title: Onset of an outbreak of Bipolaris hawaiiensis fungal endophthalmitis after intravitreal injections of triamcinolone.
abstract: OBJECTIVE
  To report a series of cases with fungal endophthalmitis occurring after intravitreal injection of triamcinolone derived from a single lot prepared by a compounding pharmacy.
  
  
  METHODS
  Retrospective, observational case series.
  
  
  METHODS
  Seventeen eyes treated with triamcinolone obtained from a single lot subsequently found to be contaminated with Bipolaris hawaiiensis.
  
  
  METHODS
  A retrospective chart review in a single retina practice was performed for 15 patients (n = 17 eyes) who received intravitreal injections of triamcinolone obtained from a single compounding pharmacy. Medical records and cytologic and microbiologic results were reviewed from December 2011 through January 2013.
  
  
  METHODS
  Visual acuity; presence of vitreous cell, anterior chamber cell, or both; and fungal detection in samples obtained by vitreous needle aspiration or vitreous biopsy.
  
  
  RESULTS
  Fungal endophthalmitis developed in 82% (14/17) of eyes after intravitreal triamcinolone obtained from the same lot. Median onset was 83 days (range, 6-322 days). Preinjection visual acuity ranged from 20/20 to counting fingers (median, 20/50). Median visual acuity at last follow-up was 20/400 (range, 20/30-no light perception). The most common signs and symptoms included decreased vision (57% [8/14]), vitreous cell (64% [9/14]), and anterior chamber cell (50% [7/14]). Fungus was detected by cytologic or culture examination in 7% (1/14) from initial vitreous tap. By comparison, vitreous samples obtained by pars plana vitrectomy (PPV) resulted in fungus-positive cytologic results in 43% (6/14) of eyes and positive culture results in 36% (5/14) of eyes. All culture-positive specimens (100% [5/5]) were identified as B. hawaiiensis. Overall, fungal infection was confirmed in 57% (8/14) of eyes by either cytologic or microbiologic analysis.
  
  
  CONCLUSIONS
  Fungal endophthalmitis resulting from B. hawaiiensis developed in a series of eyes after intravitreal injections of triamcinolone obtained from a single compounding pharmacy. Clinical presentation of infection can be delayed up to 10 months. Vitreous tap may be inadequate, and direct vitreous biopsy by PPV may be preferred to identify fungal endophthalmitis and facilitate prompt diagnosis and treatment.
authors: Macula & Retina Institute, Molecular Insight Research Foundation, Cedars-Sinai Medical Towers, Los Angeles and Glendale, California. Electronic address: kentsmall@hotmail.com.
authors: Kent W
authors: KW
authors: Small
authors: Macula & Retina Institute, Molecular Insight Research Foundation, Cedars-Sinai Medical Towers, Los Angeles and Glendale, California.
authors: Candy K
authors: CK
authors: Chan
authors: Macula & Retina Institute, Molecular Insight Research Foundation, Cedars-Sinai Medical Towers, Los Angeles and Glendale, California.
authors: Rosemary
authors: R
authors: Silva-Garcia
authors: Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medical Center, New York, New York; Department of Pediatrics, Weill Cornell Medical Center, New York, New York; Department of Microbiology & Immunology, Weill Cornell Medical College, New York, New York.
authors: Thomas J
authors: TJ
authors: Walsh
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001082:Aqueous Humor / Q000382:microbiology; D001203:Ascomycota / Q000302:isolation & purification*; D004196:Disease Outbreaks; D004339:Drug Compounding; D004340:Drug Contamination; D009877:Endophthalmitis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D015821:Eye Infections, Fungal / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage; D006801:Humans; D058449:Intravitreal Injections; D008269:Macular Edema / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D012189:Retrospective Studies; D014222:Triamcinolone Acetonide / Q000008:administration & dosage*; D014821:Vitrectomy; D014822:Vitreous Body / Q000382:microbiology
chemical_list: D005938:Glucocorticoids; D014222:Triamcinolone Acetonide