Fungal Endophthalmitis

Fungal endophthalmitis is an infection that affects the inside of the eye. In simple terms, it happens when tiny living organisms called fungi enter the clear fluids or soft tissues deep inside the eye. These fluids include the vitreous (the gel-like substance filling most of the eye) and the aqueous (the fluid in the front part of the eye). Once inside, the fungi can grow and spread, causing inflammation and damage to delicate eye structures. Because the eye has few defenses against fungus, the infection can worsen quickly if it is not found and treated early. Fungal endophthalmitis is less common than bacterial endophthalmitis, but it often takes longer to show signs and can be harder to cure. Doctors usually use both medicines (antifungal drugs) and surgery to control the infection and protect vision. PMCMedscape

Fungal endophthalmitis is a rare, pus-forming infection inside the eye caused by fungi invading the vitreous (the gel filling the eyeball) and/or aqueous (the fluid in front of the lens). It can arise when fungi enter during surgery or trauma (“exogenous”) or spread through the bloodstream from another infection site (“endogenous”) EyeWiki NCBI.

Types of Fungal Endophthalmitis

Fungal endophthalmitis is divided into two main types, based on how the fungus enters the eye.

Exogenous Fungal Endophthalmitis

In exogenous endophthalmitis, the fungus comes from outside the eye. This can occur after events that break the eye’s natural barrier, such as eye surgery, a wound, or a severe corneal infection. For example, people who have cataract surgery or corneal transplant may accidentally get fungal cells inside the eye during the procedure. Likewise, an injury with a sharp object can carry fungus deep into the eye. Symptoms of exogenous cases often appear weeks to months after the initial injury or surgery, and they may worsen slowly over time. PMC

Endogenous Fungal Endophthalmitis

Endogenous endophthalmitis starts inside the body and spreads to the eye through the bloodstream. When someone has a fungal infection elsewhere—like in the blood, heart, or lungs—fungal cells can travel to the eye. People with weakened immune systems, such as those with diabetes, cancer, or on long-term steroid therapy, are at higher risk. Endogenous fungal endophthalmitis often has a more gradual onset, with vision changes and mild discomfort that may not seem serious at first. EyeWiki

Yeast (Candida) Endophthalmitis

Yeasts are single-celled fungi. The most common yeast in these infections is Candida albicans. Yeast endophthalmitis usually occurs in people with a fungal bloodstream infection. It often starts as small, white spots in the back of the eye, known as “chorioretinal lesions.” Over days to weeks, the infection can spread deeper into the eye, causing more pain and vision loss. PMC

Mold (Aspergillus and Fusarium) Endophthalmitis

Molds are fungi that grow in long strands. The main molds causing eye infections are Aspergillus and Fusarium. Mold infections often happen after eye trauma or surgery, especially if a piece of plant material or soil gets into the eye. Mold endophthalmitis tends to progress faster and can cause severe vision loss quickly if not treated early. Mold infections often lead to dense clouding of the gel in the eye (vitritis) and may require urgent surgery. PMC

Causes of Fungal Endophthalmitis

Below are 20 common causes or risk factors that can lead to fungal endophthalmitis. Each cause is explained in simple terms.

1.  Cataract Surgery – When the natural lens of the eye is replaced, even a tiny fungal spore on surgical instruments can enter the eye and start an infection. PM
2. Intravitreal Injections – Medicines injected into the eye’s gel (vitreous) can introduce fungus if the injection site is not fully sterile. PMC
3. Corneal Transplant – Replacing a damaged cornea can carry fungal cells from the donor tissue into the eye if the tissue isn’t perfectly cleaned. PMC
4. Penetrating Eye Trauma – Any sharp object, like a stick or metal fragment, can carry mold spores into the eye when it pierces the eyeball. PMC
5. Endophthalmitis from Corneal Ulcers – Severe fungal keratitis (corneal infection) can spread deeper into the eye if not controlled, leading to endophthalmitis. PMC
6. Contaminated Intraocular Lenses – IOLs (artificial lenses) used in surgery can harbor fungus if not processed under strict cleanroom conditions. PMC
7. Intravenous Drug Use – Using non-sterile needles can lead to fungus in the bloodstream, which can then travel to the eye. EyeWiki
8. Central Venous Catheters – Long-term IV lines provide a route for fungal cells to enter the blood and reach the eye. EyeWiki
9. Total Parenteral Nutrition – Nutrition given by vein often requires a catheter that can become colonized by fungus. EyeWiki
10. Immunosuppressive Therapy – Medications like steroids or drugs for organ transplants weaken the body’s defense, making it easier for fungus to spread to the eye. EyeWiki
11. Diabetes Mellitus – High blood sugar damages small blood vessels and immune function, allowing fungal cells to enter and survive in the eye. EyeWiki
12. Cancer and Chemotherapy – Chemotherapy lowers white blood cell counts, reducing the body’s ability to fight off fungal infections that can seed the eye. EyeWiki
13. HIV/AIDS – Advanced HIV infection can let fungi like Candida grow unchecked in the blood, leading to eye involvement. EyeWiki
14. Chronic Kidney Disease – Dialysis and weakened immunity in kidney failure patients increase the risk of fungal cells entering the bloodstream and eye. EyeWiki
15. Prolonged Antibiotic Use – Long antibiotic courses can kill normal bacteria that keep fungal growth in check, allowing fungus to overgrow and spread. EyeWiki
16. Organ Transplants – Transplant patients take strong drugs to prevent rejection, which also lower their ability to fight fungal infections. EyeWiki
17. Neutropenia – Low neutrophil counts (a type of white blood cell) make it easy for fungal cells to multiply in the blood and reach the eye. EyeWiki
18. Chronic Lung Disease – Fungal lung infections can spread through the blood to the eye in patients with diseases like COPD or bronchiectasis. EyeWiki
19.  Malnutrition – Poor nutrition weakens immune defenses, giving fungi a chance to invade the bloodstream and eye. EyeWiki
20. Prolonged Hospital Stay in ICU – Long stays in intensive care, often with multiple lines and devices, increase exposure to hospital fungi and risk of bloodstream spread. EyeWiki

Symptoms

Patients with fungal endophthalmitis often present with a combination of the following symptoms:

1. Severe Eye Pain: Deep, throbbing ocular discomfort.

2. Decreased Vision: Blurred or hazy sight progressing to floaters.

3. Redness: Conjunctival injection and scleral inflammation.

4. Photophobia: Sensitivity to bright light.

5. Tearing: Excessive lacrimation.

6. Eyelid Swelling: Periorbital edema and erythema.

7. Hypopyon: Layering of white cells in the anterior chamber.

8. Corneal Opacity: White infiltrates visible on slit-lamp exam.

9. Vitreous Opacities: “Snowballs” of inflammatory debris in the vitreous.

10. Floaters: Moving spots due to vitreous inflammation.

11. Pupil Irregularity: Anterior chamber inflammation distorting pupil shape.

12. Eye Discharge: Mucopurulent secretions.

13. Pain with Eye Movement: Extraocular muscle involvement.

14. Decreased Red-Light Reflex: Due to dense vitreous exudates.

15. Elevated Intraocular Pressure: Secondary glaucoma from inflammatory debris Cleveland Clinic.

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Diagnostic Tests

Physical Examination

1. Visual Acuity Testing: Measures the degree of vision loss.

2. External Inspection: Assesses lid swelling, conjunctival injection.

3. Pupillary Response: Checks for afferent defects.

Manual Tests

4. Slit-Lamp Biomicroscopy: Visualizes anterior chamber cells, keratic precipitates.

5. Indirect Ophthalmoscopy: Examines the vitreous and retina.

6. Indirect Gonioscopy: Evaluates the angle for inflammatory debris.

Laboratory and Pathological Tests

7. Vitreous Tap and Culture: Gold standard for identifying fungal species PubMed.

8. Aqueous Humor Culture: Complements vitreous sampling.

9. Blood Cultures: Detect systemic fungemia in endogenous cases.

10. PCR for Fungal DNA: Rapid identification of fungal pathogens.

11. Cytology of Intraocular Fluid: Identifies inflammatory cell types.

Electrodiagnostic Tests

12. Electroretinography (ERG): Assesses retinal function affected by inflammation.

13. Electrooculography (EOG): Evaluates retinal pigment epithelium health.

Imaging Tests

14. B-Scan Ultrasonography: Visualizes vitreous opacities and retinal detachment Cleveland Clinic.

15. Optical Coherence Tomography (OCT): Shows macular edema and vitritis.

16. Fluorescein Angiography: Detects retinal vascular leakage.

17. MRI of the Orbit: Rules out orbital cellulitis.

18. CT Scan of the Head/Orbits: Identifies extension beyond the globe.

19. Ultrasound Biomicroscopy: High-resolution anterior segment imaging.

20. PET-CT (Selected Cases): Evaluates systemic infection foci in endogenous disease.

Non-Pharmacological Treatments

While surgery and antifungal drugs are central to managing fungal endophthalmitis, these 20 supportive measures can help reduce inflammation, ease discomfort, and support healing NCBI:

1. Ocular rest: Keep eyes closed or under a shield to minimize movement and strain on inflamed tissues. NCBI

2. Head elevation: Sleeping propped up on pillows lowers intraocular pressure and aids fluid drainage. NCBI

3. Protective eye shield: Worn continuously to prevent accidental rubbing or trauma. NCBI

4. Cold compresses: Applied briefly to reduce pain and swelling via vasoconstriction. NCBI

5. Warm compresses: Alternated with cold to improve local blood flow and immune cell delivery. NCBI

6. Darkened room: Minimizes light sensitivity (photophobia) and eye strain. NCBI

7. Humidity control: Using a humidifier prevents dryness and irritation of ocular surfaces. NCBI

8. Avoid eye rubbing: Prevents mechanical spread of infection and further inflammation. NCBI

9. Ocular hygiene: Gently cleanse eyelids with sterile saline to remove debris. NCBI

10. UV-blocking eyewear: Shields against ultraviolet light, reducing oxidative stress. NCBI

11. Stress reduction: Practices like deep breathing or meditation support immune function. NCBI

12. Adequate sleep: Enhances overall immunity and tissue repair. NCBI

13. Hydration: Drinking sufficient water maintains body-wide circulatory health. NCBI

14. Environmental control: Avoid dusty, smoky, or allergen-rich areas to reduce ocular irritation. NCBI

15. Occupational therapy: Guidance on adapting daily tasks safely with impaired vision. NCBI

16. Visual rehabilitation exercises: Gentle focus exercises to maintain eye-muscle coordination. NCBI

17. Nutrition counseling: Ensures dietary support for healing (see section on supplements). NCBI

18. Glycemic control: For diabetics, tight blood sugar management bolsters immune response. EyeWiki

19. Pain management coaching: Techniques like guided imagery to reduce perceived discomfort. NCBI

20. Follow-up monitoring: Scheduled exams to catch complications early. EyeWiki

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Drug Treatments

1. Intravitreal Voriconazole

   • Class: Triazole antifungal

   • Dosage: 100 µg in 0.1 mL saline per injection, repeated every 48–72 hours as needed

   • Purpose: Eradicate fungal organisms in the vitreous

   • Mechanism: Inhibits 14α-sterol demethylase, blocking ergosterol synthesis

   • Side Effects: Potential retinal toxicity at high concentrations PubMedMDPI

2. Intravitreal Amphotericin B

   • Class: Polyene antifungal

   • Dosage: 5–10 µg in 0.1 mL intravitreally, often combined with systemic therapy

   • Purpose: Broad-spectrum fungal kill

   • Mechanism: Binds ergosterol in fungal membranes, forming lethal pores

   • Side Effects: Retinal inflammation, toxicity at higher doses Drugs.comIOVS

3. Systemic Voriconazole

   • Class: Triazole antifungal

   • Dosage: Loading 400 mg BID × 2 doses, then 200 mg BID orally or 300 mg IV daily

   • Purpose: Treat concurrent systemic infection and ocular spread

   • Mechanism: Same as intravitreal

   • Side Effects: Visual disturbances, liver enzyme elevation MDPIPMC

4. Amphotericin B Deoxycholate

   • Class: Polyene antifungal

   • Dosage: 0.7–1 mg/kg IV daily; max 1.5 mg/kg

   • Purpose: Severe systemic fungemia

   • Mechanism: Binds ergosterol, disrupts fungal membranes

   • Side Effects: Nephrotoxicity, infusion reactions MedscapeNCBI

5. Flucytosine

   • Class: Pyrimidine analog

   • Dosage: 25 mg/kg orally QID for 4–6 weeks

   • Purpose: Synergistic partner to amphotericin B

   • Mechanism: Converted to 5-FU in fungi, halting DNA/protein synthesis

   • Side Effects: Bone marrow suppression, GI upset Medscape

6. Liposomal Amphotericin B

   • Class: Polyene lipid formulation

   • Dosage: 3–5 mg/kg IV daily

   • Purpose: Lower nephrotoxicity than conventional form

   • Mechanism: Same as amphotericin B

   • Side Effects: Infusion reactions, less renal impact NCBI

7. Intravitreal Fluconazole

   • Class: Triazole antifungal

   • Dosage: 0.1% solution, 0.2–0.3 mL every 2 weeks × 4 injections

   • Purpose: Alternative for fluconazole-sensitive fungi

   • Mechanism: Ergosterol synthesis inhibition

   • Side Effects: Lower toxicity than amphotericin, risk of resistance Journal MC

8. Intravitreal Caspofungin

   • Class: Echinocandin

   • Dosage: 50–250 µg in 0.1 mL intravitreal, repeat as needed

   • Purpose: Treat echinocandin-sensitive fungal strains

   • Mechanism: Inhibits β-(1,3)-D-glucan synthesis in cell wall

   • Side Effects: Ocular irritation; limited data SciELO

9. Systemic Micafungin

   • Class: Echinocandin

   • Dosage: 100 mg IV daily

   • Purpose: Systemic candidemia; poor vitreous penetration so adjunctive

   • Mechanism: Same as caspofungin

   • Side Effects: Hepatotoxicity, infusion reactions MDPI

10. Posaconazole

    • Class: Triazole antifungal

    • Dosage: 500–600 mg orally daily

    • Purpose: Salvage therapy for resistant cases

    • Mechanism: Ergosterol synthesis inhibition

    • Side Effects: GI upset, liver enzyme elevation PMC

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Dietary Molecular Supplements

1. Vitamin C (500–1,000 mg daily): Antioxidant that supports collagen and immune cells. Health

2. Vitamin D (1,000–2,000 IU daily): Modulates macrophage and T-cell function. Health

3. Zinc (15–30 mg daily): Essential for immune enzyme function. Health

4. Selenium (100–200 µg daily): Cofactor for glutathione peroxidase, reduces oxidative stress. Health

5. Omega-3 Fatty Acids (1 g fish oil daily): Anti-inflammatory by modulating eicosanoid synthesis. Health

6. Probiotics (≥10 billion CFU Lactobacillus daily): Supports gut-immune axis. Healthline

7. Curcumin (500 mg BID): Inhibits NF-κB, reducing inflammatory cytokines. Healthline

8. Quercetin (500 mg daily): Antioxidant, stabilizes mast cells. Health

9. Lactoferrin (200 mg daily): Binds iron, starving fungi of a key nutrient. Healthline

10. Beta-Glucans (250 mg daily): Stimulates macrophage and neutrophil activity. Health

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Immunomodulatory & Regenerative Agents

1. Interferon-γ (50 µg IM thrice weekly): Boosts macrophage and T-cell activation. UpToDate

2. Filgrastim (G-CSF) 5 µg/kg SC daily: Increases neutrophil counts. NCBI

3. Sargramostim (GM-CSF) 250 µg/m² SC daily: Stimulates granulocyte/macrophage precursors. NCBI

4. Thymosin α-1 1.6 mg SC twice weekly: Enhances T-cell differentiation. NCBI

5. Interleukin-7 10 µg/kg SC weekly: Promotes lymphocyte proliferation. NCBI

6. Platelet-Rich Plasma (PRP) Injections: Delivers growth factors to support tissue repair (protocols vary; under investigation). NCBI

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Surgical Procedures

1. Pars Plana Vitrectomy: Removal of infected vitreous to reduce fungal load and inflammatory debris EyeWiki

2. Anterior Chamber Washout & Granuloma Debulking: Clears inflammatory masses blocking vision EyeWiki

3. Intraocular Lens (IOL) Explantation: Removes infected lens implant when involved Wikipedia

4. Enucleation: Complete removal of the eyeball in refractory, painful, or life-threatening cases EyeWiki

5. Evisceration: Removal of internal eye contents with scleral shell preservation, for intractable infection Wikipedia

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Prevention

1. Preoperative Povidone-Iodine 5%: Apply to conjunctival sac and periocular skin for ≥3 minutes; cuts endophthalmitis risk by ~75% PubMedCRSToday

2. Chlorhexidine 0.05% (if iodine-allergic): Equivalent antisepsis alternative CRSToday

3. Strict Instrument Sterilization: Autoclave all surgical instruments per AAO standards ESCRS

4. Disposable Cannulas & Gloves: Single-use items reduce cross-contamination ESCRS

5. Minimize OR Traffic: Less door-opening lowers airborne contaminants ESCRS

6. Intracameral Antibiotics: Cefuroxime or moxifloxacin at surgery close can reduce bacterial endophthalmitis risk; fungal prophylaxis not routinely recommended ESCRS

7. Preoperative Topical Antibiotics: Fourth-gen fluoroquinolones 1 day before surgery (where practiced) Lippincott Journals

8. Glycemic Control in Diabetics: Tight blood sugar (<180 mg/dL) optimizes immune response EyeWiki

9. Remove Indwelling Lines Promptly: Limits sources of fungemia EyeWiki

10. Early Detection of Systemic Fungemia: Blood cultures and prompt antifungal therapy prevent seeding EyeWiki

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When to See a Doctor

Seek immediate ophthalmic evaluation if you experience:

• Sudden or worsening vision loss

• Severe eye pain or pressure

• Intense redness around the eye

• Floaters or flashes of light

• Discharge or reduced eye movement EyeWiki Wikipedia

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Diet: What to Eat & What to Avoid

Eat:

• Antioxidant-rich fruits and vegetables (e.g., citrus, berries, leafy greens) to support immune cells Health

• Lean proteins (chicken, fish) for tissue repair Health

• Probiotic foods (yogurt, kefir) for gut-immune balance Healthline

• Healthy fats (olive oil, walnuts) to reduce inflammation Health

• Spices (garlic, turmeric) with natural antifungal properties Healthline

Avoid:

• Added sugars and refined carbs (white bread, sweets) that fuel fungal growth Healthline

• Alcohol and caffeinated beverages that impair immunity Healthline

• Processed foods high in trans fats and salt PMC

• Moldy or fermented foods (aged cheeses, dried fruits) that may harbor spores Medical News Today

• Excess dairy (may contribute to mucus production) Healthline

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Frequently Asked Questions

1. What exactly is fungal endophthalmitis?
   A severe, pus-forming infection inside the eye caused by fungi in the vitreous or aqueous, often leading to pain and vision loss EyeWiki.

2. Which fungi most commonly cause it?
   Candida albicans (yeast) endogenously and Aspergillus spp. (mold) exogenously are the top culprits EyeWiki.

3. How do I know if I have it?
   Look for gradual vision loss, floaters, redness, and pain; a dilated eye exam and fluid cultures confirm the diagnosis EyeWiki.

4. What tests are done?
   Blood cultures, aqueous/vitreous tap for fungal cultures and PCR, and B-scan ultrasound if the view is hazy EyeWiki.

5. How long does treatment take?
   Systemic antifungals typically run for ≥ 6 weeks; intravitreal injections may repeat over days to weeks SpringerOpen.

6. Can I recover vision?
   Prognosis is poor if treatment is delayed; timely therapy can salvage some vision but scarring often limits full recovery EyeWiki.

7. Why is surgery needed?
   Vitrectomy clears infected debris, reduces organism load, and improves drug penetration EyeWiki.

8. Are there side effects of antifungals?
   Amphotericin B can cause kidney injury; voriconazole may affect liver enzymes and cause visual changes NCBI.

9. Can it come back after treatment?
   Recurrence is possible if systemic sources aren’t cleared or treatment is incomplete Invalid URL.

10. Is it contagious?
    No—spread is internal or via contaminated surgical equipment, not person-to-person EyeWiki.

11. What if I have diabetes?
    Tight blood sugar control is vital; high glucose impairs white blood cell function EyeWiki.

12. Can steroids be used?
    Steroids may reduce inflammation but risk worsening infection and are used very cautiously NCBI.

13. Do I need to avoid strenuous activity?
    Yes—heavy lifting or bending can raise eye pressure and exacerbate inflammation NCBI.

14. Is follow-up necessary?
    Frequent monitoring in the first week post-treatment is critical to ensure response EyeWiki.

15. What questions should I ask my doctor?
    Ask about the specific fungus, treatment duration, side effects to watch for, and visual rehabilitation options EyeWiki.

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Last Updated: August 04, 2025.

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