Sara Fatima Memon¹

1: University Hospitals Dorset NHS Foundation Trust

Introduction

The Infectious Diseases Society of America (IDSA) recommends ophthalmic examinations for all culture positive candidemia patients, acknowledging the risk of candida endophthalmitis (1). However, recent trends have shown a decline in ocular candida involvement, with rates as low as 1%. The Royal College of Ophthalmologists (RCOphth) therefore suggests a more selective, risk-based approach to referrals, considering factors such as whether the patient reports ocular symptoms, overall prognosis, microbiology results, and ocular penetrance of the chosen antifungal agent (2). As a result of a discrepancy in guidelines, the decision often falls to ward doctors whether or not to make a referral, who may lack specific expertise in this area.

Whilst endogenous endophthalmitis may be a rare complication, it can be sight threatening. The recommendation by IDSA is rooted in the variable and sometimes subtle symptomatology associated with the infection, making it difficult to identify ocular involvement without thorough examination. However, much guidance is based on historical studies that reported higher prevalence rates of ocular candidiasis as high as 28%, particularly in the U.S. population (3,4). Earlier studies often included non-specific signs such as Roth spots and cotton wool spots in their diagnostic criteria, which are not exclusively indicative of ocular candidiasis (4,5)Over time, there seems to be a general decline in the incidence of ocular candida. The reasons for this could include increased awareness and prompt treatment of candida infection, and new generation antifungal agents with improved intraocular bioavailability (6). One must also consider the high morbidity and mortality associated with candidemia, meaning the immediate management of the critically unwell patient takes priority over a formal ophthalmology referral (7).
Due to the apparent low prevalence of treatable intraocular disease in patients with candidemia, the RCOphth recommends a case-by-case approach for screening, focusing on only patients with symptoms, abnormal eye appearance, or those unable to report symptoms. As a result, a joint guideline was published between the RCOPhth and the Intensive Care Society, stating that because patients in ICU may be non-verbal, fundoscopy screening should be performed on all ICU patients with positive-fungal cultures (2). The RCOphth also advises to consider patient risk factors and their general prognosis, whilst also collaborating with microbiologists to ensure the use of antifungals with adequate ocular penetration (2).

El-Abiary et al. carried out an audit over two years in a trust that routinely screened all candidemia patients for ocular involvement (8). The authors reviewed the cases of 168 adult patients with candida positive blood cultures, focusing on their subsequent referral to ophthalmology and the findings of fundoscopic examinations, and found the prevalence of ocular candidiasis to be very low (1.3%). The authors supported a more targeted approach, aligning with the recommendations from RCOphth (2,8). Gluck et al. carried out a retrospective observational study in all ICU patients who were blood culture positive for candida infection and found that signs of ocular candidiasis were only present in one (2.9%) patient, who required an increased duration of treatment. The authors therefore suggested that whilst the prevalence may be low, routine ophthalmic examination could still be indicated as treatment regimens may be altered when diagnosed (9).

In conclusion, hospitals should conduct internal audits to track referrals of candidaemia patients to ophthalmology. This data can inform the development of trust-specific guidance, incorporating a risk factor-based scoring system to aid referral decisions. It’s crucial to equip junior doctors with this guidance as a safety net, including standardized questions on visual symptoms to ask patients, and guidance for assessing visual acuity. Such a system will enable accurate patient risk stratification, aid junior doctors in making informed decisions, and reduce unnecessary referrals.

References

1. Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am. 2016 Feb 15;62(4):e1-50.
2. Eye Care in the Intensive Care Unit (ICU) [Internet]. The Royal College of Ophthalmologists. [cited 2023 Dec 27]. Available from: https://www.rcophth.ac.uk/resources-listing/eye-care-in-the-intensive-care-unit-icu/
3. Vinikoor MJ, Zoghby J, Cohen KL, Tucker JD. Do all candidemic patients need an ophthalmic examination? Int J Infect Dis. 2013 Mar 1;17(3):e146–8.
4. Brooks RG. Prospective study of Candida endophthalmitis in hospitalized patients with candidemia. Arch Intern Med. 1989 Oct;149(10):2226–8.
5. Edwards JE, Foos RY, Montgomerie JZ, Guze LB. Ocular manifestations of Candida septicemia: review of seventy-six cases of hematogenous Candida endophthalmitis. Medicine (Baltimore). 1974 Jan;53(1):47–75.
6. Khan FA, Slain D, Khakoo RA. Candida endophthalmitis: focus on current and future antifungal treatment options. Pharmacotherapy. 2007 Dec;27(12):1711–21.
7. Zaoutis TE, Argon J, Chu J, Berlin JA, Walsh TJ, Feudtner C. The epidemiology and attributable outcomes of candidemia in adults and children hospitalized in the United States: a propensity analysis. Clin Infect Dis Off Publ Infect Dis Soc Am. 2005 Nov 1;41(9):1232–9.
8. El-Abiary M, Jones B, Williams G, Lockington D. Fundoscopy screening for intraocular candida in patients with positive blood cultures—is it justified? Eye. 2018 Nov;32(11):1697–702.
9. Gluck S, Headdon WG, Tang DWS, Bastian IB, Goggin MJ, Deane AM. The Incidence of Ocular Candidiasis and Evaluation of Routine Ophthalmic Examination in Critically Ill Patients with Candidaemia. Anaesth Intensive Care. 2015 Nov 1;43(6):693–7.