Fig. 9.42 Sporothrix schenckii. (a) Fundus photography showing retinal granuloma and fluffy opacities in the vitreous in the left eye. (b) Ulcerated skin lesions. (c) Positive culture for Sporothrix schenckii. (Modified and reprinted with permission from Curi AL, Felix S, Azevedo KM, et al. Retinal granuloma caused by Sporothrix schenckii. Am J Ophthalmol. 2003; 136:205–207)

Controversies and Perspectives

The last few decades have seen significant changes in health care with increasing numbers of heavily immunocompromised patients.

Because of new and more aggressive treatments, patients with severe immune defects are surviving longer and the spectrum of fungal pathogens is increasing. Until relatively recently, Candida albicans and Aspergillus fumigatus were considered the only important nosocomial fungal pathogens. However, nonalbicans Candida species and other yeasts, together with an increasing range of molds apart from A. fumigatus are now reported to cause nosocomial fungal infections. The widespread use of azoles for prophylaxis and treatment has been linked with the emergence of non-albicans Candida species and other yeasts. Therefore prevention of nosocomial fungal infections is an increasingly important aspect of infection control.

Despite enormous advances in the field of infectious diseases, the identification of fungi as the cause of an infection is difficult to establish in cases of presumed fungus infection because of the nonspecific clinical signs and symptoms and the difficulties encountered in the isolation of these microorganisms in the microbiology laboratory. Delays in identification of fungal pathogens often lead to advanced disease and delay in the use of targeted antifungal therapy. To further compound the dilemma, treatment of fungus infection can be difficult given the paucity of commercial antifungal ophthalmic agents and the not-well-established criteria for antifungal sensitivity testing.

New classes and newer generations of antifungal therapies are being developed and may be important in combating this sight-threatening infectious disease.

The role of corticosteroids and its proper use in the treatment of fungal infections continues to be debated among experts. The controversy arises because there are two goals in the treatment of fungus infection that are inherently incompatible: (1) to get rid in the affected tissue of the replicating microorganisms causing the infection and (2) to limit the degree of structural damage caused by the infectious process.

Focal Points

•Fungal infections can be exogenous (postsurgical or posttraumatic) or endogenous.

•Fungal endophthalmitis usually presents as a chronic panuveitis.

•Fluffy deep yellow-white retinal or choroidal lesions are frequently present, and the vitreous often contains “fluff balls.”

•The patient may not be symptomatic for days or even months until he or she develops blurred vision or floaters.

•Later in the course, redness, pain, hypopyon, and dense vitreitis may occur.

•Candida species are the most common organisms responsible for endogenous (as well as exogenous) fungal endophthalmitis.

•Candida endophthalmitis usually occurs in chronically ill patients with an indwelling catheter. It is also a frequent complication of intravenous drug use.

•Aspergillus species are the second most common cause of endogenous fungal endophthalmitis.

•Diagnosis is confirmed unequivocally by culturing the fungus from patient specimens on appropriate media and by specific laboratory methods, including the finding of fungi on direct microscopic examination of specially stained tissue sections.

•Histological features can be more rapidly diagnostic than culture when mycoses are caused by slow-growing fungi.

•The time saved by allowing appropriate introduction of antifungal therapy can be critically important to preserving ocular structures.

•Biopsy may provide proof that the fungus is invading tissue and that it is not merely a contaminant or saprophyte.

•Histological examination and culture ideally are performed together.

•For fungus infections that are limited to the eye, vitrectomy combined with intravitreal antifungals are the treatment of choice.

Acknowledgments The authors have no financial or proprietary interest in any of the products or techniques mentioned in this article.

Supported in part by the Arévalo-Coutinho Foundation for Research in Ophthalmology, Caracas, Venezuela.

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