Intraocular mycoses: causes, symptoms, diagnosis, treatment

The introduction of fungi into the eyeball cavity during penetrating wounds, perforating corneal ulcers or hematogenous penetration is fraught with severe intraocular inflammations, often ending in the death of the eye. An unfavorable outcome is predetermined not only by the reaction of the eye to the pathogen, but also by far from always timely recognition of the fungal etiology of the disease. The diagnosis of these, fortunately rare processes is complicated, on the one hand, by the absence of signs in their clinical picture that would clearly indicate mycosis, and on the other hand, by the low availability of substrates for the most conclusive mycological and other studies. Doctors are reluctant to perform the punctures of the anterior chamber of the eye required for this; often patients do not agree to this, especially at the onset of the disease. The tissues of the vascular tract and retina are subjected to histological examination only after enucleation of the eyes. Based on the clinical manifestations of the disease and a general examination, intraocular mycosis can only be suspected.

Of the numerous fungi pathogenic to humans, intraocular lesions are most often caused by Candida albicans, smoky and black aspergillus, sporotrichon, cephalosporium, etc. The disease can manifest itself as anterior uveitis, choroiditis, retinitis, but fungal panuveitis and endophthalmitis seem to develop more often. Data on the latter predominate in the literature devoted to intraocular mycoses.

Mycotic anterior uveitis and panuveitis may be granulomatous and nongranulomatous, develop either acutely, with pronounced irritation of the eye, high hypopyon, extensive synechiae, secondary glaucoma, or from the very beginning acquire a sluggish, chronic character. In the latter case, in some patients, large white precipitates with dark dots in the center can be detected biomicroscopically, and when examined with a slit lamp at high magnification of the microscope, a dense interweaving of brown threads, somewhat reminiscent of moss, can sometimes be seen in the moisture of the anterior chamber of the eye.

Uveitis with a thick viscous hypopyon covering 1/2-2/3 and the entire anterior chamber is also highly suspicious of fungal infection, with moderate eye irritation and the hypopyon possibly having a brownish tint. However, the manifestations of fungal anterior uveitis (precipitates, granulomas, synechiae, hypopyop) are more often than not indistinguishable from those of bacterial and other processes. In such cases, the only criterion is the resistance of the disease to antibacterial or antiviral therapy. Unfortunately, it takes time to identify this essential differential diagnostic feature. While the patient is receiving the most common antibiotics or sulfonamides, especially in combination with corticosteroids, the disease may spread deep into the eye, thereby worsening the prospects for fungicidal therapy.

Mycotic panuveitis, in addition to changes in the anterior vascular tract, is manifested by pronounced pathology of the choroid, in which the retina and vitreous body are also involved. While the optical media are transparent, flocculent foci are detected ophthalmoscopically in the fundus. According to some authors, they are round, white, scattered throughout the fundus, according to observations of others - hemorrhagic, but with a white center, located near the optic disc and in the macula, and along with them, small cotton-like foci protruding into the vitreous body appear on the periphery, with Candida albicans detected during histological examination. Reflecting only chorioretinal changes in hematogenous introduction of pathogens, such foci can be detected in patients without signs of anterior uveitis. Subsequently, they scar, leaving pigmented foci. However, more often the intensity of the foci increases, the vitreous body begins to quickly become cloudy and the process takes on the character of torpid endophthalmitis.

Whitish color of vitreous opacities, which also form lumps, is suspicious for mycosis. Subsequently, perforation of the outer membranes of the eye may occur and phthisis of the eyeball that was not removed for some reason may occur. In addition to ophthalmoscopic data, the detection of general damage to the body by fungi has a certain value in the clinical diagnosis of intraocular mycoses. Without a penetrating wound, purulent perforation of the membranes or abdominal surgery, fungi can enter the eye only with blood or lymph from a focus located outside the eye. Mycotic panuveitis or endophthalmitis are often one of the manifestations of mycosepsis or prior to impingement into the eye from internal organs.

By sowing blood, urine, sputum on appropriate media, targeted examination of the liver, lungs, gastrointestinal tract, genitals, serological tests and reactions with fungal antigens, important data for the ophthalmologist can be obtained. First of all, such a study is indicated for patients in whom intraocular inflammation developed after abdominal or thoracic surgery, with liver diseases, diseases of the digestive organs, genitals, etc. resistant to conventional therapy, as well as people who have received antibiotics, corticosteroids or both for a long time due to some pathology.

Exudate in the vitreous body that appears and intensifies against the background of more or less pronounced irritation of the eye serves as an indication for urgent puncture for the purpose of bacteriological and mycological examination, although the absence of fungi in the vitreous body does not always allow me to deny mycosis. All ocular substrates obtained during the treatment of intraocular inflammations, as well as enucleated eyes and evisceration masses, are subject to examination for fungi. In the latter cases, this is necessary to exclude a disseminated process.

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Treatment of intraocular mycoses

Treatment of intraocular mycoses is still being developed. Insufficient effectiveness of antifungal drugs used parenterally, orally and locally justifies attempts to introduce them into the vitreous body, a combination of antifungals with vitrectomy, etc. An indispensable condition for a positive result of any treatment is its use at the onset of the disease, since a delay in prescribing leaves only one possibility of radical help to the patient - removal of the eye affected by fungi.