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International Journal
of Ophthalmology
2017; 10(9): 1479-1480
·Comment and Response·
Comment on “Surgical management of fungal
endophthalmitis resulting from fungal keratitis”
Dubbaka Srujana, Reena Singh, Koushik Tripathy
Dr. Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi 110029,
India
Correspondence to: Reena
Singh. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute
of Medical Sciences (AIIMS), New Delhi 110029, India. reenasurvaar@gmail.com
Received: 2016-08-04
Accepted: 2017-01-22
Citation: Srujana D, Singh R, Tripathy K. Comment on “Surgical management of fungal
endophthalmitis resulting from fungal keratitis”. Int J Ophthalmol 2017;10(9):1479-1480
Dear Editor,
We read with interest the article by Gao et al[1] on
fungal endophthalmitis associated with fungal keratitis in 27 eyes of 27
patients. They have reported[1] that multiple surgeries including
penetrating keratoplasty (PKP), pars plana vitrectomy (PPV), intracameral or
intravitreal antifungals, cataract extraction and evisceration resulted in a
final visual acuity better than counting fingers in 55.6% eyes. Most common
causative fungal pathogens in their study[1] were Fusarium
(44%), Aspergillus (22%), and Alternaria (7%).
The exact incidence for endophthalmitis with
keratitis is not known, but it can vary from 0.5% to 6.3%[2-3]. Most
common organism noted by Henry et al[2] in a large series of
49 such eyes was fungus. Patients in the primary keratitis group were more
likely (78%) to have fungal etiology compared to surgical wound
associated keratitis (23%). Treatment modalities included in this study were
intraocular antifungals, PKP and anterior chamber irrigation with antifungal
agents but no vitrectomy was performed. The outcome in their study was very
poor, wherein evisceration was done in 31% eyes[2]. Dursun et al[3]
looked at 159 cases of Fusarium keratitis, of which 10 (6.3%) progressed
to culture-proven endophthalmitis. All patients received oral ketoconazole or
fluconazole and topical natamycin 5%. In two cases, intravitreal amphotericin B
injections were also given. Four patients required a PKP, enucleation was
performed in 2 patients, 2 patients required a combination of a PKP and PPV and
one patient developed phthisis[3]. Chakrabarti et al[4] and
Kim et al[5] reported that prompt vitrectomy combined with intravitreal
antifungals can improve visual acuity in fungal keratitis with endophthalmitis.
In current study[1], the authors mention that out of 27 eyes
of culture proven exogenous fungal endophthalmitis, posterior segment was
involved in only 21 eyes, which is not understood. We believe a diagnosis of
endophthalmitis cannot be made without posterior segment inflammation. It would
be interesting to know why the 6 eyes without posterior segment were clinically
diagnosed as endophthalmitis. Also it has been shown that the corneal infection
was more than 3 mm×3 mm in 24 eyes and PPV was carried out as initial surgical
procedure in 9 cases out of total 15 cases which underwent PPV[1].
Visibility would be very poor for carrying out PPV in the presence of large areas
of corneal infection which could result in incomplete removal of infection and
higher rate of PPV related complications. PPV with temporary keratoprosthesis
could be another surgical modality in such cases of endophthalmitis with hazy
media[6]. Intra-cameral and intra-stromal antifungal delivery could
be part of aggressive strategy to tackle fungal keratitis. The treatment of
endophthalmitis in keratitis is difficult due to severity of infection, late
diagnosis and difficulties in examination of the posterior segment due to
corneal involvement. In the current study[1], more than half eyes
with fungal endophthalmitis had been reported to achieve a final visual acuity
of better than finger-counting. This may be explained by 6 (22%) cases which
actually had no posterior segment infection. Long term use of corticosteroids,
weak systemic immunity, dry eye, lack of intact posterior capsule, corneal
perforation and inadequate wound closure may predispose to endophthalmitis in
cases of microbial keratitis[7].The manuscript will be enriched if
the details of ocular and systemic predisposing factors for keratitis
progressing to endophthalmitis in the current study[1] are analyzed.
The outcome
of keratitis with endophthalmitis is dismal even in the current era, some cases
can go to phthisis or require evisceration[1-4]. In these cases
early diagnosis with aggressive management remains the mainstay of therapy.
ACKNOWLEDGEMENTS
Conflicts of Interest: Srujana D, None; Singh R, None;
Tripathy K, None.
REFERENCES
1 Gao Y, Chen N, Dong XG, Yuan GQ, Yu B, Xie LX. Surgical management of
fungal endophthalmitis resulting from fungal keratitis. <ii>Int J
Ophthalmol</ii> 2016;9(6):848-853. [PMC free article] [PubMed]
2 Henry CR, Flynn HW Jr, Miller D, Forster RK, Alfonso EC. Infectious
keratitis progressing to endophthalmitis: a 15-year study of microbiology,
associated factors, and clinical outcomes. <ii>Ophthalmology</ii>
2012;119(12):2443-2449. [CrossRef] [PMC free article] [PubMed]
3 Dursun D, Fernandez V, Miller D, Alfonso EC. Advanced fusarium
keratitis progressing to endophthalmitis. <ii>Cornea</ii>
2003;22(4):300-303. [CrossRef]
4 Chakrabarti A, Shivaprakash MR, Singh R, Tarai B, George VK, Fomda BA,
Gupta A. Fungal endophthalmitis: fourteen years’ experience from a center in
India. <ii>Retina</ii> 2008;28(10):1400-1407. [CrossRef] [PubMed]
5 Kim DY, Moon HI, Joe SG, Kim JG, Yoon YH, Lee JY. Recent clinical
manifestation and prognosis of fungal endophthalmitis: a 7-year experience at a
tertiary referral center in Korea. <ii>J Korean Med Sci </ii> 2015;
30(7):960-964. [CrossRef] [PMC free article] [PubMed]
6 Tripathy K, Venkatesh P. <ii>Surgical management of
endophthalmitis.</ii> In: CME on endophthalmitis. Rajasthan
Ophthalmological Society; 2015:36-53.
7 Scott IU, Flynn HW Jr, Feuer W, Pflugfelder SC, Alfonso EC, Forster
RK, Miller D. Endophthalmitis associated with microbial keratitis.
<ii>Ophthalmology</ii> 1996;103(11):1864-1870. [CrossRef]
Author Reply to the Editor
Dear Editor,
We appreciate the comments about our article[1] from Srujana
D and colleagues. In our study, 27 cases of fungal endophthalmitis contiguously
spreading from keratitis with positive fungal culture results, including 21
cases with the posterior segment involved and 6 cases with infection confined
in the anterior segment, were evaluated. Srujana et al mentioned that
the diagnosis of endophthalmitis could not be established without an
involvement of the posterior segment. We insist that because of the special diffusion
mode of fungal endophthalmitis resulting from keratitis and the relatively slow
growth of fungi, there are cases with severe infection in the anterior chamber
but no definite involvement of the posterior segment. Endophthalmitis with only
the anterior segment involved was mentioned in many studies[2-6]. In
our study, positive fungal culture results of hypopyon were found in the 6
cases with anterior segment infection. Ocular echography can be useful in
evaluating the posterior segment of patients[7]. Mild anterior
vitreous inflammation certainly cannot be ruled out in patients with no obvious
vitreous opacitiy.
In our series, a total of 15 patients underwent vitrectomy, 9 of whom
was in the first surgery. We agree with Srujana et al that in eyes with
a large corneal infection focus, the complications after vitrectomy would
increase due to the opaque vision and subsequently incomplete removal of the
infection. As a matter of fact, 6 out of 9 eyes received vitrectomy combined
with penetrating keratoplasty for the first time. The reason why vitrectomy
could be successfully performed in the other 3 eyes was that the opacity in
these eyes was small or off center. In addition, there were 6 patients who did
not undergo vitrectomy in their first operation. They were treated with
penetrating keratoplasty, before vitrectomy was implemented because of the
accelerating posterior segment infection. In these eyes, the vitreous could not
be removed thoroughly for the unclear media. However, the condition would be better
with infection control, and a second vitrectomy would be easier if necessary.
More than half of our patients got the final visual acuity of better
than finger counting. We believe that the relatively good prognosis was not
only related to the 6 patients with only the anterior segment infected, but
also to the appropriate treatment protocol. Among our patients, except the 6
cases with only hypopyon (cases 3, 4, 11, 13, 18 and 19) and 3 cases with
infection extending to the posterior chamber (cases 1, 9 and 23), the remaining
18 cases were severely infected with vitreous abscess or even orbital
cellylitis. Even though, eight out of the 18 cases (44%) achieved visual acuity
of better than finger counting (including one case with retinal detachment).
There were also 5 of the 18 eyes which were eviscerated for the infection
progress. A prompt and aggressive intervention can effectively reverse the
deterioration and improve the prognosis of fungal endophthalmitis.
Srujana et al recommended to obtain the
medical history of whether there was long-term use of glucocorticoids, low
immunity, dry eye, capsular integrity breaking, corneal penetrating injury or
delayed wound closure, which may make eyes susceptible to bacterial keratitis.
We believe this is helpful for diagnosis and therapy of such cases, especially
those with unknown causes, and will pay more attention to these items in the
future work.
REFERENCES
1 Gao Y, Chen N, Dong XG, Yuan GQ, Yu B, Xie LX. Surgical management of
fungal endophthalmitis resulting from fungal keratitis. <ii>Int J
Ophthalmol</ii> 2016;9(6):848-853. [PMC free article] [PubMed]
2 Pflugfelder SC, Flynn HW Jr, Zwickey TA, Forster RK, Tsiligianni A,
Culbertson WW, Mandelbaum S. Exogenous fungal endophthalmitis.
<ii>Ophthalmology </ii>1988;95(1):19-30. [CrossRef]
3 Shen YC, Wang CY, Tsai HY, Lee HN. Intracameral voriconazole injection
in the treatment of fungal endophthalmitis resulting from keratitis.
<ii>Am J Ophthalmol</ii> 2010;149(6):916-921. [CrossRef] [PubMed]
4 Durand ML. Endophthalmitis. <ii>Clin Microbiol Infect</ii>
2013;19(3):227-234. [CrossRef] [PMC free article] [PubMed]
5 Greenwald MJ, Wohl LG, Sell CH. Metastatic bacterial endophthalmitis:
a contemporary reappraisal. <ii>Surv Ophthalmol</ii>
1986;31(2):81-101. [CrossRef]
6 Vilela RC, Vilela L, Vilela P, Vilela R, Motta R, Pôssa AP, de Almeida
C, Mendoza L. Etiological agents of fungal endophthalmitis: diagnosis and
management. <ii>Int Ophthalmol </ii> 2014;34(3):707-721. [PubMed]
7 Dacey MP, Valencia M, Lee MB, Dugel PU, Ober RR, Green RL, Lopez PF.
Echographic findings in infectious endophthalmitis. <ii>Arch
Ophthalmol</ii> 1994;112(10):1325-1333. [CrossRef]
Yan Gao, Nan Chen
Qingdao Eye Hospital, Shandong Eye Institute,
Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
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