Candida Retinochoroiditis

Abstract

Candida is an important cause of fungal endophthalmitis that can lead to serious blinding complications. Although uncommon in developed countries, it represents an important clinical problem in the developing world due to its potential for significant visual loss despite aggressive therapy. Immunocompromised patients are at a particular risk of developing the disease. Often, long-term therapy with systemic antifungal agents and debulking surgeries such as pars plana vitrectomy may be required in order to salvage vision. The following chapter will discuss the protean clinical course and management of four cases of Candida endophthalmitis.

Introduction

Fungal endophthalmitis due to Candida species can occur following trauma, surgery (exogenous endophthalmitis), or, more commonly, due to hematogenous spread from other infectious foci in the body (endogenous endophthalmitis). Endogenous infection is more frequently seen in patients with intravenous drug abuse, hyperalimentation, diabetes, bone marrow transplantation, malignancy, and other immunocompromised states. Candida retinochoroiditis most often presents with focal white lesions in the superficial retina along with vitritis and characteristic vitreous cotton ball opacities. Multiple hemorrhages surrounding the chorioretinitis may also be seen. It is important to differentiate Candida retinochoroiditis from other causes of retinitis that present with a similar picture, as the treatment options may be vastly different depending on the diagnosis.

Case 1: Posterior Segment Features of Candida Endophthalmitis

A 57-year-old woman diagnosed with type 2 diabetes presented with sudden-onset progressive decreased vision in both eyes for 2 days. The best-corrected visual acuity (BCVA) was 20/100 in the right eye and 20/120 in the left eye. Fundus photographs revealed multiple, raised, white chorioretinal lesions in both eyes. There was significant vitreous inflammation, and posterior hypopyon was also noted in the left eye (Fig. 1). The patient underwent vitreous tap and the sample was sent for microbiological analysis. The potassium hydroxide mount was positive for Candida sp. The patient was started on antifungal treatment with intravenous amphotericin B and intravitreal voriconazole in both eyes. The retinochoroidal lesions decreased in size following therapy. Two weeks after the initial visit (Fig. 2), fundus photography was performed which demonstrates an interval reduction in the vitreous haze and the size of the chorioretinal lesions. Six weeks after initiation of therapy, complete resolution of the lesions was seen in both eyes (Fig. 3). The patient was started on strict glycemic control. Two months following therapy, the BCVA improved to 20/50 in both eyes.

Fig. 1

Fundus photographs (at presentation) showing multiple raised white chorioretinal lesions in both eyes (white arrows). A posterior hypopyon is also seen in the left eye inferiorly (black arrow)

Fig. 2

Fundus photographs 2 weeks post treatment showing a reduction in the size of the chorioretinal lesions

Fig. 3

Fundus photographs from both eyes 6 weeks post treatment showing complete resolution of the lesions

Case 2: Candida Endogenous Endophthalmitis in a Renal Transplant Recipient

A 28-year-old immunocompromised woman presented with unilateral decreased vision in the right eye. The patient had previously received a renal transplantation and was on treatment with oral mycophenolate mofetil. BCVA in the right eye was 20/200. On examination, anterior segment inflammation was noted with 1+ cells and 1+ flare. Fundus photographs revealed large whitish chorioretinal lesions in the central and inferior macula along with vitritis (Fig. 4a). A diagnosis of Candida endophthalmitis was made following a positive vitreous biopsy. The patient was given intravenous as well as intravitreal amphotericin (along with intravitreal dexamethasone). The dose of systemic mycophenolate mofetil was decreased. Fundus photographs after 4 weeks showed substantial reduction in the size of the chorioretinal lesions and decrease in the severity of vitritis (Fig. 4b). Complete resolution of the macular lesion with formation of a residual scar was seen 6 weeks after initiation of treatment (Fig. 4c).

Fig. 4

Fundus photographs from a 28-year-old immunocompromised woman with unilateral decreased vision: (a) – at presentation, showing multiple white chorioretinal lesions and vitritis; (b) – 4 weeks post treatment, showing a reduction in the size of the chorioretinal lesions and resolution of the vitritis; and (c) – 6 weeks post treatment, showing complete resolution of the chorioretinal lesion and residual scar in the central macula

Case 3: Postoperative Candida Endophthalmitis

A 47-year-old woman presented with decreased vision, pain, and redness in the left eye 72 h post-cataract surgery. BCVA was 20/200 in the left eye at presentation. On further evaluation using slit-lamp biomicroscopy, the main corneal incision appeared to gape and Seidel’s test was positive for aqueous leakage. Significant anterior segment inflammation was noted with anterior chamber cells (3+) and flare (3+). Fundus photographs of the left eye revealed significant vitritis and the presence of whitish chorioretinal lesions in the central macula (Fig. 5a). Vitreous tap was performed and intravitreal vancomycin and ceftazidime were injected. Vitreous tap was positive for Candida sp. and, therefore, the patient was started on intravitreal amphotericin B. Subsequent visits demonstrated decrease in the vitreous inflammation. The foci of retinitis also decreased in size.

Fig. 5

Fundus photographs from a 47-year-old woman with unilateral decreased vision; (a) – at presentation, showing severe vitritis and the presence of active chorioretinal lesions in the central macula; (b) – 2 weeks post treatment showing reduction in the vitritis; and (c) – 4 weeks post treatment, demonstrating clearing of the vitreous but the presence of dense vitreoretinal membranes

Case 4: Candida Endophthalmitis in an HIV-Positive Patient

A 47-year-old HIV-positive woman presented with decreased vision in the left eye. BCVA was hand motion at face. On examination, there were significant anterior chamber cells and flare (3+). Examination of the posterior segment revealed large confluent chorioretinal lesions with dense vitritis, vitreous exudates, and membranes. Both macular and peripheral involvements were seen (Fig. 6). The patient was admitted for further evaluation and management of her systemic comorbidities. Vitreous tap was positive for Candida sp., and the patient was started on intravitreal and intravenous amphotericin B. Highly active antiretroviral therapy was also initiated. Unfortunately, the patient passed away within the next few weeks due to multiple organ failure.

Fig. 6

Fundus photograph demonstrates dense vitreous inflammation and the presence of vitreous exudates and membranes in a patient who developed Candida endophthalmitis amid setting of systemic HIV infection

Key Points

• Candida retinochoroiditis may present in patients with immunocompromised status, hyperalimentation, or those with history of intravenous drug abuse.

• Typical presenting features include focal, superficial, white chorioretinal lesions along with white “cotton balls” in the vitreous, which is often accompanied by vitritis.

• Early diagnosis and treatment are necessary to salvage the vision and improve visual outcomes.