Intraocular candidiasis is a potentially sight-threatening complication of candidemia. While the incidence of candidemia in North America has increased, the prevalence of intraocular candidiasis appears to be decreasing. In the USA and Europe, an ophthalmic examination is recommended for all candidemic patients to rule out intraocular involvement. However, improvements in management, clarification of the diagnosis, and trends in the epidemiology of intraocular candidiasis suggest that some candidemia patients might be safely managed without the recommended dilated ophthalmic examination

Cohen, Kenneth L.

Tucker, Joseph D.

Vinikoor, Michael J.

Zoghby, Jonathan

International Journal of Infectious Diseases

Carolina Digital Repository

International Journal of Infectious Diseases 17 (2013) e146–e148PerspectiveDo all candidemic patients need an ophthalmic examination?Michael J. Vinikoor a,*, Jonathan Zoghby b, Kenneth L. Cohen b, Joseph D. Tucker aa Department of Medicine, University of North Carolina, 130 Mason Farm Road, CB #7030, 2nd Floor Bioinformatics Building, Chapel Hill, NC 27599, USAb Department of Ophthalmology, University of North Carolina, Chapel Hill, North Carolina, USAA R T I C L E I N F OArticle history:Received 1 November 2012Received in revised form 28 November 2012Accepted 2 December 2012Corresponding Editor: Eskild Petersen,Skejby, DenmarkKeywords:CandidaEndophthalmitisChorioretinitisOphthalmic examinationVitrectomyS U M M A R YIntraocular candidiasis is a potentially sight-threatening complication of candidemia. While theincidence of candidemia in North America has increased, the prevalence of intraocular candidiasisappears to be decreasing. In the USA and Europe, an ophthalmic examination is recommended for allcandidemic patients to rule out intraocular involvement. However, improvements in management,clarification of the diagnosis, and trends in the epidemiology of intraocular candidiasis suggest that somecandidemia patients might be safely managed without the recommended dilated ophthalmicexamination. 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.Contents lists available at SciVerse ScienceDirectInternational Journal of Infectious Diseasesjou r nal h o mep ag e: w ww .e lsev ier . co m / loc ate / i j id1. IntroductionThe incidence of invasive candidiasis is increasing.1,2 Anestimated 7–29 individuals per 100 000 population in NorthAmerica will have an invasive Candida infection each year, with themajority being bloodstream infections.1 Candidemia is usually aresult of a central line-associated bloodstream infection and maylead to systemic manifestations. One of the most feared systemicmanifestations of candidemia is eye involvement, which can resultin loss of vision. The Infectious Diseases Society of America (IDSA)and European expert opinion currently recommend that allpatients with documented candidemia receive at least one dilatedeye examination, preferably by an ophthalmologist, to rule outintraocular involvement.3,4 IDSA considers receipt of the ophthal-mic examination a measure of quality of care for candidemicpatients.3 Timely diagnosis of intraocular candidiasis is criticalbecause patients may require consideration for intravitrealantifungal therapy and/or vitrectomy. However, advances in themanagement, clarification of the diagnosis, and a possible decreasein the prevalence of intraocular candidiasis raise importantquestions about whether all candidemic patients should undergoan ophthalmic examination.* Corresponding author. Tel.: +1 919 966 2536; fax: +1 919 966 6714.E-mail address: mjv@med.unc.edu (M.J. Vinikoor).1201-9712/$36.00 – see front matter  2013 International Society for Infectious Diseahttp://dx.doi.org/10.1016/j.ijid.2012.12.0142. Intraocular candidiasisIntraocular candidiasis is a spectrum of disease from chorior-etinitis to gross infection of the vitreous body. Definitive diagnosisrequires isolation of the organism from the eye in culture orhistopathology. Usually a positive blood culture for Candidaspecies and characteristic findings on ophthalmic examinationare adequate evidence to justify treatment. During ophthalmicexamination, chorioretinitis is characterized by the presence ofdeep focal, creamy white/yellow infiltrative lesions in the choroidor retina (Figure 1). Once identified, chorioretinitis rarely requiresintraocular intervention. However, knowledge of the proximity ofa lesion to the macula guides therapy, which usually consists of 4–6 weeks of systemically administered antifungal agents.3 Ocularinterventions are sometimes required when a vitreal abscess isfound. A vitreal abscess presents as a fluffy white ball seen onocular examination (Figure 1). Given the threat to vision and highermortality associated with vitreal abscess, in addition to systemictherapy, intravitreal amphotericin and vitrectomy should beconsidered.3,5The recommended ophthalmic examination for all candidemicpatients is based partly upon studies from an era when lesseffective antifungal agents were used.6–8 Systemic antifungalsincluding amphotericin alone and echinocandins poorly penetratethe vitreous humor, and have been largely replaced by fluconazolein the treatment of most episodes of candidemia.3 The regular useof a central nervous system (CNS) penetrating agent in cases ofses. Published by Elsevier Ltd. All rights reserved.Figure 1. Dilated ophthalmoscopic images of chorioretinitis (left), vitreal abscess (center), and nonspecific fundus lesions (right). Images provided by Lee M. Jampol (FeinbergSchool of Medicine, Northwestern University) (left), James P. Gilman (Moran Eye Center, University of Utah) (center), and Glen S. Jenkins (Moran Eye Center, University ofUtah) (right).M.J. Vinikoor et al. / International Journal of Infectious Diseases 17 (2013) e146–e148 e147candidemia is hypothesized as one factor in the observed decline incases of vitreal abscess.2,9,10While chorioretinitis and vitreal abscess are sought during theeye examination in the setting of candidemia, ‘nonspecific funduslesions’ are by far the most common abnormalities found(Figure 1). Nonspecific fundus lesions include cotton wool spots,retinal hemorrhages, and/or white centered hemorrhages (Rothspots). Although they are not manifestations of intraocularcandidiasis, these non-specific findings have been included inprior disease estimates, leading to inaccurate prevalence rates.6–8Such nonspecific lesions are associated with hypertension,atherosclerosis, renal failure, anemia, thrombocytopenia, andother comorbid conditions. Finding a nonspecific lesion duringexamination does not require a change in the standard 2-weekduration of systemic antifungal therapy for uncomplicatedcandidemia.3When candidemia is complicated by ocular involvement,speciation and resistance testing of all isolated Candida speciesshould be performed to rule out fluconazole resistance. Flucona-zole’s broad antifungal spectrum and wide therapeutic index haveled to its widespread usage. More than 17 different species ofCandida can cause bloodstream infections, and frequent use offluconazole selects for resistant ones, namely Candida krusei andCandida glabrata.11 C. krusei is usually intrinsically resistant tofluconazole through alteration in the target enzyme, 14a-demethylase,12 while C. glabrata rapidly develops resistance inthe presence of the drug via efflux pumps.13 Regardless of themechanism of resistance, most fluconazole-resistant Candidaspecies are sensitive to the echinocandins. However, in suspectedTable 1Prevalence of intraocular candidiasis among patients with candidemiaaFirst author Year(s) of study or publication Number of exams Edwards 1974 34 Parke 1982 38 Brooks 1989 32 Donahue 1994 118 Rodriguez-Adrian 1993–1994 180 Krishna 1996–1997 31 Femanb 1995–2000 82 Oude Lashof 1998–2003 370 Popovich 2003–2005 80 Shah 2006 38 Dozier 2007–2009 211 a Diagnosis based upon a positive blood culture and characteristic findings on histopathology).b Included patients with non-Candida fungal bloodstream infections.or confirmed intraocular infections, amphotericin plus flucytosineor voriconazole are preferred due to better CNS penetration.33. DiscussionWhile prompt diagnosis of intraocular candidiasis is critical tooptimal management, trends in the epidemiology of the diseasechallenge the need to screen all candidemic patients with dilatedophthalmoscopy. In the setting of candidemia, the prevalence ofintraocular Candida was estimated at 28–45% in studies thatincluded nonspecific lesions (e.g., Roth spots) and utilized olderantifungal agents.6–8 More recent studies in the era of fluconazoleand excluding nonspecific lesions have estimated the prevalence oftrue intraocular Candida at 1–16% (Table 1).14–20 In addition toreclassification of nonspecific lesions, earlier diagnostic suspicionand prompt initiation of potent antifungals are likely to havecontributed to the decrease in the rate of true intraoculardisease.2,9,10In the setting of decreasing prevalence, symptom-guidedscreening should be further evaluated as an approach to obviatethe need for ophthalmic examinations in all candidemic patients.Many patients with candidemia are systemically ill and unable toarticulate the presence or absence of visual symptoms. Intraoculardisease can be present in the absence of symptoms, yet somestudies have suggested that symptom reports among patients ableto reliably communicate might be helpful in determining whoshould undergo dilated ophthalmic examination. During 118examinations for candidemia, 50% of patients who reported visualsymptoms (eye pain, red eyes, or floaters) were found to havePercent with intraocular candidiasis Included nonspecific fundus lesions44.6% Yes28.9% Yes28.1% Yes9.3% No5.0% No25.8% No2.4% No10.8% No6.0% No7.9% No0.9% Noophthalmic examination (few cases were confirmed by intraocular culture orM.J. Vinikoor et al. / International Journal of Infectious Diseases 17 (2013) e146–e148e148intraocular candidiasis.15 In a different study, symptom reportsfrom patients who could communicate (which authors defined asanyone aged 18 years old who was not delirious and wasexamined outside of the intensive care unit) were analyzed.Among 211 candidemic patients who could communicate theabsence of vision symptoms, none were found to have eyeinvolvement.19 In retrospective studies, symptom reports can beinaccurate and these findings require prospective confirmation.In light of changes in the epidemiology, diagnosis, andtreatment of intraocular candidiasis, and in order to improvethe value of medical care, we suggest that further prospectiveresearch be done to refine the role of the ophthalmic examinationfor patients with candidemia. The cost-effectiveness of dilatedophthalmoscopy in cases of candidemia has not been assessed.Each examination can cost as much as US$ 400 and carries a smallrisk of acute angle-closure glaucoma. Given the increasedincidence of candidemia and decreased prevalence of intraoculardisease, the requirement that every patient with candidemia havea dilated ophthalmic examination should be reconsidered.AcknowledgementsMJV was funded by NIH grant 5T32 AI07001-35. KLC wassupported by an unrestricted grant from Research to PreventBlindness.Conflict of interest: No conflict of interest to declare.References1. Pfaller M, Diekema DJ. Epidemiology of invasive mycoses in North America. CritRev Microbiol 2010;36:1–53.2. Fortun J, Martin-Davila P, Gomez-Garcia de la Pedrosa E, Pintado V, Cobo J,Fresco G, et al. Emerging trends in candidemia: a higher incidence but a similaroutcome. J Infect Dis 2012;65:64–70.3. Pappas PG, Kauffman CA, Andes D, Benjamin Jr DK, Calandra TF, Edwards Jr JE,et al. Clinical practice guidelines for the management of candidiasis: 2009update by the Infectious Diseases Society of America. Clin Infect Dis2009;48:503–35.4. Kullberg BJ, Verweij PE, Akova M, Arendrup MC, Bille J, Calandra T, et al.European expert opinion on the management of invasive candidiasis in adults.Clin Microbiol Infect 2011;17:1–12.5. Menezes AV, Sigesmund DA, Demajo WA, Devenyi RG. Mortality of hospitalizedpatients with Candida endophthalmitis. Arch Intern Med 1994;154:2093–7.6. Edwards Jr JE, Foos RY, Montgomerie JZ, Guze LB. Ocular manifestations ofCandida septicemia: review of seventy-six cases of hematogenous Candidaendophthalmitis. Medicine (Baltimore) 1974;53:47–75.7. Parke DW, Jones DB, Gentry LO. Endogenous endophthalmitis among patientswith candidemia. Ophthalmology 1982;89:789–96.8. Brooks RG. Prospective study of Candida endophthalmitis in hospitalizedpatients with candidemia. Arch Intern Med 1989;149:2226–8.9. Picazo JJ, Gonzalez-Romo F, Candel FJ. Candidemia in the critically ill patient. IntJ Antimicrob Agents 2008;32:S83–5.10. Feman SS, Nichols JC, Chung SM, Theobald TA. Endophthalmitis in patients withdisseminated fungal disease. Trans Am Ophthalmol Soc 2002;100:67–72.11. Pfaller MA, Diekema DJ, Jones RN, Messer SA, Hollins RJ, SENTRY ParticipantsGroup. Trends in antifungal susceptibility of Candida spp. isolated from pediat-ric and adult patients with bloodstream infections: SENTRY AntimicrobialSurveillance Program, 1997 to 2000. J Clin Microbiol 2002;40:852–6.12. Orozco AS, Higginbotham LM, Hitchcock CA, Parkinson T, Falconer D, IbrahimAS, et al. Mechanism of fluconazole resistance in Candida krusei. AntimicrobAgents Chemother 1998;42:2645–9.13. Bennett JE, Izumikawa K, Marr KA. Mechanism of increased fluconazole resis-tance in Candida glabrata during prophylaxis. Antimicrob Agents Chemother2004;48:1773–7.14. Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C, et al.Ocular manifestations of candidemia. Clin Infect Dis 2011;53:262–8.15. Donahue SP, Greven CM, Zuravleff JJ, Eller AW, Nguyen MH, Peacock Jr JE, et al.Intraocular candidiasis in patients with candidemia. Clinical implicationsderived from a prospective multicenter study. Ophthalmology 1994;101:1302–9.16. Rodriguez-Adrian LJ, King RT, Temayo-Derat LG, Miller JW, Garcia CA, Rex JH.Retinal lesions as clues to disseminated bacterial and candidal infections.Medicine (Baltimore) 2003;82:187–202.17. Krishna R, Amuh D, Lowder CY, Gordon AM, Adal KA, Hall G. Should all patientswith candidemia have an ophthalmic examination to rule out ocular candidia-sis? Eye 2000;14:30–4.18. Popovich K, Malani PN, Kauffman CA, Cinti SK. Compliance with InfectiousDiseases Society of America guidelines for ophthalmologic examination ofpatients with candidemia. Infect Dis Clin Pract 2007;15:254–6.19. Dozier CC, Tarantola RM, Jiramongkolchai K, Donahue SP. Fungal eye disease ata tertiary care center: the utility of routine inpatient consultation. Ophthalmol-ogy 2011;118:1671–6.20. Shah CP, McKey J, Spirn MJ, Maguire J. Ocular candidiasis: a review. Br JOphthalmol 2008;92:466–8.

Do all candidemic patients need an ophthalmic examination?

SummaryIntraocular candidiasis is a potentially sight-threatening complication of candidemia. While the incidence of candidemia in North America has increased, the prevalence of intraocular candidiasis appears to be decreasing. In the USA and Europe, an ophthalmic examination is recommended for all candidemic patients to rule out intraocular involvement. However, improvements in management, clarification of the diagnosis, and trends in the epidemiology of intraocular candidiasis suggest that some candidemia patients might be safely managed without the recommended dilated ophthalmic examination

Elsevier - Publisher Connector 

Do all candidemic patients need an ophthalmic examination? 

International Journal of Infectious Diseases 17 (2013) e146–e148Perspective
Do all candidemic patients need an ophthalmic examination?
Michael J. Vinikoor a,*, Jonathan Zoghby b, Kenneth L. Cohen b, Joseph D. Tucker a
aDepartment of Medicine, University of North Carolina, 130 Mason Farm Road, CB #7030, 2nd Floor Bioinformatics Building, Chapel Hill, NC 27599, USA
bDepartment of Ophthalmology, University of North Carolina, Chapel Hill, North Carolina, USA
A R T I C L E I N F O
Article history:
Received 1 November 2012
Received in revised form 28 November 2012
Accepted 2 December 2012
Corresponding Editor: Eskild Petersen,
Skejby, Denmark
Keywords:
Candida
Endophthalmitis
Chorioretinitis
Ophthalmic examination
Vitrectomy
S U M M A R Y
Intraocular candidiasis is a potentially sight-threatening complication of candidemia. While the
incidence of candidemia in North America has increased, the prevalence of intraocular candidiasis
appears to be decreasing. In the USA and Europe, an ophthalmic examination is recommended for all
candidemic patients to rule out intraocular involvement. However, improvements in management,
clariﬁcation of the diagnosis, and trends in the epidemiology of intraocular candidiasis suggest that some
candidemia patients might be safely managed without the recommended dilated ophthalmic
examination.
 2013 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Contents lists available at SciVerse ScienceDirect
International Journal of Infectious Diseases
jou r nal h o mep ag e: w ww .e lsev ier . co m / loc ate / i j id1. Introduction
The incidence of invasive candidiasis is increasing.1,2 An
estimated 7–29 individuals per 100 000 population in North
America will have an invasive Candida infection each year, with the
majority being bloodstream infections.1 Candidemia is usually a
result of a central line-associated bloodstream infection and may
lead to systemic manifestations. One of the most feared systemic
manifestations of candidemia is eye involvement, which can result
in loss of vision. The Infectious Diseases Society of America (IDSA)
and European expert opinion currently recommend that all
patients with documented candidemia receive at least one dilated
eye examination, preferably by an ophthalmologist, to rule out
intraocular involvement.3,4 IDSA considers receipt of the ophthal-
mic examination a measure of quality of care for candidemic
patients.3 Timely diagnosis of intraocular candidiasis is critical
because patients may require consideration for intravitreal
antifungal therapy and/or vitrectomy. However, advances in the
management, clariﬁcation of the diagnosis, and a possible decrease
in the prevalence of intraocular candidiasis raise important
questions about whether all candidemic patients should undergo
an ophthalmic examination.* Corresponding author. Tel.: +1 919 966 2536; fax: +1 919 966 6714.
E-mail address: mjv@med.unc.edu (M.J. Vinikoor).
1201-9712/$36.00 – see front matter  2013 International Society for Infectious Disea
http://dx.doi.org/10.1016/j.ijid.2012.12.0142. Intraocular candidiasis
Intraocular candidiasis is a spectrum of disease from chorior-
etinitis to gross infection of the vitreous body. Deﬁnitive diagnosis
requires isolation of the organism from the eye in culture or
histopathology. Usually a positive blood culture for Candida
species and characteristic ﬁndings on ophthalmic examination
are adequate evidence to justify treatment. During ophthalmic
examination, chorioretinitis is characterized by the presence of
deep focal, creamy white/yellow inﬁltrative lesions in the choroid
or retina (Figure 1). Once identiﬁed, chorioretinitis rarely requires
intraocular intervention. However, knowledge of the proximity of
a lesion to the macula guides therapy, which usually consists of 4–
6 weeks of systemically administered antifungal agents.3 Ocular
interventions are sometimes required when a vitreal abscess is
found. A vitreal abscess presents as a ﬂuffy white ball seen on
ocular examination (Figure 1). Given the threat to vision and higher
mortality associated with vitreal abscess, in addition to systemic
therapy, intravitreal amphotericin and vitrectomy should be
considered.3,5
The recommended ophthalmic examination for all candidemic
patients is based partly upon studies from an era when less
effective antifungal agents were used.6–8 Systemic antifungals
including amphotericin alone and echinocandins poorly penetrate
the vitreous humor, and have been largely replaced by ﬂuconazole
in the treatment of most episodes of candidemia.3 The regular use
of a central nervous system (CNS) penetrating agent in cases ofses. Published by Elsevier Ltd. All rights reserved.
Figure 1. Dilated ophthalmoscopic images of chorioretinitis (left), vitreal abscess (center), and nonspeciﬁc fundus lesions (right). Images provided by Lee M. Jampol (Feinberg
School of Medicine, Northwestern University) (left), James P. Gilman (Moran Eye Center, University of Utah) (center), and Glen S. Jenkins (Moran Eye Center, University of
Utah) (right).
M.J. Vinikoor et al. / International Journal of Infectious Diseases 17 (2013) e146–e148 e147candidemia is hypothesized as one factor in the observed decline in
cases of vitreal abscess.2,9,10
While chorioretinitis and vitreal abscess are sought during the
eye examination in the setting of candidemia, ‘nonspeciﬁc fundus
lesions’ are by far the most common abnormalities found
(Figure 1). Nonspeciﬁc fundus lesions include cotton wool spots,
retinal hemorrhages, and/or white centered hemorrhages (Roth
spots). Although they are not manifestations of intraocular
candidiasis, these non-speciﬁc ﬁndings have been included in
prior disease estimates, leading to inaccurate prevalence rates.6–8
Such nonspeciﬁc lesions are associated with hypertension,
atherosclerosis, renal failure, anemia, thrombocytopenia, and
other comorbid conditions. Finding a nonspeciﬁc lesion during
examination does not require a change in the standard 2-week
duration of systemic antifungal therapy for uncomplicated
candidemia.3
When candidemia is complicated by ocular involvement,
speciation and resistance testing of all isolated Candida species
should be performed to rule out ﬂuconazole resistance. Flucona-
zole’s broad antifungal spectrum and wide therapeutic index have
led to its widespread usage. More than 17 different species of
Candida can cause bloodstream infections, and frequent use of
ﬂuconazole selects for resistant ones, namely Candida krusei and
Candida glabrata.11 C. krusei is usually intrinsically resistant to
ﬂuconazole through alteration in the target enzyme, 14a-
demethylase,12 while C. glabrata rapidly develops resistance in
the presence of the drug via efﬂux pumps.13 Regardless of the
mechanism of resistance, most ﬂuconazole-resistant Candida
species are sensitive to the echinocandins. However, in suspectedTable 1
Prevalence of intraocular candidiasis among patients with candidemiaa
First author Year(s) of study or publication Number of exams 
Edwards 1974 34 
Parke 1982 38 
Brooks 1989 32 
Donahue 1994 118 
Rodriguez-Adrian 1993–1994 180 
Krishna 1996–1997 31 
Femanb 1995–2000 82 
Oude Lashof 1998–2003 370 
Popovich 2003–2005 80 
Shah 2006 38 
Dozier 2007–2009 211 
a Diagnosis based upon a positive blood culture and characteristic ﬁndings on 
histopathology).
b Included patients with non-Candida fungal bloodstream infections.or conﬁrmed intraocular infections, amphotericin plus ﬂucytosine
or voriconazole are preferred due to better CNS penetration.3
3. Discussion
While prompt diagnosis of intraocular candidiasis is critical to
optimal management, trends in the epidemiology of the disease
challenge the need to screen all candidemic patients with dilated
ophthalmoscopy. In the setting of candidemia, the prevalence of
intraocular Candida was estimated at 28–45% in studies that
included nonspeciﬁc lesions (e.g., Roth spots) and utilized older
antifungal agents.6–8 More recent studies in the era of ﬂuconazole
and excluding nonspeciﬁc lesions have estimated the prevalence of
true intraocular Candida at 1–16% (Table 1).14–20 In addition to
reclassiﬁcation of nonspeciﬁc lesions, earlier diagnostic suspicion
and prompt initiation of potent antifungals are likely to have
contributed to the decrease in the rate of true intraocular
disease.2,9,10
In the setting of decreasing prevalence, symptom-guided
screening should be further evaluated as an approach to obviate
the need for ophthalmic examinations in all candidemic patients.
Many patients with candidemia are systemically ill and unable to
articulate the presence or absence of visual symptoms. Intraocular
disease can be present in the absence of symptoms, yet some
studies have suggested that symptom reports among patients able
to reliably communicate might be helpful in determining who
should undergo dilated ophthalmic examination. During 118
examinations for candidemia, 50% of patients who reported visual
symptoms (eye pain, red eyes, or ﬂoaters) were found to havePercent with intraocular candidiasis Included nonspeciﬁc fundus lesions
44.6% Yes
28.9% Yes
28.1% Yes
9.3% No
5.0% No
25.8% No
2.4% No
10.8% No
6.0% No
7.9% No
0.9% No
ophthalmic examination (few cases were conﬁrmed by intraocular culture or
M.J. Vinikoor et al. / International Journal of Infectious Diseases 17 (2013) e146–e148e148intraocular candidiasis.15 In a different study, symptom reports
from patients who could communicate (which authors deﬁned as
anyone aged 18 years old who was not delirious and was
examined outside of the intensive care unit) were analyzed.
Among 211 candidemic patients who could communicate the
absence of vision symptoms, none were found to have eye
involvement.19 In retrospective studies, symptom reports can be
inaccurate and these ﬁndings require prospective conﬁrmation.
In light of changes in the epidemiology, diagnosis, and
treatment of intraocular candidiasis, and in order to improve
the value of medical care, we suggest that further prospective
research be done to reﬁne the role of the ophthalmic examination
for patients with candidemia. The cost-effectiveness of dilated
ophthalmoscopy in cases of candidemia has not been assessed.
Each examination can cost as much as US$ 400 and carries a small
risk of acute angle-closure glaucoma. Given the increased
incidence of candidemia and decreased prevalence of intraocular
disease, the requirement that every patient with candidemia have
a dilated ophthalmic examination should be reconsidered.
Acknowledgements
MJV was funded by NIH grant 5T32 AI07001-35. KLC was
supported by an unrestricted grant from Research to Prevent
Blindness.
Conﬂict of interest: No conﬂict of interest to declare.
References
1. Pfaller M, Diekema DJ. Epidemiology of invasive mycoses in North America. Crit
Rev Microbiol 2010;36:1–53.
2. Fortun J, Martin-Davila P, Gomez-Garcia de la Pedrosa E, Pintado V, Cobo J,
Fresco G, et al. Emerging trends in candidemia: a higher incidence but a similar
outcome. J Infect Dis 2012;65:64–70.
3. Pappas PG, Kauffman CA, Andes D, Benjamin Jr DK, Calandra TF, Edwards Jr JE,
et al. Clinical practice guidelines for the management of candidiasis: 2009
update by the Infectious Diseases Society of America. Clin Infect Dis
2009;48:503–35.4. Kullberg BJ, Verweij PE, Akova M, Arendrup MC, Bille J, Calandra T, et al.
European expert opinion on the management of invasive candidiasis in adults.
Clin Microbiol Infect 2011;17:1–12.
5. Menezes AV, Sigesmund DA, Demajo WA, Devenyi RG. Mortality of hospitalized
patients with Candida endophthalmitis. Arch Intern Med 1994;154:2093–7.
6. Edwards Jr JE, Foos RY, Montgomerie JZ, Guze LB. Ocular manifestations of
Candida septicemia: review of seventy-six cases of hematogenous Candida
endophthalmitis. Medicine (Baltimore) 1974;53:47–75.
7. Parke DW, Jones DB, Gentry LO. Endogenous endophthalmitis among patients
with candidemia. Ophthalmology 1982;89:789–96.
8. Brooks RG. Prospective study of Candida endophthalmitis in hospitalized
patients with candidemia. Arch Intern Med 1989;149:2226–8.
9. Picazo JJ, Gonzalez-Romo F, Candel FJ. Candidemia in the critically ill patient. Int
J Antimicrob Agents 2008;32:S83–5.
10. Feman SS, Nichols JC, Chung SM, Theobald TA. Endophthalmitis in patients with
disseminated fungal disease. Trans Am Ophthalmol Soc 2002;100:67–72.
11. Pfaller MA, Diekema DJ, Jones RN, Messer SA, Hollins RJ, SENTRY Participants
Group. Trends in antifungal susceptibility of Candida spp. isolated from pediat-
ric and adult patients with bloodstream infections: SENTRY Antimicrobial
Surveillance Program, 1997 to 2000. J Clin Microbiol 2002;40:852–6.
12. Orozco AS, Higginbotham LM, Hitchcock CA, Parkinson T, Falconer D, Ibrahim
AS, et al. Mechanism of ﬂuconazole resistance in Candida krusei. Antimicrob
Agents Chemother 1998;42:2645–9.
13. Bennett JE, Izumikawa K, Marr KA. Mechanism of increased ﬂuconazole resis-
tance in Candida glabrata during prophylaxis. Antimicrob Agents Chemother
2004;48:1773–7.
14. Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C, et al.
Ocular manifestations of candidemia. Clin Infect Dis 2011;53:262–8.
15. Donahue SP, Greven CM, Zuravleff JJ, Eller AW, Nguyen MH, Peacock Jr JE, et al.
Intraocular candidiasis in patients with candidemia. Clinical implications
derived from a prospective multicenter study. Ophthalmology 1994;101:
1302–9.
16. Rodriguez-Adrian LJ, King RT, Temayo-Derat LG, Miller JW, Garcia CA, Rex JH.
Retinal lesions as clues to disseminated bacterial and candidal infections.
Medicine (Baltimore) 2003;82:187–202.
17. Krishna R, Amuh D, Lowder CY, Gordon AM, Adal KA, Hall G. Should all patients
with candidemia have an ophthalmic examination to rule out ocular candidia-
sis? Eye 2000;14:30–4.
18. Popovich K, Malani PN, Kauffman CA, Cinti SK. Compliance with Infectious
Diseases Society of America guidelines for ophthalmologic examination of
patients with candidemia. Infect Dis Clin Pract 2007;15:254–6.
19. Dozier CC, Tarantola RM, Jiramongkolchai K, Donahue SP. Fungal eye disease at
a tertiary care center: the utility of routine inpatient consultation. Ophthalmol-
ogy 2011;118:1671–6.
20. Shah CP, McKey J, Spirn MJ, Maguire J. Ocular candidiasis: a review. Br J
Ophthalmol 2008;92:466–8.


Do all candidemic patients need an ophthalmic examination?

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