DISEASE
Ocular candidiasis is a well-known complication of candidemia. Candidemia has become increasingly prevalent in the hospital setting as a complication of surgery and with increased use of parenteral nutrition, central venous catheters, and treatment with broad-spectrum antibiotics.
Systemic candidemia can lead to ocular candidiasis via hematogenous seeding of retinal and choroidal blood vessels and can have various ocular manifestations.
Ocular candidiasis can occur from exogenous or endogenous routes. Exogenous methods include trauma or direct inoculation from surgery or other procedures. Exogenous ocular candidiasis is uncommon in North America and Europe, and more commonly seen in tropical regions such as India.
Endogenous ocular candidiasis occurs from hematogenous seeding in the eye from transient fungemia, and while still rare, occurs most commonly in patients who are severely immunocompromised or who have indwelling catheters.
Diagnostic procedures
In cases where the clinical diagnosis is unclear, a vitreous tap to obtain intraocular fluid can be performed for gram staining and cultures. Intraocular culture specimens can also be obtained during pars plana vitrectomy.
While this is an effective method for obtaining intraocular culture specimens, this is often only performed in cases of severe endophthalmitis in conjunction with antifungal intravitreal injections for treatment.
When a patient has characteristic ocular candidiasis findings and known systemic candidiasis, ocular culture is not needed and this can be defined as probable ocular candidiasis. Positive growth of Candida species in conjunction with characteristic fundus features as described above is defined as proven ocular candidiasis.
B-scan ultrasound should be performed in cases where the retina is obscured by media opacity. In early cases, a fluorescein angiogram may demonstrate chorioretinitis.
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From Choroida — the team behind this siteMANAGEMENT
If possible, removal of the inciting cause of systemic candidemia is advised (e.g. removal or replacement of indwelling lines/catheters). Systemic antifungal therapy is targeted based on culture susceptibilities, and options include intravenous amphotericin B, azoles (e.g. voriconazole, fluconazole), and echinocandins (e.g. micafungin, caspofungin).
In general, initial therapy with an intravenous echinocandin is recommended for both non-neutropenic and neutropenic patients with candidemia. Fluconazole may be used as an alternative in non-neutropenic patients who are not critically ill.
However, as neutropenic patients are often placed on fluconazole prophylaxis, there has been an increasing number of Candida species with reduced susceptibility. In patients who are clinically stable, have repeat negative blood cultures, and have Candida species susceptible to fluconazole, step-down therapy to oral fluconazole may be pursued after 5-7 days.
Access to various medications will be dictated by region and the involvement of infectious disease specialists is recommended. A review of contemporary studies suggests that ocular candidiasis responds well to systemic medical management.
In the review by Breazzano et al., chorioretinitis was identified in 78 patients with resolution on systemic monotherapy.
Of the 19 endophthalmitis cases included in the review, 12 patients were treated with systemic therapy alone, 6 received combined systemic and local therapy (2 pars plana vitrectomy, 2 combined pars plana vitrectomy/tap and injection, and 2 taps and injection), and 1 patient improved solely with IV catheter removal.
Six of the 12 patients with endophthalmitis treated with systemic monotherapy died. Of the 6 surviving endophthalmitis patients treated with systemic monotherapy, complete ocular resolution occurred.
The patients who received both local intervention and systemic treatment achieved resolution with 3 patients having permanent vision loss. These results may be influenced by the severity of the disease.
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Two smartphone imaging tools built for everyday clinic use — one for the slit lamp, one for the fundus.
From Choroida — the team behind this siteREFERENCES
- Fraser VJ, Jones M, Dunkel J, Storfer S, Medoff G, Claiborne Dunagan W. Candidemia in a tertiary care hospital: Epidemiology, risk factors, and predictors of mortality. Clin Infect Dis. 1992;15(3):414-421. doi:10.1093/clind/15.3.414.
- Shah CP, McKey J, Spirn MJ, Maguire J. Ocular candidiasis: A review. Br J Ophthalmol. 2008;92(4):466-468. doi:10.1136/bjo.2007.133405.
- Son HJ, Kim MJ, Lee S, et al. Risk factors and outcomes of patients with ocular involvement of candidemia. PLoS One. 2019;14(9):1-13. doi:10.1371/journal.pone.0222356.
- Donahue SP, Greven CM, Zuravleff JJ, et al. Intraocular Candidiasis in Patients with Candidemia: Clinical Implications Derived from a Prospective Multicenter Study. Ophthalmology. 1994;101(7):1302-1309. doi:10.1016/S0161-6420(94)31175-4.
- Khalid A, Clough LA, Symons RCA, Mahnken JD, Dong L, Eid AJ. Incidence and clinical predictors of ocular candidiasis in patients with Candida fungemia. Interdiscip Perspect Infect Dis. 2014;2014. doi:10.1155/2014/650235.
- Abusamra K. Candidiasis. In: Foster CS, Anesi SD, Chang PY, eds. Uveitis: A Quick Guide to Essential Diagnosis. Springer International Publishing; 2021:189-191. doi:10.1007/978-3-030-52974-1_41.
Test yourself
A few questions straight from this article.
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How does systemic candidemia reach the eye in endogenous ocular candidiasis?
Systemic candidemia seeds the retinal and choroidal circulation haematogenously, which is why ocular candidiasis is a recognised complication of bloodstream infection. -
Which hospital factors have driven the rising prevalence of candidemia?
Candidemia has become more common in hospital as a complication of surgery and with wider use of parenteral nutrition, central venous catheters and broad-spectrum antibiotics. -
Which route of ocular candidiasis follows trauma or direct inoculation during surgery?
Exogenous ocular candidiasis arises from trauma or direct inoculation at surgery or other procedures, and is uncommon in North America and Europe but seen more in tropical regions. -
Endogenous ocular candidiasis occurs most commonly in which group of patients?
Although rare overall, endogenous ocular candidiasis from transient fungemia occurs mainly in the severely immunocompromised and in patients with indwelling catheters. -
What defines probable ocular candidiasis?
When characteristic ocular findings occur in a patient with known systemic candidiasis, ocular culture is unnecessary and the case is termed probable ocular candidiasis. -
When should B-scan ultrasonography be performed in suspected ocular candidiasis?
B-scan ultrasound is indicated when the retina cannot be seen because of media opacity, allowing assessment of vitreous and retinal involvement. -
What may fluorescein angiography demonstrate in early ocular candidiasis?
In early disease a fluorescein angiogram may show chorioretinitis, supporting the diagnosis before more advanced changes appear. -
Alongside antifungal therapy, what source-control measure is advised in ocular candidiasis?
Where possible the inciting cause of candidemia is removed, for example by removing or replacing indwelling lines and catheters, alongside targeted systemic antifungal therapy. -
Which initial systemic therapy is recommended for candidemia in neutropenic and non-neutropenic patients?
Initial therapy with an intravenous echinocandin is recommended for both neutropenic and non-neutropenic patients; fluconazole is an alternative only in non-neutropenic patients who are not critically ill. -
When may step-down to oral fluconazole be considered in candidemia?
Step-down to oral fluconazole may follow after 5 to 7 days in patients who are clinically stable, have repeat negative blood cultures, and carry a fluconazole-susceptible Candida species.
