Title : A case of progressive bilateral candidal endogenous endophthalmitis
Abstract:
Endogenous fungal endophthalmitis can occur secondary to fungaemia with haematogenous seeding of the choroid, most commonly due to Candida species. Recognised risk factors include hospitalisation, indwelling intravenous lines, immunosuppression, malignancy, and broad-spectrum antibiotic use. Early ophthalmic assessment is essential in patients with candidaemia who develop visual symptoms.
We report the case of a 77-year-old female who developed candidaemia whilst admitted to intensive care following biliary drain insertion for cholangiocarcinoma. The patient was subsequently referred to our ophthalmology unit with bilateral blurred vision and floaters. Visual acuity was reduced to counting fingers in the right eye and 6/18 in the left. Dilated fundus examination demonstrated a large yellow chorioretinal macular lesion characteristic of candidal chorioretinitis, with mild vitritis in the right eye, and a smaller lesion temporal to the macula in the left eye. A clinical diagnosis of candidal endophthalmitis was made based on the characteristic fundus appearances in the context of recent candidaemia.
The patient was treated with intravenous caspofungin and intravitreal amphotericin. Despite systemic improvement, clearance of candidaemia on blood cultures and initial ocular stability, she developed progressive bilateral vitritis and enlargement of chorioretinal lesions. Repeat intravitreal amphotericin was administered, and systemic therapy continued with oral voriconazole; however, her endophthalmitis continued to progress over a month. Vitreous biopsy did not isolate any candidal growth. The patient was recommended for diagnostic and therapeutic pars-plana vitrectomy.
This case highlights progressive bilateral fungal endophthalmitis as a rare but serious sequela of systemic candidal infection, showing that choroidal seeding may occur following transient candidaemia and progress despite subsequent systemic clearance and intravitreal antifungal therapy. It emphasises the importance of prompt ophthalmic assessment in patients with suspected candidaemia and new visual symptoms, particularly those with malignancy-related immunosuppression, indwelling lines and prolonged hospitalisation.
