Post-cataract surgery endophthalmitis can be classified according to the time of onset of clinical signs: acute, within the first week; subacute, with symptoms in the first 4 weeks; chronic saccular, which can appear months or even years after surgery.1 Chronic saccular endophthalmitis 2,3 is a rare complication after modern cataract surgery; fungal etiology is uncommon in western countries but has an incidence of up to 15% in tropical countries such as India.4Alternaria alternata is a conidiophores filamentous fungus whose spores can be found suspended in the air, on the ground, on objects, and in water both outside and inside the home. As an allergen, it is responsible for respiratory or hypersensitivity reactions.5 It causes opportunistic infections in immunocompromised individuals.
Alternaria alternata ocular infection is extremely rare; the first of the few articles that refer to this endophthalmitis was published in 1991.6 The keratitis due to this microorganism is more frequent7,8 and is the first cause of this particular infection. Exogenous endophthalmitis by A alternata may have a latent period of weeks to months before clinically detectable disease occurs. The infection can remain in the saccular space until an exogenous factor, such as a laser shot, disperses the fungus into the anterior chamber, pupillary space, or anterior vitreous.
The case we describe illustrates our experience in the management of this complicated endophthalmitis. The delay in diagnostic confirmation and initiation of specific treatment was instrumental in the poor outcome despite specific medical and surgical treatment.
A 78-year-old woman with panuveitis in the left eye was referred to our department in February 2010. Cataract surgery with hydrophobic acrylic intraocular lens (IOL) implantation had been performed under topical anesthesia in June 2009. Postoperatively, the course was irregular with progressive loss of visual acuity without pain and redness. The posterior capsule developed an early opacification, and neodymium:YAG laser capsulotomy was performed in October 2009, giving rise to a latent panuveitis unresponsive to 2 repeated injections of intravitreal antibiotics—ceftazidime and vancomycin.
On arrival at our department, the patient's visual acuity was hand motion at 50 cm in the left eye. Biomicroscopy showed ciliary hyperemia, an anterior reaction with 10 cells per field, and intense vitritis preventing retinal observation (Figure 1). B-scan ultrasound showed vitreous bands originating from the optic disc. Surgery was performed and included obtaining samples of aqueous and vitreous humor for cultures and polymerase chain reaction (PCR), anterior chamber cleanup, a vitrectomy with band release, and an intravitreal injection of 2 mg of ceftazidime and 1 mg of vancomycin.
Standard media cultures were negative. The PCR was positive for A alternata. An intravitreal injection of voriconazole (100 mg) was given, and oral voriconazole 200 mg every 12 hours was started. An additional intravitreal voriconazole injection (100 mg) was given a week later due to persistent vitritis. Little improvement was observed; the visual acuity was hand motion. Because of persistent vitritis and an anterior reaction with thick Tyndall 2 weeks later (Figure 2), another surgery was performed. Anterior chamber and vitreous samples for culture and PCR were obtained, the IOL and capsular bag were explanted and also sent for culture and PCR, a vitrectomy was performed during which white plaques on the entire retina (Figure 3) were seen, and liposomal amphotericin B (10 μg), vancomycin, and ceftazidime were administered intravitreally. The culture identified A alternata (Figure 4). Postoperatively, 2 additional intravitreal injections of amphotericin B were given. Intravenous liposomal amphotericin was started but suspended because of secondary renal failure. The eye was phthisical, and the visual acuity was light perception. There was no anterior or posterior vitreous reaction.
The most common cause of fungal endophthalmitis is keratitis, followed by intraocular surgery and penetrating ocular trauma.9Alternaria alternata is a filamentous fungus not usually detected in chronic saccular endophthalmitis. Chronic saccular endophthalmitis is usually due to less virulent bacteria such as Propionibacterium acnes or Corynebacterium and fungi such as Candida spp, Aspergillus, and Fusarium spp. Other less frequent seen bacteria are Mycobacterium chelonae, environmental or nontuberculous mycobacteria, and Nocardia spp.
The classic antifungal agent for the treatment of systemic and ocular fungal infections is intravenous amphotericin B, previously used as deoxycholate and more recently in liposomal form, which can also be administered intravitreally. Voriconazole is a more recently available antifungal drug, belonging to the group of triazoles with broad spectrum; it can be administered orally and intravitreally. It has proved effective in infections caused by Candida albicans, emerging opportunistic filamentous fungi such as Aspergillus terreus, Fusarium, and Scedosporium, as well as against clinically less common species such as A alternata.10,11 We used amphotericin primarily but had an adverse reaction with renal failure, causing us to use voriconazole. Voriconazole has also been used in immunosuppressed patients with dermatological infections caused by A alternata.12
The differential diagnosis must be made with other forms of sterile postoperative inflammation. The diagnosis of fungal endophthalmitis is difficult and should be suspected in the presence of vitreous bands, as in our case. The PCR test is particularly relevant owing to the difficulty and delay in the culture results.13 Having an antifungal susceptibility test would help us identify the most effective drug, but often antifungal drug combinations are used.
Amphotericin is especially useful for yeasts, but voriconazole is increasingly used as a first-line antifungal for endophthalmitis,14 displacing the former due to its wide spectrum. Voriconazole works by inhibiting cytochrome P450-dependent fungal sterol 14-α-demethylase, an enzyme essential in the biosynthesis of ergosterol with a greater safety profile than any currently used antifungal agents.15
Intravitreal antifungals have a relatively short half-life, and no consensus exists about a pattern of use by this route. Unlike with antibiotics, a large number of injections are usually required, which increases toxicity. In a recent series of exogenous fungal endophthalmitis, a final vision of 20/400 or better was achieved in 54% of eyes and 24% were enucleated.10
Fungal endophthalmitis requires regular follow-ups. Aggressive surgery, IOL removal, and full vitrectomy should be performed when the infection it is not responding well. A delay can lead to irreversible damage. Silicone oil has been used increasingly as an internal tamponade16 because no microorganisms appear able to penetrate and grow in this inert material. It is an alternative that can be used to prevent progression in cases with a poor prognosis.17–19
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