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Candida Retinitis/Endophthalmitis

URGENT — Uveitis

Symptoms

Presentation

  • Decreased vision and floaters.
  • Ocular pain.
  • Often bilateral involvement.

Clinical context

  • Recent hospitalization or major abdominal/GI surgery (e.g., perforated viscus, pancreatitis).
  • Immunocompromised state (e.g., malignancy, transplant, HIV, chemotherapy).
  • Presence of indwelling lines/catheters (hyperalimentation, hemodialysis, PICC/TPN).
  • History of intravenous (IV) drug use.

Clinical Findings

Pathophysiology

  • Hematogenous seeding of Candida (usually C. albicans) from candidemia.
  • Fungi reach the eye via choroidal vasculature as septic emboli.

Stage 1 — chorioretinitis

  • Isolated fluffy, creamy-white to yellow-white deep retinal/chorioretinal lesions.
  • Typically 1/4–1 disc diameter in size, scattered around the posterior pole.
  • Minimal or no vitritis; treatable with systemic antifungals alone.

Stage 2 — endophthalmitis

  • Lesions break through the internal limiting membrane (ILM) into the vitreous.
  • Pathognomonic "string of pearls" or "cotton balls": Fluffy fungal aggregates on vitreous strands.
  • Associated vitritis, AC cell/flare, and hypopyon.
  • Retinal hemorrhages with pale centers (Roth-spot-like).

IDSA screening guideline

  • Every patient with candidemia requires a dilated fundus exam within 1 week of positive blood culture.
  • Repeat exam at 2 weeks if the initial check is negative.
  • Screening is mandatory regardless of symptoms, as ocular involvement is often asymptomatic.

Risk groups

  • Patients on long-term broad-spectrum antibiotics or total parenteral nutrition (TPN).
  • Premature neonates (NICU patients).
  • Patients with burns, prolonged neutropenia, or diabetes.

Etiology

Causative organisms

  • Candida species: C. albicans (most common), glabrata, parapsilosis, krusei, or tropicalis.

Primary mechanisms

  • Hematogenous spread from candidemia seeding the choroid and retina.

Risk factors

  • Indwelling central venous or hemodialysis catheters.
  • Intravenous drug use.
  • Prolonged hospitalization and broad-spectrum antibiotic use.
  • Major abdominal/GI surgery with contamination.

Red Flags

  • Candidemia mandates a dilated fundus exam within 1 week (asymptomatic screening).
  • Fluffy white retinal lesions + vitritis + "string of pearls" = Candida endophthalmitis.
  • Echinocandins (caspofungin, etc.) have poor ocular penetration and are inadequate as monotherapy for endophthalmitis.
  • Delaying treatment can lead to permanent vision loss even if systemic infection is managed.

Investigations

Clinical assessment

  • Skin check for IV drug injection track marks.
  • Serial dilated funduscopic exams (initial within 72 hours, repeat at 2 weeks).

Microbiology

  • Blood, urine, and catheter-tip fungal cultures.
  • Vitreous biopsy with smear, culture, and PCR (definitive diagnosis).
  • Note: Blood cultures may be negative at the time ocular findings appear.

Imaging & labs

  • B-scan ultrasound: Identifies vitritis and fungal balls if the posterior view is obscured.
  • OCT: Shows hyperreflective inner retinal or vitreous infiltrates.
  • Baseline CBC, renal function, and liver function tests.

Treatment

Chorioretinitis (no vitritis)

  • Systemic therapy alone is usually sufficient.
  • Fluconazole (for C. albicans) or Voriconazole (broad coverage, excellent ocular penetration).

Endophthalmitis (with vitritis)

  • Combined systemic and intravitreal antifungal therapy.
  • Intravitreal: Amphotericin B (5–10 µg/0.1 mL) or Voriconazole (50–100 µg/0.1 mL).
  • Urgent PPV for diagnostic specimen, clearing opacities, or poor medical response.

Duration & source control

  • Minimum 4–6 weeks of therapy; often extends to 3 months.
  • Mandatory removal of all offending indwelling hardware/catheters.

Clinical Pearl

A fluffy chorioretinal lesion in a patient with candidemia is Candida chorioretinitis — systemic fluconazole or voriconazole often suffices if there is no vitritis; vitritis needs intravitreal antifungals and often vitrectomy.

Differential Diagnosis

  • CMV retinitis (immunocompromised)
  • P. carinii (history of aerosolized pentamidine)
  • Aspergillus (aggressive, hemorrhagic, macular involvement)
  • Endogenous bacterial endophthalmitis (rapid progression, high pain)
  • Toxoplasmosis (headlight in fog near pigmented scar)
  • Nocardia, Cryptococcus, or Coccidioides

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