Vision at Risk !!!!

Dr.SreeLekshmy.S, Dr.Jayasree, Dr.Praveena,DrC Jayakumar 
Thirty four weeks old expreterm female ba, born to A 29year old G3A2 mother emergency LSCS developed respiratory distress at birth, was started on CPAP and surfactant in view of type 1 RDS. Caffeine given in view of apnea of prematurity was stopped on day 31 .Subsequently all support were tapered and stopped. 
ECHO showed small ASD/PFO. 
Feeds were started gradually and increased to full feeds. On day 21 of life, ba was found to have Right eye endogenous endophthalmitis and Intravitreal vancomycin and ceftazidime was given. 
On day 28 of life, repeat screen of the eye showed no improvement and Intravitreal vancomycin and voriconazole were given. 
On day 34 of life, there was increase in size of the lesion and hence was referred to AIMS. At admission ba was on room air and had stable vitals. 
Auxology Weight-1.25kg (< 3rdcentile), HC-26.5cm(< 3rd centile), Length-40.5cm (< 3rd centile). 
Systemic examination was normal. 
Right eye vitrectomy with instillation of intravitreal Vancomycin, Ceftazidime and Voriconazole was done on day 2 of admission. 
Inj. Amphotericin B was added on day 3 of admission due to clinical suspicion of fungal endopthalmitis. 
Vitreous PCR reported positive for candida and intravitreal amphotericin was given on day 38 of life. 
NSG, ECHO, URINE, CSF and USG KUB were screened for fungus. 
CSF Beta D glucan was suggestive of fungal sepsis. 
As the CSF analysis was suggestive of partially treated meningitis inj piperacillin tazobactam was given or a total period of 21 days and Amikacin for 10days. Due to right eye lesion , IV Voriconazole was added on day 8 of admission. 
Preoperative ECHO was normal. 
ECHO was repeated on day 6 of admission to rule out infective endocarditis and was normal. 
USG Abdomen was normal. 
NSG showed multiple nodular hyperechoic foci scattered in bilateral cerebral hemispheres ranging between 2 to 6 mm in size. Several of them having punctate central hypoechoic foci.
Grade I intraventricular hemorrhage, bilaterally. 
Corpus callosum is normal. 
Posterior fossa is normal. 
No extra axial collection. No hydrocephalus. Impression: Multiple nodular hyperechoic foci and a small in bilateral cerebral hemispheres- likely disseminated infective etiology. 
Repeat ophthalmology evaluation prior to discharge showed right eye(RE) fungal endophtalmitis persisting ; Right eye exudates into vitreous at macula, nasal infiltrates reduced. Plan is to decide on duration of Amphotericin B and Voriconazole based on repeat CSF cytology and CSF B D Glucan levels and follow up of CNS lesions.
 
Discussion: 
Fungal endophthalmitis in preterm neonates is a rare but serious condition characterized inflammation of the inner eye structures due to fungal infection. This can occur in neonates who are at higher risk due to factors such as low birth weight, prolonged hospitalization, and exposure to invasive procedures.
Etiology: Common pathogens include Candida species, especially in the context of systemic candidiasis. Aspergillus and other fungi may also be involved.
                  Risk Factors:
              -Low birth weight
o Prolonged use of intravenous catheters
o Immunosuppression
o Premature rupture of membranes
Symptoms: Symptoms may be subtle and can include:
o Redness of the eye
o Purulent discharge
o Poor feeding
o Lethargy
o Visual impairment (though this may be difficult to assess in neonates)
Diagnosis:
o Clinical examination an ophthalmologist
o Fundus examination, often using indirect ophthalmoscopy
o Culture of vitreous or other ocular fluids to identify the causative organism
Management:
o Systemic antifungal therapy (e.g., amphotericin B, fluconazole)
o Possible surgical intervention, such as vitrectomy, in cases of severe infection
o Supportive care and management of any underlying conditions
Prognosis: The prognosis can vary depending on the severity of the infection, the promptness of diagnosis, and the initiation of treatment. Early detection and intervention are critical for improving outcomes.
Prevention: Minimizing risk factors, such as careful handling of intravenous lines and early identification of infections, can help reduce the incidence of fungal endophthalmitis in this vulnerable population.