Postoperative Aspergillus Endophthalmitis With Iris Granuloma: A Case Report

This report describes a rare case of a fungal iris granulomatous lesion in a 67-year-old female who underwent cataract surgery in the left eye and, one month later, developed culture-positive postoperative Aspergillus endophthalmitis. On initial presentation in the emergency room, slit-lamp examination of the left eye revealed subconjunctival hemorrhage, 360-degree subconjunctival hemorrhage, mild corneal edema with Descemet's folds, a deep anterior chamber with a fibrinous reaction causing pupillary membrane formation, and an in situ intraocular lens with no view of the fundus. A bright-scan (B-scan) ultrasound revealed mild vitreous opacities with a vitreal membrane, shallow choroidal detachment, and no significant retinal and choroid layer thickening. The patient was admitted into the anterior segment division for anterior chamber (AC) tap culture and AC washout for suspected retained cortical matter removal, intracameral antibiotics (vancomycin and ceftazidime), and IOL explantation in the left eye. The initial aqueous tap culture had no growth. Nine days later, repeat aqueous tap and pupillary membrane cultures were positive for Aspergillus spp. Intravitreal voriconazole was administered along with topical natamycin and amphotericin B eye drops. There was a resolution of the clinical picture, and three weeks later a rebound occurred, for which AC washout, pars plana vitrectomy (PPV), capsulectomy, and intravitreal vancomycin, ceftazidime, and voriconazole were given. A week later, the patient developed a fungal granuloma behind the iris, which was successfully managed with an AC washout, removal of the granuloma, and repeated intravitreal and intracameral voriconazole administration. The best-corrected visual acuity (BCVA) during the last visit was 20/80 in the affected eye, with a plan for a secondary IOL implant. Endophthalmitis is a rare but serious intraocular infection, with fungal endophthalmitis having a lower prevalence than bacterial endophthalmitis, which explains the lack of well-established guidelines for diagnosing and managing exogenous fungal endophthalmitis. This case highlights the rare presentation of post-cataract Aspergillus endophthalmitis with a fungal iris granuloma and demonstrates how the chronicity of this infection, along with surgical manipulation, may accelerate the seeding of these organisms into the anterior chamber structures.