CHRONIC CURVULARIA LUNATA ENDOPHTHALMITIS FOLLOWING CATARACT EXTRACTION Robert A. Sisk, MD, William E. Smiddy, MD, Sander R. Dubovy, MD, Darlene Miller, DHSc, MPH
Purpose: To describe a case of chronic endophthalmitis after cataract extraction caused by an unusual pathogen. Methods: Chart review. Results: A 79-year-old male presented with chronic endophthalmitis from Cuvularia lunata and received vitrectomy with serial injections of intravitreal voriconazole. Conclusion: Curvularia endophthalmitis presents late and is difficult to eradicate but responds to intravitreal voriconazole. RETINAL CASES & BRIEF REPORTS 3:438 – 439, 2009
From the University of Miami, Miller School of Medicine, Bascom Palmer Eye Institute, Miami, Florida.
was given, resulting in a paradoxically profound increase in inflammation. He was referred to the Bascom Palmer Eye Institute for retinal consultation. Visual acuity had declined to hand motions, and a fluffy, white iridocapsular plaque associated with hypopyon and fibrin was noted (Figure 1). Vitrectomy, capsulectomy, and intraocular lens explantation were performed, and the iridocapsular plaque was excised and sent for culture and pathology. Intravitreal vancomycin, amikacin, and voriconazole were administered. Cultures grew Curvularia lunata, and biopsy of the plaque yielded fungal elements. Inflammation recurred intermittently over the next 6 months despite oral and topical voriconazole but resolved with 3 additional injections of intravitreal voriconazole administered at 1-month intervals. Visual acuity with aphakic correction stabilized at 20/200, and fundus examination demonstrated macular pigmentary changes.
C
urvularia Lunata is a dematiaceous fungus that has been rarely reported to cause endophthalmitis after cataract surgery.1,2 In general, dematiaceous fungal endophthalmitis has a delayed onset, is difficult to eradicate, and carries a poor visual prognosis.3,4 Curvularia more commonly causes keratitis than endophthalmitis, and at least one reported case describes concurrence of both.1 Case Report A 79-year-old male returned to his surgeon 1 year after uneventful cataract extraction with intraocular lens implantation with moderate anterior chamber cellular reaction in his right eye. The inflammation initially resolved with topical and periocular corticosteroids but rebounded upon discontinuation. Laboratory testing for uveitis was negative, and Proprionobacterium acnes was suspected. He was referred to a retinal surgeon, who performed a diagnostic vitrectomy with intravitreal injection of vancomycin. No organisms grew in culture. Postoperatively, inflammation recurred, and the patient received intravitreal vancomycin and amikacin empirically. A subtenon’s injection of triamcinolone acetate
Comment Curvularia species are facultative pathogens of subtropical and tropical climates that produce wound infections in immunocompetent hosts. In vitro at room temperature, they produce rapidly growing, white, cottony colonies and show susceptibility to amphotericin B, azole fungal agents, and voriconazole.5 Diagnostic anterior chamber aspiration should be avoided, as it may result in secondary keratitis.1 There is no standardized treatment for Curvularia infections, but anecdotal cases of keratitis and endophthalmitis have responded favorably to voriconazole, itraconazole, na-
The authors have no proprietary interest in any aspect of this article. Reprint requests: Robert A. Sisk, MD, Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136; e-mail: rsisk@med. miami.edu
438
439
CURVULARIA LUNATA ENDOPHTHALMITIS
Fig. 1. (a) Slit-lamp photograph of the right eye demonstrating white iridocapsular plaque, anterior chamber fibrin, and conjunctival injection. (b) Fundus photograph of retinal pigment epithelial disturbance and retinal arterial attenuation noted in the right macula postoperatively. (c) Photomicrograph of fungal elements with septate hyphae within chronic inflammatory infiltrate (40⫻ PAS stain). (d) Photomicrograph of branching fungal elements within necrotic iris (100⫻ GMS stain).
tamycin, and amphotericin B.1,2 Despite reported penetration of oral voriconazole into the vitreous cavity, inflammation recurred postoperatively but was controlled with intravitreal voriconazole.6,7 Dematiaceous postoperative fungal endophthalmitis typically presents with an indolent, smoldering course. As with other infections, this can be aggravated by immune suppression with corticosteroids. Among the reported cases, those recognized later had a poorer visual prognosis. As dematiaceous fungi are difficult to eradicate, aggressive treatment involves surgical debulking of the fungal plaque, removal of synthetic implants, and intravitreal antifungal agents. This case emphasizes the tenacity of Curvularia lunata endophthalmitis, the need for close postoperative follow-up, and the efficacy of intravitreal antifungals in controlling recrudescences. Key words: endophthalmitis, fungal infection, vitrectomy, cataract extraction, voriconazole.
References 1.
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Kaushik S, Ram J, Chakrabarty A, et al. Curvularia lunata endophthalmitis with secondary keratitis. Am J Ophthlamol 2001;131:140 –142. Pathengay A, Shah GY, Das T, Sharma S. Curvularia lunata endophthalmitis presenting with a posterior capsular plaque. Indian J Ophthalmol 2006;54:65– 66. Rummelt V, Ruprecht KW, Boltze HJ, et al. Chronic alternaria alternate endophthalmitis following intraocular lens implantation. Arch Ophthalmol 1991;109:178. Holting-Lima AL, Freitas D, Fischman O. Exophialia jeansemei causing late endophthalmitis after cataract surgery. Am J Ophthalmol 1999;128:512–514. Guarro J, Akiti T, Almada-Horta R, et al. Mycotic keratitis due to Curvularia senegalensis and in vitro antifungal susceptibilities of Curvularia species. J Clin Microbiol 1999;37:4170 – 4173. Hariprasad SM, Mieler WF, Holz ER, et al. Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans. Arch Ophthalmol 2004;122: 42– 47. Hariprasad SM, Mieler WF, Lin TK, Sponsel WE, Graybill JR. Voriconazole in the treatment of fungal eye infections: a review of current literature. Br J Ophthalmol 2008;92:871– 878.
Purpose: To describe a case of chronic endophthalmitis after cataract extraction caused by an unusual pathogen. Methods: Chart review. Results: A 79-year-old male presented with chronic endophthalmitis from Cuvularia lunata and received vitrectomy with serial injections of intravitreal voriconazole. Conclusion: Curvularia endophthalmitis presents late and is difficult to eradicate but responds to intravitreal voriconazole. RETINAL CASES & BRIEF REPORTS 3:438 – 439, 2009
From the University of Miami, Miller School of Medicine, Bascom Palmer Eye Institute, Miami, Florida.
was given, resulting in a paradoxically profound increase in inflammation. He was referred to the Bascom Palmer Eye Institute for retinal consultation. Visual acuity had declined to hand motions, and a fluffy, white iridocapsular plaque associated with hypopyon and fibrin was noted (Figure 1). Vitrectomy, capsulectomy, and intraocular lens explantation were performed, and the iridocapsular plaque was excised and sent for culture and pathology. Intravitreal vancomycin, amikacin, and voriconazole were administered. Cultures grew Curvularia lunata, and biopsy of the plaque yielded fungal elements. Inflammation recurred intermittently over the next 6 months despite oral and topical voriconazole but resolved with 3 additional injections of intravitreal voriconazole administered at 1-month intervals. Visual acuity with aphakic correction stabilized at 20/200, and fundus examination demonstrated macular pigmentary changes.
C
urvularia Lunata is a dematiaceous fungus that has been rarely reported to cause endophthalmitis after cataract surgery.1,2 In general, dematiaceous fungal endophthalmitis has a delayed onset, is difficult to eradicate, and carries a poor visual prognosis.3,4 Curvularia more commonly causes keratitis than endophthalmitis, and at least one reported case describes concurrence of both.1 Case Report A 79-year-old male returned to his surgeon 1 year after uneventful cataract extraction with intraocular lens implantation with moderate anterior chamber cellular reaction in his right eye. The inflammation initially resolved with topical and periocular corticosteroids but rebounded upon discontinuation. Laboratory testing for uveitis was negative, and Proprionobacterium acnes was suspected. He was referred to a retinal surgeon, who performed a diagnostic vitrectomy with intravitreal injection of vancomycin. No organisms grew in culture. Postoperatively, inflammation recurred, and the patient received intravitreal vancomycin and amikacin empirically. A subtenon’s injection of triamcinolone acetate
Comment Curvularia species are facultative pathogens of subtropical and tropical climates that produce wound infections in immunocompetent hosts. In vitro at room temperature, they produce rapidly growing, white, cottony colonies and show susceptibility to amphotericin B, azole fungal agents, and voriconazole.5 Diagnostic anterior chamber aspiration should be avoided, as it may result in secondary keratitis.1 There is no standardized treatment for Curvularia infections, but anecdotal cases of keratitis and endophthalmitis have responded favorably to voriconazole, itraconazole, na-
The authors have no proprietary interest in any aspect of this article. Reprint requests: Robert A. Sisk, MD, Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136; e-mail: rsisk@med. miami.edu
438
439
CURVULARIA LUNATA ENDOPHTHALMITIS
Fig. 1. (a) Slit-lamp photograph of the right eye demonstrating white iridocapsular plaque, anterior chamber fibrin, and conjunctival injection. (b) Fundus photograph of retinal pigment epithelial disturbance and retinal arterial attenuation noted in the right macula postoperatively. (c) Photomicrograph of fungal elements with septate hyphae within chronic inflammatory infiltrate (40⫻ PAS stain). (d) Photomicrograph of branching fungal elements within necrotic iris (100⫻ GMS stain).
tamycin, and amphotericin B.1,2 Despite reported penetration of oral voriconazole into the vitreous cavity, inflammation recurred postoperatively but was controlled with intravitreal voriconazole.6,7 Dematiaceous postoperative fungal endophthalmitis typically presents with an indolent, smoldering course. As with other infections, this can be aggravated by immune suppression with corticosteroids. Among the reported cases, those recognized later had a poorer visual prognosis. As dematiaceous fungi are difficult to eradicate, aggressive treatment involves surgical debulking of the fungal plaque, removal of synthetic implants, and intravitreal antifungal agents. This case emphasizes the tenacity of Curvularia lunata endophthalmitis, the need for close postoperative follow-up, and the efficacy of intravitreal antifungals in controlling recrudescences. Key words: endophthalmitis, fungal infection, vitrectomy, cataract extraction, voriconazole.
References 1.
2.
3.
4.
5.
6.
7.
Kaushik S, Ram J, Chakrabarty A, et al. Curvularia lunata endophthalmitis with secondary keratitis. Am J Ophthlamol 2001;131:140 –142. Pathengay A, Shah GY, Das T, Sharma S. Curvularia lunata endophthalmitis presenting with a posterior capsular plaque. Indian J Ophthalmol 2006;54:65– 66. Rummelt V, Ruprecht KW, Boltze HJ, et al. Chronic alternaria alternate endophthalmitis following intraocular lens implantation. Arch Ophthalmol 1991;109:178. Holting-Lima AL, Freitas D, Fischman O. Exophialia jeansemei causing late endophthalmitis after cataract surgery. Am J Ophthalmol 1999;128:512–514. Guarro J, Akiti T, Almada-Horta R, et al. Mycotic keratitis due to Curvularia senegalensis and in vitro antifungal susceptibilities of Curvularia species. J Clin Microbiol 1999;37:4170 – 4173. Hariprasad SM, Mieler WF, Holz ER, et al. Determination of vitreous, aqueous, and plasma concentration of orally administered voriconazole in humans. Arch Ophthalmol 2004;122: 42– 47. Hariprasad SM, Mieler WF, Lin TK, Sponsel WE, Graybill JR. Voriconazole in the treatment of fungal eye infections: a review of current literature. Br J Ophthalmol 2008;92:871– 878.
