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