EPIDEMIOLOGY
of FUNGAL ENDOPHTHALMITIS
Niranjan Nayak
Ocular Microbiology
AIIMS
New Delhi-110029
ENDOPHTHALMITIS - INFLAMMATION OF INTRA-OCULAR TISSUE - ALWAYS AN OPTHALMOLOGICAL EMERGENCY - LACK OF RAPID CAUSAL IDENTIFICATION LEADS TO PROFOUND VISUAL LOSS/EVISCERATION
NONINFECTIOUS
INFECTIOUS
ENDOGENOUS
EXODGENOUS
TRAUMA POSTOPERATIVE
CLINICAL FEATURES
• External signs of inflammation
– Ciliary injection
– Chemosis
– Lid oedema
– Raised intra-ocular pressure
– Restriction of extra ocular motility
– Proptosis
CLINICAL FEATURES (Contd.)
• Intra-ocular signs and symptoms – Decreasing visual acuity
– Afferent pupillary defect
– Increasing pain and redness
– Hypopyon
– Corneal oedema
– Corneal infiltrate
– Retinitis
– Severe vitreous inflammation with persistent iritis, whitish puff balls and strands
RELEVANT RISK FACTORS
• Post-traumatic
– Lens disruption
– Intra-ocular foreign body
– Plant/soil related injury
– Injury in rural environment
– Penetration with an obviously contaminated missile or device
Kresloff MS et al. Survey of Ophthalmol 1998;43:193-224
RELEVANT RISK FACTORS (Contd.)
• Post-surgical
– Preoperative
• Canaliculitis
• Dacryocystitis
• Lacrimal duct obstruction
• Contact lens
• Diabetes mellitus
• Contamination of the donor
• Corneal button in Penetrating keratoplasty Kresloff MS et al. Survey of Ophthalmol 1998;43:193-224
Klotz SA et al. Clin Microbiol Rev 2000;13:662-685
RELEVANT RISK FACTORS (Contd.)
– Intraoperative
• Inadequate eyelid/conjunctival disinfection
• Prolonged surgery
• Vitreous loss
– Postoperative
• Wound leak/dehescnce
• Inadequately baried sutures
• Filtering bleb
• Silicon lenss rather than polymethyl methacrylate lenses
Klotz SA et al. Clin Microbiol Rev 2000;13:662-685
Reported associations with endogenous endophthalmitis
Medical Conditions Iatrogenic Causes Other Associations
Diabetes mellitus Immunosuppression Intravenous drug abuse
Cardiac abnormalities Parenteral hyperlimentation Recent nonocular trauma
Leukemia Antibiotic therapy
Lymphoma Prosthetic cardiac valves
Chronic renal failure Hemodialysis
Alcoholism Gastrointestinal endoscopy
Alcoholic hepatitis Extracorporeal shock-wave lithotripsy
Asplenia Bladder catheter
Gastrointestinal malignancy Dental procedure
Neutropenia Recent nonocular surgery
Hypogammaglobulinemia Induced abortion
Systemic lupus erythematosus
AIDS
Parturition
Prematurity
Survey of Ophthalmology 1998; 43 (3) : 193-224
Spectrum of Etiological Agents (RPC data 2000-2008)
Nayak N and Satpathy G. Intl Res J Microbiol 2011
Clinical diagnosis Fungal isolates
Post operative (20) A flavus 7 A fumigatus 4 Fusasium spp 4 Alternaria spp 4 Curvularia spp 1
Post traumatic (13) A niger 4 Alternaria spp 4 Fusarium spp 4 Rhdotorulla spp 1
Metastatic (6) C albicans 4 A flavus 2
Following keratitis (15) A flavas 2 A fumigatus 6 Fusarium spp 6 Curvularia spp 1
Total 54
Endophthal-mitis groups
Aspergillus spp No. (%)
Yeasts No. (%)
Dematiaceo-us fungi No. (%)
Others
No. (%)
Total
No. (%)
Post operative 11 (55) – 5 (25) 4 (20) 20 (37)
Post traumatic 4 (30.8) 1 (7.7) 4 (30.8) 4 (30.8) 13 (24)
Metastatic 2 (33.3) 4 (66.6) – – 6 (11.1)
Post Keratitic 8 (53.3) – 1 (6.7) 6 (40) 15 (27.8)
Total 25 (46.3) 5 (9.3%) 10 (18.6) 14 (26) 54 (100)
Nayak N,Satpathy G. IRJM 2011 Proportion of different fungi isolated 2000-2008
Fungal isolates
Mean latent period (days)
No. (%)
Postoperative
(%)
Post trauma
(%)
Endogenous (%)
Aspergillus spp
9.8 31 (54.4)
15 (51.7) 14 (60.9) 2 (40.0)
A. flavus 5.0 14 (24.6)
8 4 2
A. fumigatus
8.7 8 (14.0)
2 6 0
A. niger 30 5 (8.8) 2 3 0
A. terreus
4.5 2 (3.5) 2 0 0
A. ustus 2 1 (1.8) 0 1 0
A. versicolor
4 1 (1.8) 1 0 0
Yeasts 17.7 14 (24.6)
9 (31.0) 3 (13.0) 2 (40.0)
C. tropicalis 7 5 (8.8) 2 2 0
C. albicans 2 4 (7.0) 4 1 0
C. guilliermondii
2 1 (1.8) 1 0 0
C. parapsilosis
80 1 (1.8) 1 0 0
C. glabrata 4 1 (1.8) 1 0 0
Trichosporon cutaneum
30 1 (1.8) 0 0 1
Cryptococcus neoformans
90 1 (1.8) 0 0 1
Spectrum of fungal agents isolated from patients with fungal endophthalmitis Chakrabarti A et al.Retina 2008;28:1400-7
Fungal isolates
Mean latent period (days)
No. (%)
Postoperative (%)
Post trauma
(%)
Endogenous (%)
Melanized fungi
24.6 6 (10.5)
3 (10.3) 3 (13.0) 0
Fonsecaea pedrosi
30.6 3 (5.3) 2 1 0
Curvularia lunata
25 2 (3.5) 1 1 0
Colletotrichum dematium
6 1 (1.8) 0 1 0
Others 9.8 6 (10.5)
2 (6.9) 3 (13.0) 1 (20.0)
Fusarium solani 2.6 3 (5.3) 1 2 0
Paecilomyces lilacinus
10.5 2 (3.5) 1 0 1
Pseudallescheria boydii
30 1 (1.8) 0 1 0
Total 14.5 57 (100)
29 (50.9) 23 (40.4)
5 (8.8)
Percentage isolation of fungi out of total culture positive isolates
Nayak N,Satpathy G. Intl Res J Microbiol 2011
60%24%
11% 5%
Gram +veGram -veFungiMixed
Similar study Anand AR et al. Indian J Ophthalmol 2000;48:123-128 Gram –ve 41.2%; Gram+ve 36.4%;Fungi 20.6%; mixed 1.8%
Kunimoto DY, et al. Am J Ophthalmol 1999; 128: 242-244
Kunimoto DY, et al. Am J Ophthalmol 1999; 128: 240-242
Fungal isolates from intra-ocular specimens for postoperative endophthalmitis cases
Isolates Total Acute Delayed Chronic Bleb
Aspergillus spp 19 1 11 7 -
Unidentified fungi 12 2 3 7 -
Acremonium falciforme 2 1 1 - -
Candida spp 2 - 1 1 -
Fusarium spp 1 1 - - -
Paecilomyces spp 1 - 1 - -
Total 37* 5 17 15 -
*21.4% of all culture positive isolates Anand AR et al, Indian J Ophthalmol 2000; 48: 123-8
Clinical Category
Post-operative Post-traumatic
Study period
RPC study 2000-08
Wykoff et al 1990-06
Narang et al 1995-99
Kunimoto et al 1991-97
Majji et al 1991-96
Chakrabarti et al 1992-2005
RPC study 2000-08
Wykoff et al 1990-06
Kunimoto et al 1991-97
Majji et al 1991-96
Gupta et al 2003-2005
Chakrabarti et al 1992-2005
Place of study
India Florida India India India India India Florida India India India India
No. of patients
20 13 27 21 11 29 13 10 20 09 08 23
Isolates Yeasts Molds
0% 100% (Asp 55%)
23% 77% (Asp 50%)
19% 81% (Asp 91%)
0% 100% (Asp 81%)
0% 100% (Asp 82%)
31% 69% (Asp 75%)
7.7% 92.3% (Asp 30%)
20% 80% (Asp 25%)
0% 100% (Asp 45%)
0% 100% (Asp 44%)
12.5% 87.5% (Asp 43%)
13 87% (Asp 70%)
Fungal endophthalmitis series reported by different centres
Clinical Category
Keratitis Metastatic
Study period
RPC study 2000-2008
Wykoff et al 1990-2006
RPC study 2000-2008
Chakrabarti et al 1992-2005
Place of study India Florida India India
No. of patients 15 18 06 05
Isolates Yeasts Molds
0% 100% (Asp 53%)
6% 94% (Asp 6%, Fus 76%)
66% 34% (Asp 100%, all A flavus)
40% 60% (Asp 67%. All A flavus)
Fungal endophthalmitis series reported by different centres
Cases Sl no.
Sex Age (yrs) Time from event to diagnosis
Isolates
Post operative 1 M 40 2 months A flavus
2 F 68 3 months Fusarium
3 F 70 21 days Fusarium
4 M 81 24 days Curvularia
5 M 82 18 days Fusarium
6 F 49 2 months A flavus
7 F 46 1 month A flavus
8 F 71 2 months Alternaria
9 F 76 2 months A fumigatus
10 F 80 2 yrs A flavus
Demographic data along with culture findings (available data out of 74 isolates 2000 – 2011)
RPC data
Cases Sl no. Sex Age (yrs) Time from event to diagnosis
Isolates
Post operative 11 F 76 1 month A flavus
12 M 81 1 month A fumigatus
13 F 72 13 days A fumigatus
14 F 48 2 months A flavus
15 M 62 1 month Fusarium
16 M - - Alternaria
17 M - - A flavus
18 F 46 - Alternaria
19 F - - Alternaria
20 F - - A fumigatus
Demographic data along with culture findings (available data out of 74 isolates 2000 – 2011)
Cases Sl no. Sex Age (yrs) Time from event to diagnosis
Isolates
Post traumatic 1 M 60 14 days A niger
2 M 80 4 months A niger
3 F 54 13 days Alternaria
4 F 58 1 day Alternaria
5 M 61 1 day Alternaria
6 F 67 2 months Fusarium
7 M 71 12 days Alternaria
8 M 70 4 months A niger
9 M 68 4 weeks Fusarium
10 M 69 6 months A niger
11 M 72 3 months Fusarium
12 13
M M
74 05
3 months -
Fusarium Rhodotorulla
Demographic data along with culture findings (available data out of 74 isolates 2000 – 2011)
Influence of Fungal Species on Clinical Presentation and Outcome of Infection
(Nayak N.Nepal Med College J. 2008; 10: 48-63)
Diminished visual acuity, severe vitreous inflammation with persistent iritis, whitish puff balls and strands seen in Candida and Aspergillus infections.
Choroidal neovascularization in C albicans endophthalmitis is a potential cause of late visual loss in patients who have had sepsis and endogenous chorioretinitis
Postoperative endophthalmitis exhibits focal choroiditis,”string of pearls” infiltrates in AC and vitreous
Endogenous Aspergillus endophthalmitis: manifested as macular chorioretinal abscess,subretinal hypopyon and final outcome is very poor due to frequent macular involvement
Conclusion • Fungal endophthalmitis is a challenge before the clinician ? high index of suspicion • Postoperative endophthalmitis (POE) is rare in the developed
countries, but not infrequent in the developing world • POE is usually seen in clusters evident within 4 weeks following
the event – Contaminated intraocular irrigating solution – Donor corneas – IOLs – Ventilation system – Hospital construction activities – Possible source
– less stringent practices in the OT – Poor qualities of sterilization measures in eye camps
• Need for improvement in surgical care practices not only in eye camps but also in hospital settings in developing countries
Aspergillus seems to be the most ubiquitous as expected. As has rightly been said “Aspergillus conidia have been recovered by weather balloons in the upper atmosphere, from snow in the Antarctic and from winds over the Sahara”. The omnipresence of this organism is a major factor to designate this planet as “our moldy earth (Cooke WB 1971)”
Thank You