Cryptococcosis Soil contaminated with pigeon droppings contains an encapsulated yeast. Cryptococcus IlcojiJr/Il(/lls.

which enters the body through inhalation (see Chapter 24). Cryptococcal infection is usually limited to patients with cell-mediated immune dysfunction and occurs in )-10% of patients with AIDS. Ocular involvement is present in approximately 6% of patients with cryptococcalmeningitis. The most likely route of infection is via direct extension from the optic nerve or by haematogenous spread to the choroid and retina. I. Signs . J'vleningitis-associated manifestations are the most common and include papilloedema. ophthalmoplegia. ptosis. optic neuropathy and sixth nerve palsy. .. Nlultilocal choroiditis (Fig. 14.44). Iris infiltration. keratitis and conjunctival granuloma hm'e been reported. 2. Treatment of sight-threatening lesions is with intravenous amphotericin. oral l'Iuconazole and itraconazole. Fig. 14.44 Multifocal cryptococcal choroiditis (Courtesy of A Curi)
Endogenous fungal endophthalmitis Pathogenesis
The major source of fungal infection within the eye is metastatic spread from a septic focus associated with catheters. intravenous drug abuse. parenteral nutrition and chronic lung disease such as cystic fibrosis. Neutropenia following immunosuppression and AIDS are also major risk factors. Approximately 75% of isolates are ClIlldidllspp.; other pathogens include CryplococcllS spp.. Sporoll1ri.r Sclll'llCkiiand Blllslomyces spp.

Diagnosis
I. Presentation is dependent on the location of the inl1ammatory focus. Peripheral lesions may cause few or no visual symptoms while central lesions or those resulting in severe vitritis will manifest earlier. The progression is. however. much slower than in bacterial endophthalmitis and bilateral involvement is common.

2. Signs

Anterior uveitis is uncommon in the early stages but

may become prominent later.

Creamy white chorioretinal lesions with overlying

vitritis (Fig. 14.45a).

Extension into the vitreous (Fig. 14.45b).

Vitritis and floating 'cotton-ball' colonies (Fig. ] 4,45c).

Chronic endophthalmitis characterized by severe

vitreous infiltration and abscess formation (Fig. 14.45d).

14. Uveitis 485

3. Course is relatively chronic and may result in the development of retinal necrosis and retinal detachment associated with severe proliferative vitreoretinopathy. 4. Investigations involving vitreous biopsy and smears and cultures may be required to confirm the diagnosis and test sensitivity of the organisms to antifungal agents.

Treatment
I. Medical treatment is indicated for systemic disease and

ocular disease without vitreous involvement.

Intravenous amphotericin 5'X,dextrose; the initial dose

is 5mg and arter a few days can be increased to 20mg. disseminated disease) for 3-6 weeks. lt can be used in conjunction with flucytosine (I OOmg/kg/day).

Oral fluconazole ltJO-200mg/day (400-800mg for

Oral voriconazole to treat cases resistant to [1uconazole.

NB Systemic steroids are contraindicated in fungal infections. 2. Pars plana vitrectomy combined with intravitreal injection of amphotericin 5-1 O~g in 0.1 ml is indicated in

the presence of vitreous involvement.

(clinical ophtalmology edisi 6 )