Prevalence of Ocular Complications in Candidemia: Defining the "Battlefield".

Abstract

(See the Major Article by Phongkhun et al. “Prevalence of Ocular Candidiasis and Candida Endophthalmitis in Patients with Candidemia: a Systematic Review and Meta-analysis,” https://doi.org/10.1093/cid/ciad064.) Ocular candidiasis (OC) is one of the major and most feared complications in patients with candidemia given the risk of developing severe sight-threatening Candida endophthalmitis (CE). The discovery of ocular complications changes management in several ways, including choice of agents, duration of treatment, and possible need for invasive procedures. The Infectious Diseases Society of America (IDSA) and the European Confederation of Medical Mycology (ECMM) guidelines both recommend that all patients with candidemia undergo routine dilated funduscopic exam [1, 2]. This should preferably be performed by an ophthalmologist, regardless of ocular symptoms, as the potential benefit of ocular screening with early identification of endophthalmitis outweighs costs related to widespread exams [1]. However, this recommendation remains controversial due to the low quality of supportive evidence, including some data collected before the era of newer antifungals, updated diagnostic methods, and implementation of current definitions for ocular involvement as well as low cost-effectiveness, in particular for ophthalmologists. Estimates of ocular involvement prior to the introduction of azoles reached as high as 28% [3], but more recent studies demonstrated a lower, although variable, burden. This has led to the question, “Are we managing patients by relying on old epidemiology, and thus being overly conservative?” and there is certainly disagreement within the field of infectious diseases (ID) [4].