Endogenous fungal endophthalmitis is a well-recognized, vision-threatening disorder commonly seen in immunocompromised patients. One of the clinical findings of fungal endophthalmitis is a white, circumscribed region of chorioretinitis, called a focus, which often results in a hypopigmented scar even ifantifungal therapy is successful. We report a rare case of endogenous fungal endophthalmitis that led to a macular hole (MH).
A 53-year-old woman visited our clinic, requesting a second opinion on her treatment for fungal endophthalmitis following intravenous hyperalimentation after thyroid cancer surgery. Her best-corrected visual acuity was 20/20 with–7.0 diopter sphere (DS) OD, and 20/200 with –7.0 DS OS. Slitlamp examination revealed a mild inflammatory response in the vitreous of both eyes. Fundus examination showed a focus involving the macula and surrounding retinal hemorrhages in the left eye (Figure 1). Foci that did not involve the macula were present in the right eye. A Weiss ring was not present in either eye. According to the referral letter, her blood culture was positive for Candida albicans, and intravenous administration of fluconazole (200 mg/d) had already been given for approximately 4 weeks, which seemed to be effective. The patient was therefore advised to continue the treatment at the previous hospital.
A, Fundus photograph of the left eye at the initial visit showing a focus with surrounding hemorrhage. B, Fundus photograph of the left eye on the second visit showing a large macular hole that had developed at a previous site of a focus. C, Fundus photograph of the left eye at the second visit showing an operculum on the posterior vitreous surface. D, An optical coherence tomographic (OCT) image through the center of the macular hole, showing swollen edges on both sides, with a vertical diameter of 920 µm. E, Postoperative OCT images through the center of the macula showing flattened edges.
Five months after the initial visit, the patient again visited our clinic. She had noticed an increase of metamorphopsia around the central blind area, which began approximately 3 months previously. Her best-corrected visual acuity was 20/20 OD and 20/100 OS. No inflammatory response was observed in either eye. Fundus examination of the left eye showed a circular MH with a vertical diameter of 920 µm, a Weiss ring, and an operculum above the macula. Optical coherence tomography (OCT) showed that the edges of the MH were swollen(Figure 1).
To prevent further visual deterioration, a pars plana vitrectomy with internal limiting membrane removal and 12% perfluoropropane gas tamponade were performed on the left eye. Histopathologic examination of the operculum revealeda neurosensory retinal component and pigment-laden macrophages (Figure 2). After the surgery, a flattening of the MH edge was observed; however, the visual acuity remained unchanged.
A, Photomicrograph of the operculum. A cellular fragment composed of numerous round cells with a smooth inner surface(vitreous side) and an irregular and edematous outer surface is present. Pigment-containing cells are present in the operculum (bar = 50 µm) (original magnification×320). B, Transmission electron photograph of the operculum. Numerous neural cells, with round to oval heterochromatic nuclei measuring 5 to 7 µm in diameter, and some foci with degenerative changes, are present. Many cells have some elongated mitochondria, vesicles of smooth-surface endoplasmic reticulum, and a moderate amount of free ribosomes in their cytoplasm. Many neurotubules are aggregated around the nuclei of these cells (bar = 5 µm) (original magnification ×1500). The inset shows high magnification of the transmission electron micrograph of the operculum. A cross-section of a bundle of neurotubules 20 to 30 nm in diameter is shown (arrow) around the neural cells (bar = 500 nm) (original magnification ×17 000).
Vitreoretinal complications following fungal endophthalmitis include epiretinal membranes, 1 traction and/or rhegmatogenous retinal detachments, 1,2 and choroidal neovascularization.3 However, an MH secondary to fungal endophthalmitis seems to be very rare; only 1 case has been reported, to our knowledge.4 That patient was a 51-year-old woman who developed an MH adjacent to a focus but not at a preexisting focus as in our patient.
Although the mechanism of MH formation in our patient is unclear, the presence of a Weiss ring at the second visit and the existence of sensory retinal components in the operculum suggest that the sensory retina, including thefocus, was torn from the surrounding retina when a posterior vitreous detachment occurred. In addition to the high myopia and age of 53 years, vitreous inflammation may have facilitated the development of the posterior vitreous detachment. Ophthalmologists should be aware that, although rare, an MH can develop secondary to fungal endophthalmitis.
The authors have no relevant financial interest in this article.
This work was supported by Grant-in-Aid No. 03671836 for Scientific Research from the Japanese Ministry of Education, Science, and Culture, and a Grant for Research on Eye and Ear Science, Immunology, Allergy, and Organ Transplantation from the Ministry of Health and Welfare, Tokyo, Japan.
Corresponding author and reprints: Shunji Kusaka, MD, Division of Ophthalmology, Osaka Prefectural General Hospital, 3-1-56 Bandai-Higashi, Sumiyoshi, Osaka 558-0056, Japan (e-mail: firstname.lastname@example.org).
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