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Brief Report |

Clinical and Pathologic Features of Bipolaris Endophthalmitis After Intravitreal Triamcinolone

Don Minckler, MD, MS1; Kent W. Small, MD2; Thomas J. Walsh, MD3
[+] Author Affiliations
1University of California, Irvine
2Molecular Insight LLC, Los Angeles, California
3Weill Cornell Medical College, New York, New York
JAMA Ophthalmol. 2014;132(5):630-632. doi:10.1001/jamaophthalmol.2014.257.
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Importance  This is a notice to ophthalmologists performing intravitreal injections of triamcinolone or other medications of the risk for endophthalmitis caused by Bipolaris hawaiiensis–contaminated medications.

Observations  Histopathologic review of 5 eyes from a series of 17 treated with intravitreal triamcinolone for retinal vascular disease and diabetes mellitus over 1 year from 1 lot prepared by a compounding pharmacy. Endophthalmitis occurred in 14 of 17 eyes, the first presenting a mild vitritis 5 days following injection. The onset of signs and symptoms of endophthalmitis (eg, decreased vision, anterior chamber, or vitreous cells) in the 5 cases presented here varied from 5 to 174 days.

Conclusions and Relevance  Vitreous biopsy with cytospin and periodic acid–Schiff stain for hyphae was the most sensitive method for proving that fungus was present (positive in 3 of 5 of our cases). Five of 5 sample results from the whole series of 14 clinical cases were confirmed as positive for Bipolaris hawaiiensis by genotyping at the Centers for Disease Control and Prevention. Three of the removed eyes received fresh were culture negative; however, all 5 demonstrated organisms with fungal stains. Symptoms of fungal endophthalmitis can be minimal and delayed long beyond the 5 to 7 days expected for acute bacterial endophthalmitis. Also, apparently viable organisms persist in ocular tissues despite prolonged exposure to antifungal agents. This series reminds us that cytological or histological examination of tissue specimens may be necessary to exclude fungal infections that fail to grow in culture.

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Figure.
Histopathology

A, Hematoxylin and eosin (H&E) stain of case 9 demonstrating massive obliteration of the retina, choroidal expansion, fibrosis, subretinal hemorrhage, and an inflammatory focus temporally encompassing the retina and choroid (original magnification ×1). B, Myriad hyphae obvious with H&E or periodic acid–Schiff histology were present within the abscess in case 9 (H&E, original magnification ×40). C, Spore chains (chlamydoconidia) from case 3 (Gomori methenamine silver, original magnification ×40). D, Variety of hyphal forms from case 3 (Gomori methenamine silver, original magnification ×788).

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