Expedited Publication, Original Article

Endogenous fungal endophthalmitis following intensive corticosteroid

therapy in severe COVID‑19 disease

Daraius Shroff, Ritesh Narula1, Neelam Atri, Arindam Chakravarti1, Arpan Gandhi2, Neelam Sapra3,
Gagan Bhatia, Shraddha R Pawar1, Shishir Narain

Purpose: To report endogenous fungal endophthalmitis, postrecovery from severe COVID‑19 infection Access this article online
in otherwise immunocompetent individuals, treated with prolonged systemic steroids. Methods: Website:
Retrospective chart review of cases with confirmed and presumed fungal endogenous endophthalmitis, www.ijo.in
following severe COVID‑19 disease, treated at two tertiary care referral eye institutes in North India. DOI:
Results: Seven eyes of five cases of endogenous fungal endophthalmitis were studied. All cases had been 10.4103/ijo.IJO_592_21
hospitalized for severe COVID‑19 pneumonia and had received systemic steroid therapy for an average PMID:
*****
duration of 42  ±  25.1  days  (range 18–80  days). All the cases initially complained of floaters with blurred
vision after an average of 6 days (range 1–14 days) following discharge from hospital. They had all been Quick Response Code:
misdiagnosed as noninfectious uveitis by their primary ophthalmologists. All eyes underwent pars plana
vitrectomy (PPV) with intravitreal antifungal therapy. Five of the seven eyes grew fungus as the causative
organism (Candida sp. in four eyes, Aspergillus sp. in one eye). Postoperatively, all eyes showed control of
the infection with a marked reduction in vitreous exudates and improvement in vision. Conclusion: Floaters
and blurred vision developed in patients after they recovered from severe COVID‑19 infection. They had
received prolonged corticosteroid treatment for COVID-19 as well as for suspected noninfectious uveitis.
We diagnosed and treated them for endogenous fungal endophthalmitis. All eyes showed anatomical
and functional improvement after PPV with antifungal therapy. It is important for ophthalmologists and
physicians to be aware of this as prompt treatment could control the infection and salvage vision.

Key words: Corticosteroid therapy, COVID‑19, Endogenous endophthalmitis, Floaters, Fungal

endophthalmitis, Pars plana vitrectomy

The novel coronavirus disease (COVID‑19) caused by Severe noticed a significant increase in the number of cases of
Acute Respiratory Syndrome Coronavirus 2  (SARS‑CoV‑2) endogenous endophthalmitis reporting to our clinics. What
has affected a significantly high population of previously was unique was that all these individuals had recently
healthy individuals who developed severe pneumonia with recovered from severe COVID‑19 infection for which they
rapid oxygen desaturation requiring urgent hospitalization had received prolonged steroid therapy in an intensive care
for respiratory support, intensive care, intravenous drugs, unit (ICU) setting. These patients had initially complained of
fluids, and steroids all of which predispose them to secondary floaters along with blurred vision and had been diagnosed as
infections.[1] noninfectious uveitis by their primary ophthalmologists and
had received further steroid therapy. However, their clinical
Ophthalmic manifestations of COVID‑19 have been picture, nonresponse to steroids along with deteriorating
reported with conjunctivitis being the most common. [2] vision indicated a likely infectious etiology rather than a
Posterior segment pathology including central retinal vein hypersensitivity‑related entity. One very recent case series
occlusion,[3] central retinal artery occlusion,[4] and acute macular from India also described presumed fungal endophthalmitis
neuroretinitis[5] have been reported post COVID‑19. in four cases post COVID‑19.[7]
Endogenous endophthalmitis is a sight‑threatening ocular To our knowledge, this is the first study in the literature,
infection presenting as a potential ocular emergency. It can describing cases with confirmed fungal endogenous
manifest at any age and is generally due to a hematogenous endophthalmitis in ICU‑treated patients post their complete
spread of infection from a remote systemic location, recovery from severe COVID‑19 disease.
unrelated to prior ophthalmic surgery or trauma. It is most
often seen in patients with chronic debilitating disease or
immunocompromised states. [6] In the past 8 months, we
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
Shroff Eye Centre, 1 Centre for Sight, 2 Ocular Pathology and as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Microbiology Services, Dr. Shroff’s Charity Eye Hospital, New Delhi,
3
Dr. Sapra’s Lab, Gurgaon, Haryana, India
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Dr Shroff and Dr Narula contributed equally to this study.
Correspondence to: Dr. Daraius Shroff, Shroff Eye Centre, A‑9 Kailash Cite this article as: Shroff D, Narula R, Atri N, Chakravarti A, Gandhi A,
Colony, New Delhi ‑ 110 048, India. E‑mail: daraiuss@gmail.com Sapra N, et al. Endogenous fungal endophthalmitis following intensive
Received: 13-Mar-2021 Revision: 03-May-2021 corticosteroid therapy in severe COVID‑19 disease. Indian J Ophthalmol
2021;69:1909-14.
Accepted: 12-May-2021 Published: 31-May-2021

© 2021 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

1910 Indian Journal of Ophthalmology Volume 69 Issue 7

Methods working diagnosis were suggestive of fungal endophthalmitis in

all the cases. All seven eyes underwent a vitrectomy to salvage
We undertook a retrospective chart review of patients with a vision. All subjects were male. The median age of the cases was
diagnosis of endogenous fungal endophthalmitis between May 47 years (range 30–67 years). Three of these (Case numbers 3,
2020 and January 2021 at two tertiary Ophthalmic institutes in 4, and 5) had hypertension and two (Cases 4 and 5) had Type 2
North India. diabetes mellitus, which were well controlled systemically on
The diagnosis of endogenous endophthalmitis in our study medication. The demographic details and clinical profile of each
was based on clinical signs such as the presence of anterior and of the cases are depicted in Table 1.
posterior segment inflammation, vitritis, and characteristic All cases had previously been hospitalized in
fundal lesions such as vitreous, subretinal exudates, and the ICUs for COVID‑19 pneumonia with the mean duration
lack of any relationship to a potential exogenous cause such 18.2 ± 8.56 days (range 8–30 days) of hospital stay. All cases
as surgery and trauma.[8] had received intravenous antibiotics, as well as intravenous
All our cases had recently recovered from confirmed (RT‑PCR) or oral antiviral therapy. They had also received systemic
severe COVID‑19 disease (as per the WHO definition).[1] All cases steroid therapy for an average duration of 42  ±  25.1  days
included had been initially diagnosed as having noninfectious (range 18–80 days). All cases received systemic steroids for the
uveitis and were worsening despite treatment. Hence, we management of severe COVID‑19 pneumonia. It is of note that
decided to study this subject in greater detail. Case 2 received 20 days of steroids for COVID‑19, followed by
60 days of a tapering regimen of oral steroids from his treating
The collection of the clinical data and surgical management ophthalmologist for his ocular condition. All cases required
was done with the consent of the patients and with approval oxygen support, but none of them had been on invasive
by the Institutional Review Board of our hospital. Date mechanical ventilation.
of Approval was 1st February 2021. Demographic details,
comorbidities, duration, and treatment during hospitalization The average period between the diagnosis of COVID‑19
and ocular course details were complied. Blood culture was infection and onset of ocular complaints was 3.2  weeks
advised for all cases. All eyes underwent three‑port pars (range 3–5 weeks). The average period of onset of symptoms
plana vitrectomy  (PPV). Undiluted vitreous was collected after discharge from the hospital was 6 days (range 1–14 days).
at the beginning of each surgery using a vitreous cutter. The The average time of presentation to our institutes after the onset
vitreous biopsy aspirate was immediately transferred for of symptoms was 3.8 weeks (range 2–8 weeks). All patients were
microbiological analysis. The samples were plated directly onto initially diagnosed as noninfectious uveitis. The blood culture
chocolate agar, 5% sheep blood agar, and Sabouraud’s dextrose of these cases showed no bacterial or fungal growth. Ocular
agar (SDA). Chocolate and blood agars were incubated at 35°C features, microbiological findings, treatment administered, and
for up to 2 weeks. SDA was incubated at 35°C for 2–3 weeks. outcome are shown in Table 2.
Plates were examined daily for detection of fungal growth. The median preoperative visual acuity at presentation
In view of the strong clinical suspicion of fungal was 1.8 LogMAR (Snellen equivalent = 20/1200), Range HM
endophthalmitis, all eyes received empirical intravitreal (hand movements) to 20/200. All cases presented to us with
antifungal therapy at the time of the first intervention. The use anterior chamber inflammation. Fundus examination revealed
of silicone oil tamponade was an intraoperative decision based creamy white posterior pole lesions along with vitreous
on the surgeon’s preference and perception of future risk of exudates [Figs.  1-3]. Case 3 had undergone a previous PPV
retinal detachment. In case of bilateral involvement, the eye for suspected endophthalmitis after initial therapy elsewhere
with a better prognosis and more likely to be salvageable was with oral and topical steroids for suspected noninfectious
operated on first. At the same sitting, intravitreal antifungal uveitis. He presented to us with his vitreous cavity full of
and intravitreal antibiotics were injected into the other eye, exudates, total retinal detachment, and a large creamy‑white
which was subsequently operated after 1 week. granuloma nasally. We performed revitrectomy, with
lensectomy and relaxing retinotomy nasally to release the
The main outcomes measured included confirmation of the traction and adequately debulk the granuloma. He also had
diagnosis, infection control, reduction in inflammation, and a small subretinal abscess at the posterior pole superonasal
visual recovery postintervention. to fixation [Fig. 2]. Case 5 presented with vitreous exudates
in both eyes, with the left eye being more severely affected,
Cases were categorized as “confirmed” fungal endogenous having multiple subretinal abscesses [Fig. 3].
endophthalmitis on the basis of microbiology of the vitreous
sample, if KOH or Gram smear showed the presence of budding All cases underwent three‑port PPV with intravitreal
yeast‑like structure or fungal branching filaments or fungal injection of voriconazole at the end of the surgery. In addition,
colonies were grown on culture. They were considered as eye numbers 1, 2, 4, and 7 had silicone oil injection at the end
“presumed” fungal endophthalmitis if the clinical picture of surgery as retinal tamponade, due to the severity of the
showed ocular inflammation with the presence of fluffy infection. Microbiological examination of the vitreous biopsy
creamy yellowish lesions with a string of pearl appearance aspirate was carried out for all the cases. This revealed a growth
and responded to vitrectomy with intravitreal, topical, and of Candida sp. in four eyes, Aspergillus sp. in one eye; these
systemic antifungal therapy. were categorized as confirmed fungal endophthalmitis. There
was no growth in two eyes that were categorized as presumed
Results fungal endophthalmitis cases.
From May 2020 to January 2021, five cases presented to us All cases showed a significant improvement in terms
with endogenous endophthalmitis postrecovery from severe of control of intraocular infection with a reduction in
COVID‑19. In all the cases, the signs far exceeded the symptoms. inflammation in the form of a quiet anterior chamber and
Three cases were unilaterally affected, and two cases had clear vitreous cavity  [Table  2]. The median postoperative
bilateral involvement. The clinical picture and previtrectomy vision achieved 0.6 LogMAR  (Snellen equivalent 20/80)
 Shroff, et al.: Endogenous endophthalmitis post COVID‑19
July 2021 1911

Table 1: Demographic details and clinical profile of patients who developed endogenous endophthalmitis post COVID‑19
Case 1 Case 2 Case 3 Case 4 Case 5
Age (years) 30 62 47 44 67
Gender M M M M M
Systemic illness Nil Nil HT DM, HT DM, HT
Duration of 21 days 12 days 8 days 30 days 20 days
Hospitalization
ICU stay Yes Yes Yes Yes Yes
Duration between 2 weeks 2 weeks 4 weeks 5 weeks 3 weeks
COVID-19 diagnosis
and ocular symptoms
Duration between 1 days 6 days 14 days 8 days 1 day
discharge from hospital
to onset of symptoms
Duration of symptoms 2 weeks 8 weeks 4 weeks 2 weeks 3 weeks
prior to reporting to us
Treatment with steroids IV methylprednisolone Oral IV dexamethasone IV dexamethasone IV methylprednisolone
f/b oral dexamethasone f/b f/b oral f/b oral f/b oral
methylprednisolone oral Prednisolone Dexamethasone prednisolone methylprednisolone
Total duration of 21 days 80 days 18 days 42 days 50 days
steroid therapy
Eye affected OU OD OS OS OU
M=Male, HT=Hypertension, DM=Diabetes Mellitus, ICU=Intensive care Unit, IV=Intravenous, OD=Right, OS=Left, and OU=Both

Table 2: Ocular features, microbiological findings, treatment, and outcome for seven eyes of five cases with endogenous
endophthalmitis post COVID‑19
Eye (Case) 1 (Case 1) 2 (Case 1) 3 (Case 2) 4 (Case 3) 5 (Case 4) 6 (Case 5) 7 (Case 5)
Presenting 20/200 20/400 HM CFCF 20/600 20/1200 HM
Vision
Prior ocular Topical Topical Oral and Oral and Topical Oral, topical Oral, topical
Treatment for NSAIDs and NSAIDs and topical topical NSAIDs and Prednisolone, Prednisolone,
uveitis prednisolone prednisolone prednisolone prednisolone prednisolone periocular periocular
f/b PPV triamcinolone triamcinolone
Anterior AC cells 1+, AC cells 1+, AC cells AC Cells AC cells 3+, AC cells AC cells 3+,
segment Flare 1+ Flare 1+ 2+, Flare 1+Flare 1+ Flare 3+ 3+, Flare Flare 3+NS+PSC
findings 2+PSC 3+NS+PSC cataract
Cataract cataract
Fundus Creamy‑white Creamy‑white Vitreous Vitreous Vitreous Vitreous Vitreous exudates
findings fluffy lesion fluffy lesions exudates exudates, exudates with exudates with with retinal
at posterior at posterior with string granuloma cotton balls, retinal abscess abscess at
pole, break pole, break of pearls nasally and at small retinal inferotemporal macula and large
through through appearance. posterior pole. abscess inferior to fovea. subretinal abscess
hemorrhage. hemorrhage. Total RD. to the ONH. temporally.
Organism Candida sp. Candida sp. nil Aspergillus sp. nil Candida sp. Candida sp.
isolated on
culture
Treatment PPV with lV PPV with IV PPV with IV Re‑Vitrectomy IV voriconazole PPV with IV PPV with IV
voriconazole voriconazole voriconazole +Lensectomy f/b voriconazole+IV voriconazole+IV
and silicone and silicon oil and IV +RR silicone PPV with IV antibiotics antibiotics+silicone
oil injection injection antibiotics oil+IV voriconazole+IV oil
Voriconazole antibiotics
Postoperative Vitreous Vitreous Vitreous Vitreous cavity Vitreous cavity Vitreous cavity Vitreous cavity
status cavity clear. Cavity clear. cavity clear clear, retina clear, area of clear, area of clear, area of
ERM along ERM over PSC attached, abscess getting abscess getting central abscess
the disc to macula cataract + retinal abscess scarred scarred getting scarred,
macula resolving other abscesses
resolving
Final Vision 20/80 20/40 20/200 20/1200 20/40 20/80 CFCF
Follow up 24 weeks 24 weeks 16 weeks 10 weeks 8 weeks 8 weeks 8 weeks
NSAID=Nonsteroidal antiinflammatory drugs, PPV=Pars plana vitrectomy, PSC=Posterior subcapsular, IV=Intravitreal, AC=Anterior chamber, HM=Hand
movements, CFCF=Counting fingers close to face, ERM=Epiretinal membrane, RR=Relaxing retinotomy, and RD=Retinal detachment
1912 Indian Journal of Ophthalmology Volume 69 Issue 7

a b c

d e f
Figure 1: Bilateral involvement in case 1. (a and c) Right and left eyes, respectively, showing whitish fluffy lesions (arrows) at the posterior
pole, breakthrough preretinal hemorrhage, and mild disc hyperemia. (b and d) Postvitrectomy picture in the right and left eyes, with silicone oil
in situ, clear vitreous cavity, and small fibrous proliferation over the optic disc. (c) Wet film 10% KOH mount shows double‑walled yeasts‑like
organism. (arrow) (f) Growth on blood agar is seen as creamy white confluent colonies of Candida sp

Range CFCF (counting fingers close to face) to 20/40. All cases

received broad‑spectrum antibiotics and antifungal eye drops
(Topical Voriconazole) along with oral voriconazole.

Discussion
Endogenous endophthalmitis is a rare, but potentially
devastating intraocular infection in which pathogens reach the
b eye via the bloodstream. Identified risk factors for endogenous
endophthalmitis include chronic diseases (e.g., diabetes mellitus,
a renal failure, malignancies, and acquired immunodeficiency
syndrome); immunosuppressive treatment; recent invasive
surgery; intravenous drug abuse; indwelling catheters; organ
transplantation; and pregnancy or postdelivery.[6]
A database review from January 2019 till May 2020 at
our two tertiary care institutions revealed a total of 32 cases
of endophthalmitis of which there were only two cases of
endogenous fungal endophthalmitis. The sudden uptick in
these cases of endogenous endophthalmitis during the past
8 months of the COVID‑19 pandemic led us to conduct this
c d study.
Figure 2: Left affected eye in case 3. (a) Fundus photograph showing In our case series, otherwise immunocompetent patients
whitish retinal abscess (arrow) seen hazily through the turbid vitreous. with a history of recent severe COVID-19 infection with
(b) Intraoperatively, a large clump of exudates (arrow) was seen in the prolonged hospitalization and treatment with corticosteroids
retrolenticular space. Lensectomy and retinotomy were necessary developed endogenous endophthalmitis.
to remove this large granuloma. (c) 1 posttreatment, the retinal view
improved and the resolving retinal abscess is seen (arrow). (d) Fundus COVID‑19 viral infection causes a significant strain on
photo montage shows clear vitreous cavity, silicone oil in situ, and the immune system of a patient. Yang et al.[9] have reported a
well‑attached retina significant decrease in lymphocytes especially the CD4 counts,
 Shroff, et al.: Endogenous endophthalmitis post COVID‑19
July 2021 1913

a b c

d e f
Figure 3: Bilateral involvement in case 5. (a) Right eye showed diffuse fluffy cotton balls and a retinal abscess (arrow). (b) four weeks postvitrectomy;
the vitreous cavity is clear, and the retinal abscess (arrow) is resolving. (c) the worse affected left eye showed a large clump of vitreous
exudates (arrow). (d) intraoperatively a retinal abscess is seen at the posterior pole (arrowhead) along with two larger retinal abscesses (arrow).
(e) Blood agar showing creamy white, smooth, discrete, and well‑defined colonies of Candida sp.  (arrow) (f) Gram stain showing budding
gram‑positive yeast cells. (arrow)

which could predispose to opportunistic infections. The use of parental corticosteroids. Sen et al. [16] reported six
current guidelines in India recommend the use of intravenous cases of mucormycosis in patients with moderate to severe
corticosteroids as a life‑saving option in severe COVID‑19 COVID-19 infection. They also found that the increased use of
disease. [10] This is further supported by the RECOVERY corticosteroids increased the risk of invasive fungal infection
trial data,[11] which showed a reduction in mortality rate in with mucormycosis.
patients on mechanical ventilators or on oxygen support
when treated with steroids. An aggressive though necessary Shah et al.[7] recently reported four cases of presumed fungal
use of steroids could further worsen an already compromised endogenous endophthalmitis with a similar clinical picture in
immune system, making it susceptible to secondary infections. post COVID‑19 patients. However, a microbiological diagnosis
Widely accepted standardized protocols,[12] as well as the could not be obtained in any of their cases.
RECOVERY study, recommended using oral or intravenous In our series of patients, a fungal pathogen was identified as
steroids up to 10 days for severely ill patients with COVID-19, the causative agent for endophthalmitis in five out of the seven
who are on supplemental oxygen or ventilatory support. In eyes. In the other two eyes, presumed fungal endophthalmitis
contrast, our patients received an average of 42  ±  25.1  days was the working diagnosis. In all our cases, the signs far
(range 18–80 days) of steroid therapy. exceeded the symptoms, supporting a fungal etiology.
Fungal organisms are responsible for more than half of all Though one attempts to identify the source of infection in
cases of endogenous endophthalmitis, with Candida albicans endogenous endophthalmitis, it may not always be possible.
being the commonest pathogen  (75–80%).[13] A review of In our study, the blood culture showed no bacterial or fungal
literature revealed a number of reports of serious systemic growth in any of our cases. Binder et al.[17] in their 18‑year review
fungal infections seen in post COVID-19 patients. White et al.[14] of endogenous endophthalmitis have shown that in 44% of their
showed an incidence of 26.7% of invasive fungal disease in ICU patients no additional infection foci other than the eye was found,
patients of COVID‑19, most commonly with Aspergillus with and thus postulated it to a transient bacteremia or fungemia.
the use of corticosteroid increasing the likelihood of fungal
infection. From India, Mehta et al.[15] reported a severe case During the COVID‑19 pandemic, a fivefold increase in
of Rhino orbital mucormycosis associated with COVID‑19 in intravenous line‑related candidemia has been reported.[18]
a 60‑year‑old patient, which they attributed to the extensive These studies indicate that prolonged hospitalization and
1914 Indian Journal of Ophthalmology Volume 69 Issue 7

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