Intraocular mycoses: causes, symptoms, diagnosis, treatment

The introduction, with perforated wounds, perforated corneal ulcers or hematogenous fungal pathways into the cavity of the eyeball, is fraught with severe intraocular inflammations, often resulting in death of the eye. Unfavorable outcome predetermines not only the reaction of the eye, to the pathogen, but also not always timely recognition of the fungal etiology of the disease. Diagnosis of these, fortunately, rare processes is difficult, on the one hand, the absence in their clinical picture of signs that clearly indicate mycosis, on the other - the low availability of substrates for the most evidence-based mycological and other studies. Required for this puncture of the anterior chamber of the eye, doctors perform reluctantly; often patients do not agree to this, especially at the beginning of the illness. Tissues of the vascular tract and reticular membrane undergo histological examination only after enucleation of the eyes. Based on the same clinical manifestations of the disease and general examination, intraocular mycosis can only be suspected.

Of the numerous representatives of fungal pathogens, intraocular lesions most often cause Candida albicans, smoky and black aspergillas, sporotrichones, cephalosporiums, etc. The disease can be manifested by anterior uveitis, choroiditis, retinitis, but fungal panoveitis and endophthalmitis are more likely to develop. Data on the latter prevail in the literature on intraocular mycoses.

Mycotic anterior uveitis and panoveitis may be granulomatous and non-granulomatous, develop either acutely, with severe eye irritation, high hypopyon, extensive synechia, secondary glaucoma, or from the outset acquire a flaccid, chronic character. In the latter case, large white precipitates with dark dots in the center can be detected biomicro- scopically, and when studying with a slit lamp, with a large magnification of the microscope in the moisture of the anterior chamber of the eye, one can sometimes see a dense intertwining of brown filaments somewhat resembling moss.

Very susceptible to fungal damage is also uveitis with a thick viscous hypopion at 1/2 2/3 and the entire anterior chamber, with eye irritation expressed moderately, and hypopion can have a brownish tinge. However, more often the manifestations of fungal anterior uveitis (precipitates, granulomas, synechia, hypopiope) do not have noticeable differences from those in bacterial and other processes. In such cases, their only criterion is the resistance of the disease to antibacterial or antiviral therapy. Unfortunately, it takes time to identify this significant differential diagnostic feature. While the patient receives the most common antibiotics or sulfonamides, especially in combination with corticosteroids, the disease can spread into the depth of the eye, thereby worsening the prospect of fungicidal therapy.

Mycotic panoveitis, in addition to changes in the anterior part of the vasculature, is manifested by a pronounced pathology of the choroid, in which the reticular membrane and the vitreous humor also participate. While optical media are transparent, ophthalmoscopically on the fundus there are flocculent foci. According to some authors, they are round, white, scattered throughout the fundus, according to observations of others - hemorrhagic, but with a white center, are located near the optic nerve disk and in the macula, and along with them on the periphery there are small cotton-like vitamins, foci, histological examination of which revealed Candida albicans. Reflecting only chorioretinal changes with hematogenous drift of pathogens, such foci can be found in patients without signs of anterior uveitis. In the future they will scar, leaving pigmented foci. However, more often the intensity of the foci increases, the vitreous humor begins to quickly become turbid and the process acquires the character of torpid endophthalmitis.

The whitish color of vitreal opacities, which are also confused in lumps, is suspicious of mycosis. In the future, perforation of the outer shells of the eye can occur and a physis of the unrealized eyeball for some reason may occur. In addition to ophthalmoscopic data, a definite value in the clinical diagnosis of intraocular mycoses is the detection of a common fungal infection of the body. Without a perforated injury, a purulent perforation of the membranes or a cavitary operation, fungi can enter the eye only with blood or lymph from the outbreak. Often the mycotic panoveitis or endophthalmitis are one of the manifestations of mycosepsis, or the appearance of hipflation into the eye from the internal organs.

When blood, urine, sputum cultures are injected into appropriate media, targeted investigation of liver, lung, gastrointestinal tract, genitalia, serological tests and reactions with fungal antigens, important data for the ophthalmologist can be obtained. First of all, such a study was shown to patients with intraocular inflammation developed after abdominal or thoracic surgery, with liver diseases resistant to conventional therapy for diseases of the digestive organs, genitals, etc., and also to people who have been receiving long-term treatment due to some kind of dysfunction, or pathology of antibiotics, corticosteroids, or both.

Exuding and intensifying against the background of more or less pronounced eye irritation, exudate in the vitreous humor 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 to deny mycosis. All eye substrates obtained in the treatment of intraocular inflammations, as well as enucleated eyes and eviscerative masses, are subject to fungal research. In the latter cases, this is necessary to eliminate the disseminated process.

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Treatment of intraocular mycosis

Treatment of intraocular mycoses is still under development. Inadequate efficacy of parenterally used, inward and locally antifungal preparations, justifies attempts to introduce them into the vitreous humor, combinations of antimycotics with vitrectomy, etc. An indispensable condition for the positive result of any treatment is its use at the onset of the disease, because delay with the appointment leaves only one possibility of radical help to the patient - removal of the mushroomed eye.