Management strategies in endogenous fungal endophthalmitis: a multi-institutional retrospective cohort study

Standardised treatment guidelines for endogenous fungal endophthalmitis (EFE) are lacking. The purpose of this study is to describe treatment strategies and clinical outcomes of eyes with EFE.

Retrospective cohort study performed at eight academic institutions across the USA. Demographic, clinical and treatment data for patients with clinically or culture-proven EFE between 2010 and 2025 were included. Patients were stratified by route of systemic therapy for analysis.

A total of 118 eyes of 87 patients were included. Most patients were treated initially with intravenous systemic antifungal therapy (64%). Patients with systemic symptoms and systemic culture positivity and eyes with negative intraocular fluid cultures were more likely to be treated initially with intravenous systemic therapy. Voriconazole (34%) and fluconazole (30%) were the most used initial systemic agents. Eyes treated with intravenous antifungals were less likely to undergo surgery (intravenous 21% vs oral 50%, p=0.001), but this trend did not maintain statistical significance when controlling for confounders (OR 0.33 (95% CI 0.1 to 1.06), p=0.067). Worse presenting vision (OR 1.78, p<0.001) and infection with mould (OR 4.26, p<0.001) were associated with worse final vision. Ocular examination findings did not significantly affect the initial treatment route, the requirement for surgery or final vision.

Patients with systemic disease were more likely to be treated initially with intravenous therapy, whereas ocular findings did not significantly influence initial systemic treatment strategy. Initial treatment with intravenous therapy may decrease the odds of requiring surgical intervention.