous opacities, to control infection, therapeutic corneoscleral patch graft with core PPVt was done. The first postoperative vision was only perception of light, eye went into phthisis bulbi.
Figure 5: Case 1 (a) Corneosceral infiltrate at the SICS section (b) corneoscleral patch graft

Click here to view


Case 2

[Figure 6]a, [Figure 6]b, [Figure 6]c shows 4-week-old postcataract surgery (SICS with IOL implantation) presented with corneoscleral infiltrate at section. On presentation of vitreous tap, intravitreal vancomycin1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1 were given. Two days later, IOL explantation, therapeutic corneoscleral patch grafting, and core PPVt were performed and intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1) were given. After follow-up of 12-month vision with + 10.00 D was 6/60, with pinhole 6/18.
Figure 6: Case 2 (a) Corneal fungal infiltrate at SICS section with hypopyon (b) scleral infiltrate (c) post corneoscleral patch graft

Click here to view


Case 3

Six-week-old postcataract surgery (SICS with IOL implantation), presented with corneoscleral infiltrate, is shown in [Figure 7]a, [Figure 7]b, [Figure 7]c, 6. Vitreous tap followed by intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1) was given. Five days later, IOL explantation, therapeutic corneoscleral patch grafting, and core PPVt were performed, intravitreal injections (vancomycin, ceftazidime, and voriconazole) were given; after 7 days intravitreal antibiotics and antifungals were repeated. After 12th day, the patient presented with perforated corneal ulcer, therapeutic penetrating keratoplasty (TPK) was performed. Postoperative vision was counting fingers close to face (CFCF), after 2 months graft failed waiting for optical keratoplasty.
Figure 7: Case 3 (a) Near total corneal perforation with superior corneal fungal infiltrate (b) post TPK (c) failed graft

Click here to view


Case 4

[Figure 8]a, [Figure 8]b, [Figure 8]c shows 4-week-old postcataract surgery (SICS with IOL implantation) presented with corneoscleral infiltrate at section. On presentation day, vitreous tap and intravitreal antibiotics (vancomycin, ceftazidime, and voriconazole) were given. Two days later, IOL was explained, therapeutic corneoscleral patch grafting and core PPVt were performed, intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1) were given after surgery. Vision improved to counting 3/60, maintained up to 12 months.
Figure 8: Case 4 (a) Corneoscleral patch graft at SICS section with over hanging infiltrate into ac and hypopyon (b) 1st day of patch graft with hyphema (c) 1 month after corneoscleral patch graft

Click here to view


Case 5

[Figure 9]a, [Figure 9]b, [Figure 9]c shows 10-week-old postcataract surgery (SICS with IOL implantation), presented with corneoscleral infiltrate at section; on presentation of vitreous tap, intravitreal antibiotics (vancomycin, ceftazidime, and voriconazole) were given. Three days later, IOL was explained, therapeutic corneoscleral patch grafting was done and intravitreal injections (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.) were given. Postoperative 12-month vision was 2/60 with pinhole 6/60, with graft opacity.
Figure 9: Case 5 (a) Multiple superior corneal infiltrates with hypopyon (b) After 3 days of medical treatment infiltrate increased in size and with over hanging infiltrate into anterior chamber superiorly (c) post corneoscleral patch graft

Click here to view


Case 6

[Figure 10]a, [Figure 10]b, [Figure 10]c shows 4-week-old postcataract surgery (SICS with IOL implantation), presented with corneoscleral infiltrate at section, on presentation vitreous tap, intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1 ml) were given. After 2 days, eye progressed to perforated corneal ulcer, later IOL was explained, therapeutic corneoscleral patch grafting and core PPVt intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1) were given. Postoperative vision was hand movements, the perception of light (PL) and perception of rays (PR) accurate. Twelve months postoperatively, the vision was PL and PR accurate. Graft opacity with vascularization, on B-scan retina attached in four quadrants, and intraocular pressure was 10 mmHg.
Figure 10: Case 6 (a) fungal corneal ulcer with superior dense infiltrate (b) central impending perforation of corneal ulcer (c) vascularized graft after 6 months

Click here to view


Case 7

[Figure 11]a, [Figure 11]b, [Figure 11]c shows 4-week-old post cataract surgery (SICS with IOL implantation), presented with corneoscleral infiltrate at section, on presentation, vitreous tap, intravitreal vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1 were given. Two days later, IOL was explained, therapeutic corneoscleral patch graft and anterior vitrectomy were performed followed by intravitreal antibiotic and antifungal (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1) injection. After 12-month follow-up, vision counting fingers ½ m with + 10.00 D vision improved to 3/60, graft opacity involving the papillary zone.
Figure 11: Case 7 (a) Superior corneoscleral infiltrate with hypopyon (b) corneoscleral patch graft with inferior peripheral iridectomy (c) 1 month postoperatively with deep AC

Click here to view


Case 8

[Figure 12] shows 2-day-old postcataract surgery (phacoemulsification with IOL implantation), presented with endophthalmitis. On the same day, anterior chamber tap and vitreous tap were done for culture and sensitivity, intravitreal (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.5 mg/0.1) injections were given. KOH staining of anterior chamber tap confirmed for fungal filaments. Next day, IOL explantation, and anterior vitrectomy performed, followed by intravitreal injection of antibiotic and antifungal (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1). Core PPVt was deferred as cornea was hazy. Multiple corneal infiltrates developed on 8th day, later TPK with PPVt was done, followed by intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1 ml). The culture was positive for A. niger. Initially, it was put on hourly natamycin 5%, eye drops, voriconazole eye drops, fortified eye drops cefazolin 5%, and tobramycin eye drops 6 times for 10 days followed by supportive medication. There was relapse of graft infiltrate after 1 month. Repeat intracameral injections (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1) were given and continued on topical antifungal voriconazole 20% e/d and 5% natamycin for 2 months. Three months later, the left eye went into phthisis.
Figure 12: Case 8 Recurrence of infection at graft host junction with hypopyon

Click here to view


Case 9

[Figure 13]a, [Figure 13]b, [Figure 13]c shows 3-week-old postcataract surgery (SICS with IOL implantation), presented with fibrin in anterior chamber and thick hypopyon, vitreous filled with exudates. On the same day, vitreous tap and intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1) were performed. Two days later, IOL explantation, and core PPVt was performed followed by intravitreal injection of antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1). After the 3rd day of intravitreal injection, infiltrate noticed in two areas, at main section and at side port entry. Repeat intravitreal antibiotic and antifungal were given without any improvement, later therapeutic double corneal patch graft, PPVt was performed along with intravitreal injections (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, and voriconazole 0.50 mg/0.1). After 12-month follow-up, vision is counting fingers 1 m improved to 6/24 with + 10.00 D 6/24. No recurrence was noticed in 12 months.
Figure 13: Case 9 (a) Multiple corneal infiltrates at side port incision at 9 o' clock and 2 o' clock (b) multiple corneoscleral patch grafts (c) 4 month postoperative with graft vascularization

Click here to view


Case 10

[Figure 14]a, [Figure 14]b, [Figure 14]c, [Figure 14]d, [Figure 14]e shows RE 28 days old post cataract surgery (SICS with IOL implantation with posterior capsule rent occurred and anterior vitrectomy was performed at the time of surgery. Postoperative vision was 6/24 with pinhole 6/6) presented with defective vision, watering and redness with a history of injury to the right eye due to fall 1 week ago, diagnosed with fungal corneal ulcer, KOH, and Gram-staining positive for fungal filaments. Vision of this patient has dropped to 6/60, advised to stop steroids, started on natamycin 5% hourly, amphotericin B 0.125% e/d ½ hourly, moxifloxacin 0.3% e/d 10 times/day along with supportive treatment, reviewed after 2 days. Ulcer increased in size and depth, vision dropped to CFCF in spite of maximum medical treatment. Vitreous exudates were noticed, cultures were positive for A. flavus. After 2 days TPK with IOL explantation was performed followed by core vitrectomy. Postoperatively treated with topical antifungal eye drops, graft failed due to rejection. After 12 months scleral-fixated IOL, and PKP was performed. Final vision after a follow-up of 12 months improved to 6/12, N8 with correction, follow-up for 24 months.
Figure 14: Case 10 (a) Superficial fungal ulcer at the time of presentation, (b) deep corneal infiltrate in spite of maximum medical treatment after 2 weeks, (c) failed graft after therapeutic penetrating keratoplasty, (d) repeat penetrating keratoplasty with scleral-fixated intraocular lens after 1 year (e) scleral-fixated intraocular lens after on slit lamp on oblique illumination

Click here to view


Postoperative (corneal patch graft and IOL explantation) treatment in all cases, topical antifungal therapy (5% natamycin and 20% voriconazole) was continued for a minimum of 24 weeks, initially hourly for first 7 days, 2 hourly for next 2 weeks, followed by 4 times a day for 10 weeks along with cyclopentolate 1% eye drops and nepaflam 0.3% eye drops twice a day for 3 weeks. Natamycin 5% eye drops were stopped after 2 months, voriconazole 20% eye drops and nepaflam 0.3% eye drops were continued for the next 10 weeks and monitored for possible side effects and recurrence.

In nine cases, no recurrence of inflammation was noted following corneoscleral patch graft, PPVt, and IOL explantation after a mean follow-up period of 12 months (range 12–24 months; median 10 months). In one case (case 8), recurrence noticed after 1 month of TPK, but eye atrophied. In nine cases, visual outcome at the last follow-up ranged from PL to 20/40 [Table 3].
Table 3: Summary of anatomical and functional outcome 12 months after intervention

Click here to view



  Discussion Top


Fungal endophthalmitis is reportedly more common in tropical countries such as India.[1],[2],[13],[14] Large series have reported between 18.6% and 21.6% of postoperative endophthalmitis to be of fungal etiology,[13],[15] although vitrectomy with concomitant intravitreal antifungal agents is considered to be the treatment of choice.[1],[2]

At our center, we have observed that fungal endophthalmitis contributes significantly to the proportion of postoperative infection cases.[1],[2],[14],[16] It is possible that being a tertiary care center, predominantly rural belt contributes to this high incidence. Narang et al.[1],[2] observed that fungal endophthalmitis could mimic bacterial infection and even present as early as 48 h. It is also observed in case 8, which was presented with corneal infiltrate with severe anterior chamber reaction on the 2nd postoperative day.

In this study, we present a series of ten eyes of ten patients of fungal endophthalmitis following cataract surgery. Initially in 1, 3, 6, and 9 cases eyes showed persistent infection despite vitrectomy and IOL explantation along with capsular bag removal and intraocular use of antifungal agents, newer agents like voriconazole. Only after removal of source of infection (cornea/sclera infiltrates) with therapeutic corneal patch graft, intraocular voriconazole injection, we were able to control the infection. Later in 2, 4, 5, 7, 8, and 10 cases, we did patch graft with IOL explantation followed by plus[2],[4],[7],[8],[10] or minus (case 5) vitrectomy with intravitreal voriconazole, depending on the response, and we had later continued with topical natamycin 5% e/d, topical voriconazole over a period of 4 months in all cases.

Corneal involvement in fungal endophthalmitis has been reported to be a poor prognostic indicator.[1],[2],[11] In our case series, all patients had significant corneal involvement, requiring corneal patch graft or TPK. No recurrences were noted (follow-up 12 months). In cases 2, 5, 7, 9, and 10, vision improved in between 6/60 and 6/12, 2 cases (case 1 and 8 went into atrophic bulbi). Cases 3 and 6 waiting for PKP.

The role of IOL explantation in the treatment of endophthalmitis has been previously reported for bacterial and fungal etiologies with mixed success.[17],[18],[19],[20],[21] Persistence of infection was reported by Durand et al.,[5] despite the removal of the IOL, multiple vitrectomies and intravitreal amphotericin B injections fusarium endophthalmitis was subsequently managed with oral voriconazole alone, whereas A.fumigatus required additional intravenous caspofungin.[5] In two of our patients (cases 1 and 8), despite surgical procedure, intracameral voriconazole, the infection persisted for a period of 2 months, after 3 months eye went into phthisis bulbi, despite maximum medical and surgical management. In case no. 8, infection presented on the 3rd postoperative day and causative organism is A. niger, [Figure 3] infection is virulent, not responded to treatment. The role of newer antifungal agents in the management of recurrent cases needs further long-term, prospective trials. We did not use oral antifungals in any of our cases.

Late-onset fungal endophthalmitis has been associated with poor outcome,[6],[7],[8],[11] sometimes even resulting in ocular atrophy.[7],[8] In our study, case 1 presented with large corneoscleral infiltrate after 4 weeks of cataract surgery, after therapeutic keratoplasty and IOL explantation followed by core vitrectomy after 3 months eye atrophied.

In case of early onset (case 8) which is presented with fungal infiltrate in the 3rd day of phacoemulsification with IOL implantation, the organism isolated in SDA culture is A. niger, but in one of the case series, Cakir et al.[3] reported fusarium is the organism in the early onset of fungal endophthalmitis.

Pre and post treatment out come discussed in [Table 4]. In multiple corneal infiltrates, case 9 had infiltrate in two areas, one is at the section and the other is at the side port entry, therapeutic double corneal patch graft with PPVt along with intravitreal injection of antibiotic and antifungal. Twelve months postoperative, vision is 1/60 with + 10.00 D 6/24. The outcome is good in this case.
Table 4: Clinical outcome following surgical interventions

Click here to view


In our series, an overall anatomically good outcome was achieved in 90% (9/10 eyes), and “functional” success was achieved in 50% (5/10 eyes). In a large series, good functional outcome was reported in 37.04%.[1],[2] Corneal involvement was lower in that study compared to ours (50% vs. 90%). In tunnel infections, organism is inoculated in the potential space between the floor and roof of the tunnel and may gain early access to the anterior chamber and vitreous cavity, giving rise to endophthalmitis.[22],[23],[24],[25],[26] Even after giving voriconazole from all possible routes, infiltrates in our case kept on increasing and required surgical intervention to save the globe. Failure of voriconazole therapy for fungal keratitis has been reported in infections with fusarium and colletotrichum species.[24],[25]

The limitations of this study need to be highlighted. In this small series is 1–7 cases derived from single eye hospital surgeries and environmental conditions are risk factors. Cases 8 and 9 occur sporadically, and case 10 had a history of injury postoperatively followed by infection. Each case was managed individually, with no homogenous protocol for intervention leading to the IOL explanation precluding the comparison of the relative merits of each procedure. However, in view of the rarity of such multiple fungal endopthalmitis with corneal or corneoscleral involvement refractory to the accepted standard of management, it is of value that the final procedure resulted in elimination of infection, surgical keratectomy debulks the infected tissue, contributing to the rapid resolution of the infection.

All our cases were on topical steroids before the onset of infection, one of the reasons of poor prognosis of fungal tunnel infections for medical therapy is the use of corticosteroids before the onset of clinical signs of infection which may cause the infecting organisms to spread diffusely.


  Conclusion Top


The purpose of this case series is to highlight the role of therapeutic corneoscleral/corneal patch graft in the management of fungal endophthalmitis with corneoscleral/corneal infiltrates.

Therapeutic corneal grafting with pars plana vitreous surgery with explantation of IOL along with capsular bag removal seems to be effective in a setting of postoperative section infiltrates with fungal endophthalmitis. Successful “anatomical” and “functional” outcomes were achieved in 90% and 50%, respectively. Prospective long-term studies in larger series are necessary to establish this modality as a standard of care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vinekar A, Dogra MR, Avadhani K, Gupta V, Gupta A, Chakrabarti A, et al. Management of recurrent postoperative fungal endophthalmitis. Indian J Ophthalmol 2014;62:136-40.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Narang S, Gupta A, Gupta V, Dogra MR, Ram J, Pandav SS, et al. Fungal endophthalmitis following cataract surgery: Clinical presentation, microbiological spectrum, and outcome. Am J Ophthalmol 2001;132:609-17.  Back to cited text no. 2
    
3.
Cakir M, Imamoǧlu S, Cekiç O, Bozkurt E, Alagöz N, Oksüz L, et al. An outbreak of early-onset endophthalmitis caused by Fusarium species following cataract surgery. Curr Eye Res 2009;34:988-95.  Back to cited text no. 3
    
4.
Brar GS, Ram J, Kaushik S, Chakraborti A, Dogra MR, Gupta A. Aspergillus niger endophthalmitis after cataract surgery. J Cataract Refract Surg 2002;28:1882-3.  Back to cited text no. 4
    
5.
Durand ML, Kim IK, D'Amico DJ, Loewenstein JI, Tobin EH, Kieval SJ, et al. Successful treatment of Fusarium endophthalmitis with voriconazole and Aspergillus endophthalmitis with voriconazole plus caspofungin. Am J Ophthalmol 2005;140:552-4.  Back to cited text no. 5
    
6.
Oxford KW, Abbott RL, Fung WE, Ellis DS. Aspergillus endophthalmitis after sutureless cataract surgery. Am J Ophthalmol 1995;120:534-5.  Back to cited text no. 6
    
7.
Hofling-Lima AL, Freitas D, Fischman O, Yu CZ, Roizenblatt R, Belfort R Jr. Exophiala jeanselmei causing late endophthalmitis after cataract surgery. Am J Ophthalmol 1999;128:512-4.  Back to cited text no. 7
    
8.
Cusumano A, Busin M, Spitznas M. Mycotic infection of the capsular bag in postoperative endophthalmitis. J Cataract Refract Surg 1991;17:503-5.  Back to cited text no. 8
    
9.
Boldt HC, Mieler WF. Endophthalmitis. In: Tabbara KF, Hyndiuk RA, editors. Infections of Eye. 2nd ed. Boston, New York, Toronto, London: Little Brown and Co.; 1996.  Back to cited text no. 9
    
10.
Stern WH, Tamura E, Jacobs RA, Pons VG, Stone RD, O'Day DM, et al. Epidemic postsurgical candida parapsilosis endophthalmitis. Clinical findings and management of 15 consecutive cases. Ophthalmology 1985;92:1701-9.  Back to cited text no. 10
    
11.
Weissgold DJ, Orlin SE, Sulewski ME, Frayer WC, Eagle RC Jr. Delayed-onset fungal keratitis after endophthalmitis. Ophthalmology 1998;105:258-62.  Back to cited text no. 11
    
12.
Chakrabarti A, Chatterjee SS, Das A, Shivaprakash MR. Invasive Aspergillosis in developing countries. Med Mycol 2011;49 Suppl 1:S35-47.  Back to cited text no. 12
    
13.
Anand AR, Therese KL, Madhavan HN. Spectrum of aetiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol 2000;48:123-8.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P, et al. Spectrum and clinical profile of post cataract surgery endophthalmitis in North India. Indian J Ophthalmol 2003;51:139-45.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U, et al. Microbiologic spectrum and susceptibility of isolates: Part I. Postoperative endophthalmitis. Endophthalmitis research group. Am J Ophthalmol 1999;128:240-2.  Back to cited text no. 15
    
16.
Tarai B, Gupta A, Ray P, Shivaprakash MR, Chakrabarti A. Polymerase chain reaction for early diagnosis of post-operative fungal endophthalmitis. Indian J Med Res 2006;123:671-8.  Back to cited text no. 16
    
17.
Iyer MN, Wirostko WJ, Kim SH, Simons KB. Staphylococcus hominis endophthalmitis associated with a capsular hypopyon. Am J Ophthalmol 2005;139:930-2.  Back to cited text no. 17
    
18.
Spencer TS, Teske MP, Bernstein PS. Postcataract endophthalmitis caused by Mycobacterium goodii. J Cataract Refract Surg 2005;31:1252-3.  Back to cited text no. 18
    
19.
Teoh SC, Lee JJ, Chee CK, Au Eong KG. Recurrent Enterococcus faecalis endophthalmitis after phacoemulsification. J Cataract Refract Surg 2005;31:622-6.  Back to cited text no. 19
    
20.
Rahman MK, Holz ER. Alcaligenes xylosoxidans and Propionibacterium acnes postoperative endophthalmitis in a pseudophakic eye. Am J Ophthalmol 2000;129:813-5.  Back to cited text no. 20
    
21.
Chen JC, Roy M. Epidemic Bacillus endophthalmitis after cataract surgery II: Chronic and recurrent presentation and outcome. Ophthalmology 2000;107:1038-41.  Back to cited text no. 21
    
22.
Biswas J, Kumar SK. Cytopathology of explanted intraocular lenses and the clinical correlation. J Cataract Refract Surg 2002;28:538-43.  Back to cited text no. 22
    
23.
Mittal V, Mittal R, Sharma PC. Voriconazole-refractory fungal infection of phacoemulsification tunnel. Indian J Ophthalmol 2010;58:434-7.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
Marangon FB, Miller D, Giaconi JA, Alfonso EC.In vitro investigation of voriconazole susceptibility for keratitis and endophthalmitis fungal pathogens. Am J Ophthalmol 2004;137:820-5.  Back to cited text no. 24
    
25.
Verma S, Tuft SJ. Fusarium solani keratitis following LASIK for myopia. Br J Ophthalmol 2002;86:1190-1.  Back to cited text no. 25
    
26.
Garg P, Mahesh S, Bansal AK, Gopinathan U, Rao GN. Fungal infection of sutureless self-sealing incision for cataract surgery. Ophthalmology 2003;110:2173-7.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed144    
    Printed8    
    Emailed0    
    PDF Downloaded39    
    Comments [Add]    

Recommend this journal