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Original Investigation
June 2017

An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England

Author Affiliations
  • 1New England Eye Center, Department of Vitreoretinal Surgery, Tufts University School of Medicine, Boston, Massachusetts
JAMA Ophthalmol. 2017;135(6):534-540. doi:10.1001/jamaophthalmol.2017.0650
Key Points

Question  What are the clinical features of patients presenting with intravenous drug abuse–related endogenous fungal endophthalmitis during the height of New England’s opioid crisis?

Findings  Medical record review revealed 10 patients treated for intravenous drug abuse–related endogenous fungal endophthalmitis at New England Eye Center from May 2014 to May 2016. All patients were ambulatory at presentation, and 90% had isolated ocular symptoms without systemic signs of infection.

Meaning  Patients with intravenous drug abuse–related endogenous fungal endophthalmitis are typically systemically well on presentation, thus requiring health care professionals to maintain a high index of suspicion to facilitate timely diagnosis and initiation of treatment.


Importance  Intravenous drug abuse (IVDA) is a known risk factor for endogenous fungal endophthalmitis (EFE), a severe intraocular infection caused by hematogenous seeding of mycotic organisms to the eye. Reporting significant increases in heroin-related deaths since 2014, the New England region is in the midst of an opioid crisis that has led to a substantial increase in patients at risk for this vision-threatening disease.

Objective  To present an update on characteristics, management, and visual outcomes in patients with EFE.

Design, Setting, and Participants  Medical records review was initiated on July 1, 2016, evaluating all patients with EFE referred to New England Eye Center at Tufts Medical Center, a tertiary care ophthalmology practice distributed throughout Massachusetts, from May 1, 2014, to May 1, 2016. Patients with a history of IVDA and culture-proven or clinical evidence of fungal endophthalmitis were included.

Exposures  Intravenous drug use.

Main Outcomes and Measures  Patient demographics, comorbidities, presenting symptoms and vision, vitreoretinal findings, treatment regimens, culture data, and final visual acuities.

Results  Ten patients (5 women) with IVDA-related EFE were identified between May 1, 2014, and May 1, 2016—an increase from 3 patients treated from May 2012 to April 2014. The mean (SD) patient age was 34 (11) years (range, 24-60 years). Presenting visual acuities ranged from 20/25 to hand motion. The most common presenting symptoms were floaters (n = 8), reduced vision (n = 6), and pain (n = 5). Initial treatment included systemic antifungals in all patients and intravitreal antifungals in 9 eyes. Five patients required pars plana vitrectomy for worsening vitritis. The most commonly isolated pathogen was Candida albicans in 20% of the patients. Final visual acuity ranged from 20/40 to 20/300.

Conclusions and Relevance  The data provided in this report suggest that EFE represents severe end organ damage associated with IVDA and portends poor visual outcomes. Health care professionals must maintain a high suspicion for EFE, as patients are typically ambulatory on presentation without systemic signs of infection.