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Endophthalmitis is a severe eye infection that may result in permanent loss of useful vision in the affected eye. Most cases are exogenous and occur as a complication of cataract surgery, an intravitreal injection, or penetrating ocular trauma. Endogenous endophthalmitis results from hematogenous seeding of the eye by bacteria or fungi, but bacteremia or fungemia may be transient and patients may present without symptoms of systemic infection. Nearly all endophthalmitis patients present with decreased vision, and some also have eye pain. Eye examination usually reveals a hypopyon and intraocular inflammation. Diagnosis is clinical, supported by cultures of the vitreous and/or aqueous or by blood cultures in some endogenous cases. Molecular diagnostic techniques have been used in research laboratories for pathogen identification in endophthalmitis and offer the possibility of rapid diagnosis, including in culture-negative cases. Intravitreal injection of antibiotics is the most important component of treatment; some cases also benefit from surgical debridement of the vitreous by a vitrectomy. The visual outcome depends partly on the pathogen: coagulase-negative staphylococcal endophthalmitis has a better prognosis than does streptococcal endophthalmitis, for example. Endophthalmitis is a medical emergency, and prompt diagnosis and treatment are essential for saving vision., (Copyright © 2017 American Society for Microbiology.)

The Boston Keratoprosthesis (B-KPro) is a widely accepted modality of corneal restoration in eyes where traditional penetrating keratoplasty has little chance of success. It is the most commonly used keratoprosthesis worldwide. While the introduction of broad-spectrum antibiotic prophylaxis has virtually eliminated cases of bacterial endophthalmitis, fungal colonization and infections are a growing concern. This review of the literature summarizes risk factors for fungal infections in KPro eyes, rates of fungal infection and colonization, clinical presentation, causative organisms, management, and outcomes. We also focus on current recommendations for antifungal prophylaxis, and highlight the role of translational research at the Massachusetts Eye and Ear Infirmary (MEEI, Boston, USA) with its aim of developing novel strategies for reducing rates of fungal infections in KPro patients.

Purpose: To report a case of successful medical treatment with oral posaconazole in refractory fungal keratitis caused by Paecilomyces lilacinus., Methods: Case report., Results: A 57-year-old male, soft contact lens wearer presented with irritation, pain, photophobia, and reduced vision. Slit-lamp examination showed a large corneal epithelial defect with a peripheral infiltrate. The patient did not improve on fortified topical antibiotics. After the diagnosis of P. lilacinus fungal keratitis, oral voriconazole and topical antifungal therapy were started. Despite antifungal therapy, progressive disease required therapeutic penetrating keratoplasty. Postoperatively, because of clinical signs of recurrence and in vivo confocal microscopy findings of presumed hyphae in the cornea, intracameral miconazole was injected and oral posaconazole was started. The patient improved and demonstrated no hyphae 6 weeks after starting posaconazole. When posaconazole was stopped, the cornea remained clear with excellent acuity. However, because of acute graft rejection 2 months after stopping posaconazole, keratoprosthesis was implanted, with no evidence of infection at surgery or during the 3.5-year follow-up., Conclusions: To the best of our knowledge, this is the first report on the use of oral posaconazole for Paecilomyces keratitis. Posaconazole might be indicated in the treatment of refractory Paecilomyces keratitis that is resistant to conventional therapy.

Endophthalmitis means bacterial or fungal infection inside the eye involving the vitreous and/or aqueous humors. Most cases are exogenous and occur after eye surgery, after penetrating ocular trauma, or as an extension of corneal infection. An increasing number of cases are occurring after intravitreal injections of anti-vascular endothelial growth factor (VEGF) medications. Endophthalmitis may also be endogenous, arising from bacteraemic or fungaemic seeding of the eye. The infected eye never serves as a source of bacteraemia or fungaemia, however. The most common pathogens in endophthalmitis vary by category. Coagulase-negative staphylococci are the most common causes of post-cataract endophthalmitis, and these bacteria and viridans streptococci cause most cases of post-intravitreal anti-VEGF injection endophthalmitis, Bacillus cereus is a major cause of post-traumatic endophthalmitis, and Staphylococcus aureus and streptococci are important causes of endogenous endophthalmitis associated with endocarditis. In Taiwan and other East Asian nations, Klebsiella pneumoniae causes most cases of endogenous endophthalmitis, in association with liver abscess. Endogenous fungal endophthalmitis in hospitalized patients is usually caused by Candida species, particularly Candida albicans. Acute endophthalmitis is a medical emergency. The most important component of treatment is the intravitreal injection of antibiotics, along with vitrectomy in severe cases. Systemic antibiotics should be used in cases of endogenous endophthalmitis and exogenous fungal endophthalmitis, but their role in exogenous bacterial endophthalmitis is uncertain. Repeated intravitreal injections of antibiotics may be necessary if there is no response to the initial therapy. Many eyes that receive prompt and appropriate treatment will recover useful vision., (© 2013 The Author Clinical Microbiology and Infection © 2013 European Society of Clinical Microbiology and Infectious Diseases.)

Purpose: To determine the incidence of and risk factors for fungal keratitis and endophthalmitis in patients with a Boston keratoprosthesis (KPro) and to determine whether surveillance cultures were helpful in predicting fungal infection., Methods: A retrospective chart review was performed of 182 patients (202 eyes) who received a type 1 (through cornea) or type 2 (through cornea and lid) KPro between March 1, 1990, and December 31, 2004, and who were followed for at least 1 month (range, 1 month to 13 years; mean, 2.84 years). There were 148 eyes with type 1 and 54 eyes with type 2. Beginning in late 1999, many eyes were given a prophylactic topical regimen containing vancomycin, and many eyes with type 1 KPro were given therapeutic contact lenses. Cases of fungal keratitis or endophthalmitis were analyzed. To determine the fungal colonization rate, 70 surveillance cultures of the ocular or lid surface around the KPro optic were obtained of 36 uninfected KPro eyes (35 patients) at random time-points over 1 year (August 2002 to July 2003)., Results: There were 4 definite and 1 probable fungal infections in 6893 patient-months of follow-up, or 0.009 fungal infections per patient-year. These included 3 cases of definite or probable Candida endophthalmitis (C. parapsilosis, C. glabrata, and C. albicans) and 2 cases of mold keratitis (Alternaria, Fusarium). The rate was higher in eyes receiving a vancomycin-containing topical prophylactic regimen than those with on a non-vancomycin regimen (5 cases/2774 person-months vs. 0 cases/4119 person-months; P = 0.011). In eyes with type 1 KPro, the rate was higher with therapeutic contact lens wear than without (4/1682 vs. 0/3115 person-months; P = 0.015). Surveillance cultures did not predict fungal infection, and none of the 6 surveillance eyes colonized with fungi (all Candida) developed a fungal infection. The prevalence of fungal colonization in KPro eyes had not changed since our 1996 surveillance study (11% vs. 10%, P > 0.05)., Conclusion: Fungal infections in KPro eyes have appeared since we introduced broad-spectrum antibiotic prophylaxis and therapeutic contact lenses 5 years ago, but the infection rate remains very low in our mostly New England-based patient population. Cleaning or replacing the contact lens on a regular basis and prescribing a short course of topical amphotericin at the first visible signs of fungal colonization may prevent these infections.

Purpose: To report successful treatment of exogenous Fusarium and Aspergillus endophthalmitis with new antifungal agents., Design: Interventional case report., Methods: Treatment of two cases is reviewed., Results: A 64-year-old man developed post-cataract Fusarium moniliforme endophthalmitis. Infection persisted despite removal of the intraocular lens, three vitrectomies, and five intravitreal injections of amphotericin. Inflammation resolved and vision improved from 20/80 to 20/40 on 6 months of oral voriconazole. A 55-year-old man developed post-cataract intraocular inflammation. After three vitrectomies and removal of the intraocular lens, Aspergillus fumigatus endophthalmitis was diagnosed. Intravitreal amphotericin and systemic voriconazole were given, but one week later there were early signs of recurrence. Intravenous caspofungin was added and the eye improved. Caspofungin was continued for 6 weeks and voriconazole for 6 months. Vision improved from counting fingers to 20/80 at 6 months and 20/25 at 23 months., Conclusion: Voriconazole is a promising new therapy for Fusarium and Aspergillus endophthalmitis. Caspofungin may act synergistically with voriconazole in treating Aspergillus endophthalmitis.