February 22, 2023
Routine Eye Exams for Candidemia: Updated Incidence DataBy Christopher J. Graber, MD, MPH, FIDSA
IDSA guidelines for the management of candidemia have long recommended dilated eye exams by ophthalmologists in all patients with candidemia, preferably within 1 week of diagnosis in most cases. However, the American Academy of Ophthalmology issued a statement in 2021 calling this practice “low value,” only recommending ophthalmologic evaluation for symptomatic patients. This recommendation was based primarily on a systematic review in JAMA Ophthalmology published in 2019 that focused on 25 studies that used a “concordant” definition of endophthalmitis (e.g., frank vitreous involvement), finding a median 0.8% incidence among all patients with candidemia. This review also noted that outcomes were only available for 19 cases of concordant endophthalmitis, only 6 of which received invasive management (with successful outcomes in 3).
In a study recently published in Clinical Infectious Diseases, authors were able to find a total of 70 studies of ocular candidiasis, with 35 that met criteria for concordant endophthalmitis. The overall pooled prevalence of ocular candidiasis in patients with candidemia was 10.7%, with concordant candidal endophthalmitis accounting for 1.83%. Prevalence of concordant endophthalmitis was higher (3.64%) in studies from Asian countries. Factors associated with increased risk of endophthalmitis (determined across 5 studies) included albicans species (pooled odds ratio [pOR] 3.02) and receipt of total parenteral nutrition (pOR 6.92).
While outcomes with medical vs. surgical management were not assessed, this study noted a higher incidence of concordant candidal endophthalmitis than that quoted by the American Academy of Ophthalmology and thus influences what should be a nuanced discussion between infectious diseases specialists and ophthalmologists on the indications for dilated eye exams by ophthalmologists in patients with candidemia. While it seems there is little debate about the role of dilated eye exams in candidemic patients with eye complaints, better consensus is needed with regard to asymptomatic or critically ill patients who may not be able to articulate visual symptoms, timing and setting of examination, and role for vitreous aspiration and intravitreal therapeutics.
(Phongkhun et al. Clin Infect Dis. Published online: Feb. 8, 2023.)
