PPV and voriconazole for endogenous fungal endophthalmitis outbreak improves visual acuity
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Key Takeaway
Consider PPV plus voriconazole for endogenous fungal endophthalmitis in outbreak settings, recognizing limited evidence from a retrospective series.
A retrospective case series from the Ophthalmology Department of Ningde Municipal Hospital evaluated 26 eyes of 17 immunocompetent individuals with endogenous fungal endophthalmitis linked to a history of intravenous infusions at a rural clinic. Patients underwent pars plana vitrectomy (PPV) and intravitreal voriconazole injection, followed by systemic voriconazole therapy.
The primary outcome, best corrected visual acuity (BCVA), improved significantly. Mean BCVA improved from 20/100 to 20/50 (p = 0.00011) after three months of follow-up. Vitreous cultures were positive in 19 out of 26 eyes, showing growth of Candida albicans. Clonal outbreak confirmation was supported by SNP-based phylogenetic analysis, which showed that all sequenced isolates clustered tightly; this included 7 culture-positive Candida albicans vitreous isolates.
Safety and tolerability were not reported. Key limitations include the retrospective case series design, no comparator group, small sample size, and single-center setting. The outbreak was presumed to be caused by intravenous infusion contamination, but causation is not proven. Practice relevance is limited to this specific outbreak setting; however, primary PPV followed by systemic and intravitreal antifungal therapy and an epidemiological investigation could be effective in finding the infectious source and achieving favorable visual outcomes.
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View Original Abstract ↓
BackgroundAn outbreak of endogenous fungal endophthalmitis (EFE) caused by contaminated intravenous infusion was identified in immunocompetent individuals. We aimed to describe its clinical characteristics and outcomes.MethodsThis retrospective case series included all patients referred with EFE and had a history of intravenous infusions at the same rural clinic, between May 1st, 2024 and November 30th, 2024, to Ophthalmology Department of Ningde Municipal Hospital. Demographic and clinical data were collected. Whole-genome sequencing (WGS) and SNP-based phylogenetic analysis were performed on 7 culture-positive Candida albicans vitreous isolates.ResultsThe inclusion criteria were met in 26 eyes of 17 patients. All were healthy and immunocompetent. On average, patients presented after 24.3 days of symptoms. Presenting best corrected visual acuity (BCVA) ranged from 20/25 to no light perception (NLP). All patients were initially treated with pars plana vitrectomy (PPV) and intravitreal voriconazole injection followed by systemic voriconazole therapy. Vitreous cultures obtained during PPV were positive in 19 eyes, all showing growth of Candida albicans. Three months after treatment, patients’ BCVA improved significantly from a mean of 20/100 to 20/50 (p = 0.00011). All sequenced isolates clustered tightly in SNP-based phylogenetic analysis, supporting a clonal outbreak. Two patients with a final BCVA of NLP were initially misdiagnosed with noninfectious uveitis and treated with an intravitreal steroid injection at other hospitals. Since the closure of the rural clinic, no new cases have been reported.ConclusionsPrimary PPV followed by systemic and intravitreal antifungal therapy and an epidemiological investigation could be effective in finding the infectious source of an EFE outbreak and achieving favorable visual outcomes. Misuse of intravitreal steroids due to incorrect diagnosis could lead to severe vision loss in individuals with EFE.
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