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AimInvestigate and characterise acute post-cataract fungal endophthalmitis pooled from the Endophthalmitis Management Study occurring within 6 weeks of primary surgery.MethodsThe fungal infection was confirmed through conventional and molecular microbiology work-ups and antifungal susceptibility testing. Clinical examination included measurement of distant vision and intraocular pressure, anterior segment photo documentation and inflammation score (IS) measurement. Per the microbiology report, the eyes were divided into culture-positive (C+), sequencing-positive (S+) and sequencing-positive-unidentified (U+) fungi. Clinical correlations and statistical comparisons were performed between these three cohorts.ResultsThe study identified 21 patients with fungal endophthalmitis; it was 9.5% (21 of 220) of all acute post-cataract endophthalmitis in this study. Per the microbiology report, C+, S+ and U+ were 6, 9 and 6 patients, respectively. Fusarium and Aspergillus spp were the common fungi. The C+ fungi had higher presenting IS (p=0.023), shorter time to symptoms, worse presenting vision, corneal abscess (p=0.030) and higher probability of repeat intervention (p=0.042) than the other two groups. In the C+ group, the final vision of >20/400 was less (p=0.046) and phthisis bulbi was higher (p=0.010). All culturable fungi were resistant to amphotericin B and voriconazole.ConclusionThere is a 10% probability of acute post-cataract fungal endophthalmitis in India. The eyes presenting with corneal abscesses carry a higher risk. The polymicrobial infections shown in this cohort should be interpreted cautiously since next-generation sequencing detects DNA from all organisms, including residual or low-abundance or non-viable organisms that traditional culture might miss. Despite this, the new molecular microbiology technology is necessary to confirm diagnosis and expedite appropriate treatment. Given multi-antifungal agent resistance, routine susceptibility testing must be considered.

Purpose This study aimed to investigate the demographics, clinical characteristics, and management outcomes of patients with acute infectious endophthalmitis (AIE). Methods This retrospective chart review was conducted on all patients admitted with the clinical diagnosis of infectious endophthalmitis from 2017 to 2022. Demographic data, patients’ clinical characteristics, the type of acute infectious endophthalmitis (post-operative, post-traumatic, bleb-associated, and endogenous endophthalmitis), the type of surgical procedure in the post-operative cases, the microbiologic analysis results of vitreous samples, therapeutic measures, and visual outcomes of patients were recorded. Results In this study, 182 participants, including 122 male (67%) and 60 (33%) female, were involved. The mean age of patients was 54.56 ± 21 years, with a range of 1–88 years old. The most prevalent type of AIE was post-operative (59.9%), followed by endogenous (19.2%), post-traumatic (17%), and bleb-associated (3.8%). The most common type of intraocular surgery in the post-operative subgroups of AIE patients was phacoemulsification (57.8%). The median (interquartile range) of the primary and final BCVA of patients was 1.5 (1.35, 1.85) and 0.65 (0.35, 1.35), respectively. Vitreous haziness grade (OR, 2.89; 95% CI, 1.11–5.74; p  = 0.009) and the primary VA (OR, 60.34; 95% CI, 2.87–126.8; p  = 0.008) revealed statistical significance for final vision loss. Conclusion AIE is a devastating condition with poor visual outcomes, which presents with acute inflammatory signs and symptoms regardless of its type. However, prompt and appropriate treatment leads to visual recovery to a functional level in many patients.

PurposeTo show that an immediate vitrectomy with an intravitreal injection of antibiotics can be an effective approach for the treatment of acute endophthalmitis following intravitreal injections.MethodsWe reviewed all cases of clinical endophthalmitis caused by an intravitreal injection that were treated in our department between March 2012 and November 2019. Only patients that underwent a vitrectomy within 6 h after presentation to the clinic and with a documented visual acuity shortly before the causative event were included. Baseline best-corrected visual acuity (BCVA) before the causative event was compared to BCVA measured within a follow-up period of 8 months (up to 14 months).ResultsIn total, 30 eyes of 30 patients were included. The BCVA before the intraocular infection was a mean value of 0.55 logMAR, and the BCVA on the day of the endophthalmitis decreased significantly to 1.66 logMAR. Within 2 months following the pars plana vitrectomy (PPV), the mean BCVA improved to 0.83 logMAR. Eight months following PPV (mean value, 8.20 months; SD, 3.59 months), the mean BCVA was 0.63 logMAR. In the last follow-up interval most of the eyes recovered, and the BCVA did not differ significantly from baseline. Two eyes underwent further pars plana surgery during the follow-up period. No enucleation was required.ConclusionIn this study, we have shown that an immediate vitrectomy with subsequent intravitreal injection of antibiotics is an effective option for treating post-injection endophthalmitis and frequently results in recovery of vision; thus, it should be performed as early as possible, where available.

Purpose: To describe a series of post-coronavirus disease 2019 (COVID-19) endogenous endophthalmitis (EE) patients from a multispecialty tertiary hospital in North India. Methods: A retrospective chart review including all consecutive cases with EE following confirmed COVID-19 disease from July 2020 to June 2021. Results: Seven eyes of four patients (three female and one male) were included. Two patients had confirmed bilateral fungal (Aspergillus sp.) EE and two patients had presumed fungal EE (one bilateral and one unilateral). Three of these four patients received systemic steroids as part of COVID-19 treatment previously. Five eyes were managed with initial intravitreal injection (IVI), followed by pars plana vitrectomy (PPV), and two eyes were managed with only IVI. All patients received systemic antifungal agents. Intraocular inflammation resolved in all eyes with treatment. One patient of EE also developed voriconazole-induced transient visual hallucination, which resolved on discontinuing the medication. Conclusion: This case series represents a series of EE cases following COVID-19 disease or its sequelae or as a result of prior treatment for COVID-19. Ophthalmologists and physicians must be vigilant about these complications and initiate prompt management at the earliest.

Fungal endophthalmitis (FE), although less common than bacterial endophthalmitis, carries a disproportionately high risk of irreversible blindness. Clinical observations show that some patients continue to experience progressive visual loss even after successful microbiological clearance, suggesting that disease outcomes are strongly influenced by excessive host immune−inflammatory injury rather than pathogen burden alone. Focusing on the retinal pigment epithelium (RPE), a key component of the blood–retinal barrier, this review summarizes recent advances in intraocular microenvironmental alterations, RPE immune responses, and the remodeling of cell death pathways during FE pathogenesis. We outline a conceptual framework centered on a “metabolism–immunity–death” axis. In this model, fungal infection induces mitochondrial metabolic reprogramming and dynamic imbalance in RPE cells, which can be associated with cytosolic leakage of mitochondrial DNA (mtDNA). As a danger−associated molecular pattern, mtDNA may activate the Z−DNA binding protein 1 (ZBP1) sensor, promote PANoptosome assembly and coordinate inflammatory cell death programs including pyroptosis, apoptosis, and necroptosis. We further highlight the regulatory GSK3β–MITF–FBXW7 axis and discuss how its dysregulation may connect impaired metabolic adaptation with irreversible RPE PANoptosis. Finally, potential translational implications of host−directed therapy (HDT) are discussed, including the use of cell−free mtDNA as an early biomarker and therapeutic strategies that combine metabolic protection with antifungal treatment. Collectively, this review provides a mechanistic perspective on the poor visual outcomes of FE and identifies potential targets for retinoprotective intervention.

Ocular fungal infections annually affect more than one million individuals worldwide. The management of these infections is problematic, mainly due to the limited availability of effective antifungal agents. Thus, ocular infections are increasingly recognized as important causes of morbidity and blindness, especially keratitis and endophthalmitis. Thus, this review aims to demonstrate the importance of fungal eye infections through the description of the main related aspects, with emphasis on the treatment of these infections. For this purpose, a search for scientific articles was conducted in databases, such as Medline, published from 2000 onwards, addressing important aspects involving fungal eye infections. In addition, this work highlighted the limited therapeutic arsenal available and the severity associated with these infections. Thus, highlighting the importance of constantly updating knowledge about these pathologies, as it contributes to agility in choosing the available and most appropriate therapeutic alternatives, aiming at positive and minimally harmful results for that particular patient.

We identified Prototheca spp. microalga in ocular samples of a cat in Spain with nontreatable endogenous endophthalmitis. Within 2 years, the eye lesions progressively worsened and neurologic signs appeared, suggesting systemic spread of the infection. On multitarget sequence analysis, the feline pathogen could not be assigned to any known Prototheca species.

Fungal endophthalmitis is a potentially blinding condition. It is more often reported from Asia, including India. The incidence is lower than bacterial endophthalmitis. But it is relatively more challenging to treat than bacterial endophthalmitis. Many eyes may need therapeutic keratoplasty and/or evisceration. The current mainstays of treatment are vitrectomy irrespective of the presenting vision, intravitreal antifungal agents, and systemic therapy; additionally, the patients could require prolonged treatment with repeat vitreous surgeries and intravitreal injections. Difficulty in clinical diagnosis, delay in microbiological culture, and limited options of antifungal drugs make the treatment more difficult and less rewarding. Three common fungi causing endophthalmitis are Aspergillus, Fusarium, and Candida. The former two are molds, often identified in exogenous endophthalmitis, postoperative and traumatic; the latter is yeast and is more often identified in endogenous endophthalmitis. A faster diagnosis with newer molecular microbiological technologies might help institute treatment earlier than it is currently possible. A target trial using big data from different regions of the world might emulate a randomized clinical trial to design a definite treatment strategy. Given fewer antifungal drugs, one must be mindful of antifungal stewardship to prevent resistance to the existing drugs.

Endophthalmitis is a serious ophthalmologic condition involving purulent inflammation of the intraocular spaces. The underlying etiology of infectious endophthalmitis is typically bacterial or fungal. The mechanism of entry into the eye is either exogenous, involving seeding of an infectious source from outside the eye (e.g., trauma or surgical complications), or endogenous, involving transit of an infectious source to the eye via the bloodstream. The most common organism for fungal endophthalmitis is Candida albicans. The most common clinical manifestation of fungal endophthalmitis is vision loss, but other signs of inflammation and infection are frequently present. Fungal endophthalmitis is a clinical diagnosis, which can be supported by vitreous, aqueous, or blood cultures. Treatment involves systemic and intravitreal antifungal medications as well as possible pars plana vitrectomy. In this review, we examine these essential elements of understanding fungal endophthalmitis as a clinically relevant entity, which threatens patients’ vision.

Purpose: To investigate if inflammation score (IS), calculated from the cornea, anterior chamber, iris, and vitreous, indicates endophthalmitis severity. Methods: In a prospective study, consecutive adults with a clinical diagnosis of post-cataract endophthalmitis within 6 weeks of surgery were recruited. Patients were allocated to IS-based primary treatment (IS < 10: intravitreal injection and IS ≥ 10: vitrectomy) and randomized to two intravitreal antibiotics combinations (vancomycin + ceftazidime and vancomycin + imipenem). Undiluted vitreous microbiology work-up included culture susceptibility, polymerase chain reaction, Sanger sequencing, and targeted next-generation sequencing. Results: The average age of 175 people was 63.4 ± 10.7 years and included 52.6% small incision cataract surgery and 47.4% phacoemulsification surgery. Severe endophthalmitis (IS ≥ 20), diagnosed in 27.4% of people, had a shorter time to symptoms (average 5.4 vs 8.7 days; P = 0.018), poorer presenting vision (all ≤ hand motion), higher culture positivity (50% vs 30.7%; P = 0.032), and higher Gram-negative bacterial infection (70.8% vs 46.2%; P = 0.042). For IS ≥ 20 discriminant and Gram-negative infection, Spearman's coefficient was 0.7 [P < 0.0001, 95% confidence interval (CI) 0.59-0.82], with an area under the receiver operating characteristic curve of 0.9 (95% CI 0.85-0.94, P < 0.0001), a Youden index J of 0.74, a sensitivity of 87.2%, and a specificity of 87.5%. The final vision of >20/400 and >20/100 was regained in 50.2% and 29.1% of people, respectively. The susceptibility of common Gram-positive cocci and Gram-negative bacilli was the highest for vancomycin (95.0%) and colistin (88.6%), respectively. NGS detected polymicrobial infection in 88.5% of culture-negative endophthalmitis. Conclusions: Higher inflammation scores indicated severe disease and Gram-negative infection in post-cataract endophthalmitis.