title: Surgical management of fungal endophthalmitis resulting from fungal keratitis.
abstract: OBJECTIVE
  To report the fungal organisms, clinical features, surgical treatment strategies, and outcomes of patients with culture-proven exogenous fungal endophthalmitis (EFE) secondary to keratitis, and evaluate the role of surgery in the treatment.
  
  
  METHODS
  The clinical records of 27 patients (27 eyes) with culture-proven EFE resulting from fungal keratitis treated at Shandong Eye Institute from January 2007 to January 2015 were retrospectively reviewed. Information about fungal culture results, clinical features, surgical procedures, and final visual acuity was obtained.
  
  
  RESULTS
  There were 39 positive culture results from samples of cornea, hypopyon, vitreous and lens capsule, accounting for 56%, 26%, 15% and 2.5%, respectively. Fusarium was identified in 44% (12/27) of the eyes, followed by Aspergillus in 22% (6/27). Posterior segment infection was involved in 78% (21/27) of the patients. The corneal infection was larger than 3 mm ×3 mm in 89% (24/27) of the patients, and 22% (6/27) of them had the entire cornea, and even the sclera involved. Three eyes had silicone oil tamponade, and two eyes had retinal detachment. Twenty-two eyes (81.5%) underwent penetrating keratoplasty (PKP), and over half of them (54.5%) were operated within 3d from the onset of antifungal therapy. Fourteen eyes (52%) underwent intracameral antifungal drug injection, and three of them required repeated injections. Fifteen eyes (55.6%) underwent pars plana vitrectomy (PPV). The rate of the eyes undergoing PPV as the initial surgical procedure was 60% (9/15), lower than 77% in PKP. Intravitreal injection was given in 59% of the eyes (16/27), and 75% of them required repeated injections. The final visual acuity was 20/100 or better in 37% of the eyes, and better than counting fingers in 55.6% of the eyes. Five eyes (18.5%) were eviscerated. In the two eyes with concurrent retinal detachment, one achieved retinal reattachment, and the other was eviscerated. In the three eyes with silicone oil tamponade, two eyes received silicone oil removal, and the other one was eviscerated.
  
  
  CONCLUSIONS
  Fusarium and Aspergillus are the dominant pathogens in EFE resulting from keratitis. Aggressive antifungal surgeries including multiple intravitreal injections, PKP and core vitrectomy (especially in the initial surgery) are helpful procedures to improve prognosis of severe EFE secondary to keratitis.
authors.affiliation: Qingdao University Medical College, Qingdao 266071, Shandong Province, China; Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China.
authors.forename: Yan
authors.initials: Y
authors.lastname: Gao
authors.affiliation: Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China.
authors.forename: Nan
authors.initials: N
authors.lastname: Chen
authors.affiliation: Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China.
authors.forename: Xiao-Guang
authors.initials: XG
authors.lastname: Dong
authors.affiliation: Shandong Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Jinan 250021, Shandong Province, China.
authors.forename: Gong-Qiang
authors.initials: GQ
authors.lastname: Yuan
authors.affiliation: Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China.
authors.forename: Bin
authors.initials: B
authors.lastname: Yu
authors.affiliation: Qingdao Eye Hospital, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China.
authors.forename: Li-Xin
authors.initials: LX
authors.lastname: Xie
keywords: antifungal therapy; exogenous fungal endophthalmitis; fungal keratitis; penetrating keratoplasty; retinal detachment surgery; vitrectomy