Review ENDOGENOUS FUNGAL ENDOPHTHALMITIS Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Seoul, Korea. R3 SY Kim/ Ap.KS Kim Immunocompromised patient 에서 chorioretinal lesion 이 나타났을때에 대해 발표하겠습니다.

환자 호소 증상 더 정확하게 쓰기..전신증상 & hip 아픈것 쓰기.

ENDOGENOUS FUNGAL ENDOPHTHALMITIS Pathophysiology Differential diagnoses & Work up Treatment & Medication Follw-up 환자 호소 증상 더 정확하게 쓰기..전신증상 & hip 아픈것 쓰기.

ENDOGENOUS ENDOPHTHALMITIS Fundus : 50-62% Gram positive : 33% Gram negative : 5%

ENDOGENOUS FUNGAL ENDOPHTHALMITIS Immunosuppression Intravenous drug abuse Bacterial sepsis Prolonged hyperalimentation Systemic antibiotics, Corticosteroid therapy Recent abdominal surgery Malignancy, Alcoholism Diabetes mellitus Hemodialysis RISK FACTOR Intraocular dissemination of a systemic fungal infection Candida app. (m/c, 70-80%) Aspergilus app. Cryptococcus neoformans Coccidioides immitis cf.) Exogenous infection : Paecilomyces, Acremonium, Sporothrix But not essential

Creamy-white abscess PATHOPHYSIOLOGY Bloodstream Choroid penetrate through Bruch’s membrane form subretinal abscesses spreads to the retina and vitreous iridocyclitis = Chornioretinitis Endophthalmitis Fungal endophthalmitis 의 retinal finding 은 종류와 관계없이 비슷하다 Creamy-white abscess 생긴것 사진그림넣기

a white, circumscribed lesion, less than 1 mm in diameter PATHOPHYSIOLOGY a white, circumscribed lesion, less than 1 mm in diameter associated Hm OUR CASE the dense fluffy localized infiltrate is characteristic Candida

PATHOPHYSIOLOGY Miliary choroiditis 생긴것 사진그림넣기 Aspergilosis

PATHOPHYSIOLOGY Associated with AIDS 생긴것 사진그림넣기 Cryptococcus

PATHOPHYSIOLOGY severe endophthalmitis. extensive, confluent exudative lesions In most cases, eyes have been enucleated or patients have died. 생긴것 사진그림넣기 Tuberculosis

PATHOPHYSIOLOGY OUR CASE Fulminant / edematous variant : marked edema retinal whitening severe retinal hemorrhage vascular sheathing Classic CMV retinitis extending along inferotemporal arcade. Note the white area of inflammation with associated hemorrhage and satellite lesions at advancing border. CMV retinitis

PATHOPHYSIOLOGY well-circumscribed area of retinochoroidal edema Parasite : Toxoplasma gondii retinochoroiditis. Notice the well-circumscribed area of retinochoroidal edema Toxoplasma gondi

VITEOUS SAMPLE Aspergillic Ag/Ab Candida Ag/Ab Cryptococcus Ag Toxoplasma DNA PCR Toxocariosis IgG Treponema pallidum PCR HSV type I PCR 　 VZV PCR CMV PCR Gram stain and culture for bacteria and fungus M. Tuberculosis PCR

Differential diagnoses & Work up Revised diagnosis AC para centesis 사진 넣고,, Fd 나빠진 사진 & OCT 넣기

Differential diagnoses & Work up Blood cultures, urine cultures, sputum cultures, and cerebrospinal fluid (CSF), any site of inflammation Vitrectomy samples ?? Anterior chamber (AC) ? specimens are unreliable in the diagnosis of Candida species. PCR & CULTURE ? 임상적으로 진단하며 확진은 매우 어렵다. AC para centesis 사진 넣고,, Fd 나빠진 사진 & OCT 넣기

Aqueous VS Vitreous AC paracentesis Vitrectomy Logo Vitrectomy 는 Accurate, Less invasive, Fewer complication Less invasive, Fewer complication But small volume of sample Vitrectomy 3 2 Large volume of sample Increase VA because of the elimination of cloudy media Pathologic exam for malignancy Invasive & Higher costs Complication (RD & hypotony) 1 1 text 2 Logo 4 3 5 Vitrectomy 는 염증이 유리체로 확산되고 시력저하가 심할때만 !!!

Differential diagnoses & Work up 유리체의 Culture 배양 결과가 나와야 확진할 수 있으나 망막에 국한 되어 있을 경우에는 culture positive 나올 가능성이 희박하다. 그래서 Fungal infection 의 양상만으로 진단이 가능하기 때문에 배양결과가 나오지 않더라도 일반적으로 즉시 antifungal treatment 를 시행하는 것이 인정된다. AC para centesis 사진 넣고,, Fd 나빠진 사진 & OCT 넣기

Treatment Systemic Antifungal Tx 스테로이드는 일시적으로만 효과있을 뿐 더 악화시키므로 금기 1. Amphotericin B : Test dose 가 필요함. 1 mg of drug in 20 ml of 5% dextrose in water, infused intravenously over 20 to 30 min, 0.7 ~1.0mg/kg of drug in 500 ml of 5% dextrose in water over 2 to 6 h. Total daily dosage rarely exceeds 40 to 50 mg of drug. The most serious side-effect is decreased renal function; (80% of patients develop azotemia.) 유리체로 침투를 잘 못함 intravitreous injection of the drug is used for treatment of some patients. A single intravitreous injection of 5 μg of amphotericin B may cure candidal chorioretinitis 2. Fluconazole, : 안구내 농도가 혈장의 70%, 침투력이 크다 3. Voriconazole : 매우 효과적이나 little experience Flucytosine AC para centesis 사진 넣고,, Fd 나빠진 사진 & OCT 넣기

ENDOGENOUS CANDIDA ENDOPTHALMITIS Frequency 75-80% of endogenous fungal endophthalmitis 28-39% of systemic candidiasis 78-100% have systemic candidiasis 9-45% of candidemia without antifungal therapy 1-3% of candidemia with antifungal treatment Bilateral involvement : 2/3 of cases Metastasis through choroid retina vitreous Yellow – white choroidal lesion Single or multiple Varialbe size Indistinct border, surrounded by retinal hemorrhages 생긴것 사진그림넣기

ENDOGENOUS CANDIDA ENDOPTHALMITIS 생긴것 사진그림넣기

ENDOGENOUS CANDIDA ENDOPTHALMITIS Diagnostic tools Cliical suspicion and examination : most important Intraocular culture difficult at AC aspiration & Random vitreous tap Systemic culture Blood, urine, any infected site >> frequently negative Serum antibodies to candida : Unreliable 생긴것 사진그림넣기

ENDOGENOUS CANDIDA ENDOPTHALMITIS Treatment ID consult : evaluation for systemic disease Systemic medication : focal chorioretinal lesion Intravenous amphotericin B Broad spectrum coverage Poor vitreous penetration Numerous side effects(35-50%) : nephrotoxic Oral fluconazole Penetrates CSF Fewer systemic side effects Lack broad spectrum coverage Oral voriconazole & caspofungin – new classes Intravitreal amphotericin B – extension of lesions into vitreous Vitrectomy Insufficient clinical improvement Large lesions near macula or causing retinal detachment 생긴것 사진그림넣기

REFERENCE s 생긴것 사진그림넣기