Taraprasad Das1, Manisha Agarwal2, Appakkudal R Anand3, Umesh C Behera4, Muna Bhende5, Anthony Vipin Das6, Debarati Dasgupta5, Vivek P Dave7, Jaishree Gandhi8, Rameshkumar Gunasekaran9, Joveeta Joseph8, Sucheta Kulkarni10, Prajna Lalitha9, Priyanka A Mahendrakar5, Sanchita Mitra8, Ashik Mohamed11, Alankrita Muralidhar2, Pillutla L Nimeshika6, Gumpalli S Prashanthi MTech6, Alok Sen12, Savitri Sharma8, Prithviraj Uday13. 1. Srimati Kanuri Santhamma Center for Vitreo-Retinal Diseases, Kallam Anji Reddy Campus, L. V. Prasad Eye Institute, Hyderabad, India. Electronic address: tpdbei@gmail.com. 2. Retina and Vitreous Department, Dr. Shroff's Charity Eye Hospital, New Delhi, India. 3. L & T Microbiology Research Centre, Medical Research Foundation, Sankara Nethralaya, Chennai, India. 4. Department of Retina and Vitreous, Mithu Tulsi Chanrai Campus, L. V. Prasad Eye Institute, Bhubaneswar, India. 5. Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Medical Research Foundation, Chennai, India. 6. Department of eyeSmart and EMR, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India; Indian Health Outcomes, Public Health, and Economics Research Center, L. V. Prasad Eye Institute, Hyderabad, India. 7. Srimati Kanuri Santhamma Center for Vitreo-Retinal Diseases, Kallam Anji Reddy Campus, L. V. Prasad Eye Institute, Hyderabad, India. 8. Jhaveri Microbiology Center, Kallam Anji Reddy Campus, L. V. Prasad Eye Institute, Hyderabad, India. 9. Department of Ocular Microbiology, Aravind Eye Hospital, Madurai, India. 10. Department of Retina and Vitreous, HV Desai Eye Hospital, Pune, India. 11. Ophthalmic Biophysics, Kallam Anji Reddy Campus, L. V. Prasad Eye Institute, Hyderabad, India. 12. Retina and Vitreous Department, Sadguru Netra Chikitsalaya, Chitrakoot, India. 13. Department of Retina and Vitreous, Aravind Eye Hospital, Madurai, India.
Abstract
PURPOSE: To evaluate the clinical and microbiological features of a large cohort with culture-confirmed fungal endophthalmitis across India. DESIGN: Cross-sectional, hospital-based, retrospective medical record review. PARTICIPANTS: Seven large tertiary eye care centers from different regions of India. METHODS: Patient data were pooled from electronic or physical medical records of each participating center. Fellowship-trained vitreoretinal specialists clinically managed all patients, and in-house microbiology laboratories performed all microbiological workups. The clinical and microbiological procedures were broadly uniform across all participating centers. The essential treatment consisted of vitreous surgery as well as intravitreal and systemic therapies with antifungal agents. MAIN OUTCOME MEASURES: Clinical outcome of the causative event and causative fungus. RESULTS: In the period from 2005 to 2020, 7 centers treated 3830 cases of culture-proven endophthalmitis, and of these, 19.1% (n = 730) were cases of culture-confirmed fungal endophthalmitis. It included 46.9% cases of postoperative (87.4% postcataract surgery), 35.6% of traumatic, and 17.5% of endogenous endophthalmitis. The fungi included 39.0% of Aspergillus (high prevalence in central, east, and south zones), 15.1% of Candida (high prevalence in west zone), and 15.9% of Fusarium (high prevalence in north and west zones). The time to symptom development was between 1 week and 4 weeks in more than one third of the patients, except in patients with traumatic endophthalmitis. Less than half of the patients had hypopyon on presentation. The presenting visual acuity (PVA) in most patients was <20/400. Nearly all patients needed vitrectomy and an average of 2 intravitreal injections of antifungal agents. At least 10% of eyes needed therapeutic keratoplasty, and up to 7% of eyes were eviscerated. After treatment, the final (best corrected) visual acuity (FVA) was >20/400 in 30.5% (n = 222) of eyes and >20/40 in 7.9% (n = 58) of eyes, and 12% (n = 88) of eyes lost light perception. A post hoc analysis showed the male sex to be significantly more associated with traumatic endophthalmitis than with postoperative (P < 0.0001) and endogenous (P = 0.001) endophthalmitis, more isolation of Candida species in patients with endogenous endophthalmitis than in those with postoperative (P = 0.004) and traumatic (P < 0.0001) endophthalmitis, better PVA in eyes with Candida species infection (P < 0.0001), and poorer FVA in eyes with Aspergillus species infection. CONCLUSIONS: Fungal endophthalmitis is not uncommon in India. The inclusion of antifungal agents with antibiotics as the first empirical intravitreal therapy before microbiological confirmation should be considered when a fungal infection is suspected.
PURPOSE: To evaluate the clinical and microbiological features of a large cohort with culture-confirmed fungal endophthalmitis across India. DESIGN: Cross-sectional, hospital-based, retrospective medical record review. PARTICIPANTS: Seven large tertiary eye care centers from different regions of India. METHODS: Patient data were pooled from electronic or physical medical records of each participating center. Fellowship-trained vitreoretinal specialists clinically managed all patients, and in-house microbiology laboratories performed all microbiological workups. The clinical and microbiological procedures were broadly uniform across all participating centers. The essential treatment consisted of vitreous surgery as well as intravitreal and systemic therapies with antifungal agents. MAIN OUTCOME MEASURES: Clinical outcome of the causative event and causative fungus. RESULTS: In the period from 2005 to 2020, 7 centers treated 3830 cases of culture-proven endophthalmitis, and of these, 19.1% (n = 730) were cases of culture-confirmed fungal endophthalmitis. It included 46.9% cases of postoperative (87.4% postcataract surgery), 35.6% of traumatic, and 17.5% of endogenous endophthalmitis. The fungi included 39.0% of Aspergillus (high prevalence in central, east, and south zones), 15.1% of Candida (high prevalence in west zone), and 15.9% of Fusarium (high prevalence in north and west zones). The time to symptom development was between 1 week and 4 weeks in more than one third of the patients, except in patients with traumatic endophthalmitis. Less than half of the patients had hypopyon on presentation. The presenting visual acuity (PVA) in most patients was <20/400. Nearly all patients needed vitrectomy and an average of 2 intravitreal injections of antifungal agents. At least 10% of eyes needed therapeutic keratoplasty, and up to 7% of eyes were eviscerated. After treatment, the final (best corrected) visual acuity (FVA) was >20/400 in 30.5% (n = 222) of eyes and >20/40 in 7.9% (n = 58) of eyes, and 12% (n = 88) of eyes lost light perception. A post hoc analysis showed the male sex to be significantly more associated with traumatic endophthalmitis than with postoperative (P < 0.0001) and endogenous (P = 0.001) endophthalmitis, more isolation of Candida species in patients with endogenous endophthalmitis than in those with postoperative (P = 0.004) and traumatic (P < 0.0001) endophthalmitis, better PVA in eyes with Candida species infection (P < 0.0001), and poorer FVA in eyes with Aspergillus species infection. CONCLUSIONS: Fungal endophthalmitis is not uncommon in India. The inclusion of antifungal agents with antibiotics as the first empirical intravitreal therapy before microbiological confirmation should be considered when a fungal infection is suspected.