Sir,

We report the case of a 73-year-old woman who developed endogenous, bilateral, endophthalmitis during a protracted admission to I.T.U. following bowel resection for suspected tumour.

She presented with symptoms of decreased acuity and floaters. Indirect ophthalmoscopy revealed intraretinal and preretinal white lesions as well as large ‘snowball’ lesions in the vitreous in both eyes. Her best-corrected visual acuity was 6/9 in the right eye and 6/12 in the left. Repeated blood cultures showed no growth.

The severity of her systemic condition did not allow for early vitrectomy, therefore oral fluconazole was given, but despite 400 mg b.d. for 15 days, her vision deteriorated to counting fingers in the right eye and 6/18 in the left.

She subsequently underwent right vitrectomy and intravitreal injection of 10 μg amphoteracin B into each eye. A vitreous sample taken from the right eye during the procedure grew Candida albicans sensitive to fluconazole; however, despite postoperative treatment with oral fluconazole, 200 mg b.d., the endophthalmitis deteriorated in both eyes, with increased fungal lesions and a further decrease in visual acuity.

Because of her recent bowel surgery and recurrent episodes of bowel obstruction, we were concerned about adequate drug absorption. To ensure that a therapeutic serum level of antifungal agent was achieved, itraconazole was used in preference to fluconazole as serum levels can be monitored and oral dose adjusted in case of any malabsorption.

A radical improvement was seen on examination after 10 days of intravenous (i.v.) itraconazole 200 mg b.d. Serum concentrations were maintained in the therapeutic range. An oral maintenance dose of 200 mg b.d. was then given and tapered down to 100 mg b.d. over 3 months.

Treatment with itraconazole led to complete resolution of C. albicans endophthalmitis in both the vitrectomised and nonvitrectomised eye. Best-corrected visual acuity 4 months after presentation was 6/9-2 in both eyes.

Endogenous endophthalmitis is often associated with high mortality and poor visual acuity outcomes.1 Bowel surgery for tumour is a common predisposing condition for endogenous endophthalmitis,2 as is long-term i.v. catheter placement.3 Compared with postoperative or post-traumatic endophthalmitis, patients with endogenous endophthalmitis are more likely to have fungal isolates with a predominance of C. albicans.3

Comment

The current, established treatment for this condition is pars plana vitrectomy with intravitreal injection of amphoteracin B.1, 2, 3, 4 Fluconazole is the antifungal shown to achieve the highest concentration in the vitreous following oral administration to white rabbits.5 In this case, the right eye failed to respond to conventional treatment including vitrectomy, but both eyes responded to therapeutic serum levels of itraconazole.

This case suggests that a remarkable recovery in visual acuity is possible with antifungal treatment alone, without performing therapeutic vitrectomy.6 The location of the fungal lesions may be predictive of the success of medical treatment. It has been suggested that only chorioretinal lesions respond to medical treatment, whereas extension into the vitreous requires surgery.7 In this case, vitreous seeding responded to intravitreal amphoteracin and i.v. itraconazole without vitrectomy. Furthermore, although itraconazole is not currently first line in the treatment of Candida endophthalmitis, it should be considered when first-line agents fail to control the infection.8