Background: Ocular candidiasis is a serious metastatic complication of candidemia that may lead to irreversible visual impairment. Although recent meta-analyses suggest an overall prevalence of approximately 10%, real-world data from Southeast Asia remain limited. Regional differences in Candida species distribution, antifungal resistance patterns, and health-care resources may influence both the incidence of ocular candidiasis and the utilization of ophthalmic evaluation in routine practice. Methods: We conducted a retrospective cohort study of patients aged ≥15 years with candidemia at a 900-bed tertiary-care university hospital in southern Thailand between January 2014 and August 2025. Only the first episode of candidemia per patient was included. Ophthalmic evaluation was defined as a dilated funduscopic examination performed by an ophthalmologist within 4 weeks of candidemia onset. Ocular candidiasis was classified as Candida chorioretinitis or Candida endophthalmitis according to established definitions. Multivariable logistic regression was used to identify factors independently associated with receipt of ophthalmic evaluation. Results: Among 337 patients with candidemia, 67 (19.9%) underwent ophthalmic evaluation. Ocular candidiasis was diagnosed in 9 of 67 evaluated patients (13.4%), corresponding to an overall incidence of 2.7% in the entire cohort. Five patients (7.5%) had Candida chorioretinitis and four (6.0%) had Candida endophthalmitis, including two concordant and two discordant cases. Visual symptoms were assessable in 35 patients, among whom only 4 (11.4%) reported visual complaints; most patients with ocular candidiasis were asymptomatic at diagnosis. Candida albicans and Candida tropicalis accounted for 55.6% and 44.4% of ocular candidiasis cases, respectively, and bilateral ocular involvement was observed in 77.8%. Ophthalmic findings led to modification of antifungal therapy in 7 of 9 patients with ocular candidiasis (77.8%), most commonly through addition or switching to an azole-based regimen and/or prolongation of treatment duration. In multivariable analysis, vasopressor use at candidemia onset was independently associated with a lower likelihood of ophthalmic evaluation, whereas early infectious diseases consultation was independently associated with increased odds of receiving ophthalmic evaluation. Conclusions: In this Southeast Asian cohort, ophthalmic evaluation was infrequently performed but yielded clinically actionable findings and frequently altered antifungal management. The observed incidence of ocular candidiasis among examined patients was higher than that reported in Western countries. Underutilization of an ophthalmic evaluation appears to reflect illness severity and care pathway factors rather than low disease burden, suggesting that the true incidence of ocular candidiasis may be underestimated. Integrating ophthalmic evaluation into standardized candidemia care pathways may improve detection of ocular involvement, particularly in resource-limited settings.

BackgroundOcular candidiasis (OC) is a notorious complication of candidemia, but guidelines on fundoscopic screening are inconsistent. We aimed to determine the frequency of OC in patients with candidemia who underwent fundoscopy, regardless of visual symptoms, and to evaluate its impact on antifungal treatment selection and duration.MethodsA retrospective cohort study was performed at 2 tertiary care hospitals in the Netherlands in adult patients with at least 1 positive blood culture with Candida species between January 2018 and December 2024. Primary outcomes were the incidence of OC (defined as proven or probable chorioretinitis or endophthalmitis), persistent vision loss, and changes in the choice and/or duration of antifungal therapy in patients with OC.ResultsOf 402 patients, 307 (76.4%) underwent fundoscopy. Ocular candidiasis was diagnosed in 15 of 307 patients (4.9%), including 12 with probable chorioretinitis (3.9%) and 3 with probable endophthalmitis (1.0%). Nine of the 15 patients (60%) were asymptomatic (n = 6) or unable to report symptoms (n = 3). In all 15 patients, the fundoscopic findings resulted in a change in therapy. This consisted of therapy prolongation (n = 15), addition of (n = 7) or switch to (n = 4) an azole, and intravitreal antifungal injections (n = 2). Persistent visual impairment of any degree occurred in 3 of 15 patients (20%), all of whom were initially symptomatic.ConclusionsOcular candidiasis is a relatively rare but clinically significant complication of candidemia. Fundoscopic findings are used to guide treatment decisions. Persistent vision loss was uncommon.

Abstract Background Ocular candidiasis (OC) is a complication of candidemia. While echinocandins are recommended as first-line therapy for candidemia, their poor ocular penetration raises concern. This study evaluated whether initial echinocandin use increases the risk of OC. Methods We conducted a retrospective study at a 1,766-bed tertiary hospital in Seoul, Korea, including adults (≥19) with candidemia who underwent ophthalmologic exam within 30 days and received antifungal therapy. Exclusion criteria were prior antifungal use, combination therapy, < 3 days of treatment, antifungal resistance, or polymicrobial candidemia. OC was defined as chorioretinitis, vitritis, or nonspecific retinal lesions. Multivariable logistic regression was used to assess factors associated with OC. A subgroup analysis was performed in patients without neutropenia. Results Among 137 patients, 30 received non-echinocandin and 107 received echinocandin as initial antifungal agents. Hematologic malignancy, neutropenia, and steroid use were more common in the echinocandin group. Intra-abdominal infections predominated in the non-echinocandin group; primary and catheter-related infections were more frequent in the echinocandin group. C. albicans was the most common species. In multivariable analysis, echinocandin use was not significantly associated with OC (aOR 3.10, 95% CI 0.84–11.37; p=0.088), but neutropenia was (aOR 4.00, 95% CI 1.13–14.18; p=0.032). In the non-neutropenic subgroup, echinocandin use was significantly associated with OC (aOR 5.98, 95% CI 1.22–29.29; p=0.027). Conclusion Initial echinocandin use was not associated with increased OC risk overall. However, in non-neutropenic patients, echinocandin use was associated with higher OC risk, suggesting the need for caution when empirical therapy is initiated in this subgroup. Disclosures All Authors: No reported disclosures

Abstract Background Ocular involvement in candidaemia, while rare, carries the risk of devastating visual sequelae. Despite this, guideline recommendations remain inconsistent-ranging from universal screening to selective, symptom-driven assessment. The 2025 ECMM Global guideline now advocates a risk-stratified, patient-centered approach rather than blanket fundoscopy. In light of this evolution, we assessed real-world screening practices in a UK tertiary centre to determine how well current practices align with emerging consensus and whether they may guide future national recommendations.Figure 1:Advice to ward clinicians from microbiology specialists regarding assessment for ocular candidiasis, in the audit cohort (n=28) (Advice, Number of patients). Methods We conducted a retrospective observational study of all adult patients( ≥ 18 years) with blood culture confirmed candidaemia between June 1,2022, and June 1,2023. Data included opthalmology referral status, timing, microbiology consultation advice, and fundoscopy findings. Patients were stratified by clinical risk factors, care setting, and microbiologist input. Results Of 28 patients identified, only 7(25%) underwent opthalmology review with dialated fundoscopy; 5 within seven days, all in critical care. Among the 21 not reviewed, 28.6% had rejected referrals, while 42.9% lacked any referral attempt. Microbiologist documented ocular screening recommendations in 89.3% of cases within three days: 64% advised universal review, 28% endosed symptom-based referral, and 8% gave mixed advice. No cases of ocular candidiasis were diagnosed. Importantly, no visual symptoms were reported, and all the patients had responded clinically to antifungal therapy. Our data suggest both low pre-test probability and significant heterogeneity in practice, potentially influenced by ambiguous or outdated guidelines. Conclusion In this cohort, the absence of ocular disease and the variability in screening reflect the clinical equipoise underpinning current practice. Rather than routine fundoscopy for all, risk-adopted pathways; incorporating symptoms, clinical course, and care setting; may ensure diagnostic stewardship without unnecessary resource use. This study provides real world evidence to support a paradigm shift toward evidence-aligned, equity focused, and operationally feasible screening strategies for ocular candidiasis. Disclosures All Authors: No reported disclosures

A five-year multicentre evaluation of candidaemia in UK adults: Epidemiology, risk factors and outcomes.

Background/Objectives: This study aimed to repurpose aripiprazole (AR), an antipsychotic clinically approved by the FDA, as a novel antifungal drug and to potentiate its therapeutic efficacy through PEGylated terpesomes (PEG-TERs). Methods: PEG-TERs were prepared by thin-film hydration and optimized using a central composite design. The optimum PEG-TER formulation was characterized for entrapment efficiency (EE%), particle size (PS), polydispersity index (PDI), and zeta potential (ZP), and subsequently integrated into polylactic acid (PLA)-based 3D-printed ocuserts. Results: The optimized formulation exhibited spherical vesicles with high EE%, nanoscale PS, narrow PDI, and favorable ZP, alongside excellent stability and mucoadhesive properties. Ex vivo permeation demonstrated a sustained release profile of AR from PEG-TERs compared with an AR suspension, while confocal microscopy confirmed efficient corneal deposition of fluorescein-labeled PEG-TERs. In vivo, the optimum AR-loaded PEG-TERs ocusert exhibited a substantial therapeutic effect in a rabbit model of Candida albicans keratitis, while histopathological assessment confirmed its ocular safety and biocompatibility. Conclusions: In conclusion, AR-loaded PEG-TERs embedded in PLA-based 3D-printed ocuserts represent a promising, safe, and innovative therapeutic platform for the management of Candida albicans-induced corneal infections, offering both drug repurposing and emerging opportunities in advanced ocular drug delivery.

We evaluated the characteristics and outcomes of ocular candidiasis in patients using buprenorphine intravenously. A retrospective analysis of 35 eyes of people who use drugs diagnosed with presumed ocular candidiasis between 2000 and 2017 was performed. Data on demographics, ocular findings, and microbiological results were extracted from medical records. Logistic regression was performed to identify factors of poor visual prognosis, then multivariate analysis used the variables that were statistically significant in univariate analysis. Most patients (83%) were male, with a mean duration of 7.1±7.3 years from the onset of intravenous use of buprenorphine to diagnosis of ocular candidiasis. The mean best-corrected visual acuity (BCVA in logMAR) at diagnosis was 1.33±0.73, improving significantly to 0.94±0.91 at the last follow-up (P=.019). Diagnostic samples included aqueous humor from all patients and vitrectomy samples from 26 patients (74%), with positivity rates for Candida species culture of 23% and 27%, respectively. Extraocular sites tested positive for Candida in 54% of cases. Although representing 66% of identifications, Candida albicans was not the only identified organism. Treatment involved primarily fluconazole (91%) and intravitreal amphotericin B (69%). Poor visual outcomes correlated with low BCVA and presence of retinal detachment at baseline. Ocular candidiasis occurs in the context of chronic drug use. Diagnostic yield from ocular samples is relatively low, necessitating the investigation of extraocular infection sites or injection equipment. Poor baseline vision and retinal detachment were significant predictors of poor visual prognosis.

To examine the role of the ophthalmologist in screening for ocular candidiasis in patients with Candidemia . Recent evidence has shown that previously published incidence rates of endophthalmitis in Candidemia were overestimating risk due to nonuniform guidelines. Newer data suggest a very low rate of endophthalmitis in the Candidemia population. There is currently a lack of definitive data proving that retinal findings lead to significant changes in the clinical management of patients with regards to systemic treatment and overall outcomes. Given the low rates of endophthalmitis, minimal management changes with positive retinal findings, and recently published guidelines from the American Academy of Ophthalmology, we posit that ocular screening of all patients with Candidemia is not warranted. However, more research is required to better delineate high-risk features that could guide which patients would require ophthalmologic examination. Further collaboration between ophthalmology and infectious disease specialists is vital to create new evidence-based guidelines based on the recent data.

ABSTRACT Purpose We sought to re-evaluate the utility of inpatient ocular Candidiasis screening, subsequent interventions, and outcomes, to ultimately guide alignment between American Academy of Ophthalmology (AAO) and Infectious Diseases Society of America (IDSA) guidelines. Methods A retrospective cohort study was conducted from 2017–2024 at two tertiary care centers in the New York metropolitan area. Inclusion criteria included positive Candidal cultures, a pertinent International Classification of Diseases, 10th revision (ICD-10) code, or both. Culture results, mental status, visual acuity, ocular symptoms, systemic antifungal use, dilated fundus exam (DFE) findings, immunocompromised status, and interventions performed were recorded. Results Of 897 patient encounters meeting inclusion criteria, 285 (31.8%) underwent consultation to rule-out ocular Candidiasis. Among these patients, 212 (74.4%) had an unremarkable DFE, 35 (12.3%) had DFE findings attributable to other comorbidities, 24 (8.4%) had nonspecific DFE findings requiring follow-up, nine (3.2%) were diagnosed with Candida retinitis, and one (0.4%) had Candida endophthalmitis. There were no statistically significant differences in the odds of DFE positivity between the immunocompromised versus immunocompetent group (χ2 = 0.881, p = 0.348) or the symptomatic versus asymptomatic group (χ2 = 0.297, p = 0.586). During the entire study period, no ophthalmology-directed interventions were made. Conclusion Candida endophthalmitis and Candida retinitis are rare in the inpatient setting, even in patients with confirmed Candidemia. Patients are universally started on empiric intravenous antifungal treatment by primary or infectious disease teams prior to ophthalmology consultation, limiting the yield of these examinations. Further studies should be undertaken to create a protocol for these patients such that serious sequelae of disease are prevented while resources are also utilized appropriately.

Candidemia can lead to ocular complications, including endophthalmitis and chorioretinitis. Management of candidemia traditionally included ophthalmic exams. However, due to concerns regarding the utility of performing ophthalmic exams in all patients, there is a need for prognostic factors suggestive of ocular complications. We sought to evaluate if positive follow-up blood cultures (FUBC) are associated with ocular involvement in candidemia. We conducted a single-center, retrospective review of candidemia cases at an academic medical center (2017-2022). Data on demographics, risk factors, ophthalmic exams, eye infection, and mortality outcomes were collected. Data was analyzed using descriptive statistics, χ2 tests, and multivariate logistic regression. A total of 238 episodes of candidemia among 199 patients were included. FUBC were obtained for 97% of cases and were positive in 35%. Ophthalmic exams were performed in 82% of cases and identified 10 endophthalmitis and 11 chorioretinitis cases. There was no significant association between positive FUBC and endophthalmitis or chorioretinitis. Ocular infections were associated with presence of any visual symptom (P<.001), Candida albicans (P=.02), C. dubliniensis (P=.003), and length of antifungal regimen (P=.007). Hospital mortality was associated with age (P<.001), C. lusitaniae (P=.056), acquisition of FUBC (P =.03), completion of an ophthalmic exam (P =.046), vasopressor use (P<.001), and length of antifungal regimen (P =.009). While positive FUBC did not correlate with ocular candidiasis, specific Candida species were associated with endophthalmitis and chorioretinitis. C. lusitaniae infections, acquisition of FUBC, and ophthalmic exam were predictors of hospital mortality. Other indications for ophthalmic evaluations and further identification of mortality risk factors need to be investigated.

Ocular involvement in COVID-19 is rare and often mild. We report a case of severe bilateral ocular candidiasis post-COVID-19 infection. A male, 48 years old, suffered from sudden blurry vision in the right eye (RE). The patient had a history of COVID-19, ICU stay, ventilator use, and a hypercoagulable state. The patient had a history of tocilizumab and steroid use. The initial best corrected visual acuity (BCVA) was 6/30 (RE), with progressive worsening of light perception and 6/6 on the left eye (LE) to 3/60. Examination revealed string-of-pearls and snowball on vitreous, fibrovascular tissue with exudates and subretinal fluid on the macula. Tractional retinal detachment was found in both eyes, and these findings were consistent with fungal endophthalmitis. Culture was taken from a chest lump and it was positive for Candida albicans. The patient was diagnosed with bilateral ocular candidiasis and treated with a 14-day course of intravenous voriconazole and vitrectomy. The final BCVA was hand movement (RE) and 6/45 (LE).

Dedicator of Cytokinesis 8 (DOCK8) deficiency is a severe combined immunodeficiency that predisposes patients to recurrent and atypical infections. We report the case of an 8-year-old boy who presented with a rapidly progressive, fungating facial mass and keratomycosis, initially mimicking a neoplastic or mycobacterial process. An extensive diagnostic workup, including multiple biopsies, was necessary to identify Candida albicans as the causative pathogen. The severity and atypical nature of the infection prompted a comprehensive immunological evaluation, which revealed a biallelic pathogenic mutation in the DOCK8 gene. This case highlights the importance of meticulous microbiological and histopathological work-up and appropriate treatment of fungal infections with unusual clinical features.

The Infectious Diseases Society of America recommends a screening dilated retinal examination by an ophthalmologist for all patients with candidemia. Conversely, the American Academy of Ophthalmology recommends against routine screening in patients with candidemia without symptoms. In a collaborative effort between infectious diseases and ophthalmology, we examined the incidence of ocular complications in 308 patients with candidemia and subsequently measured the rate of fundoscopic examinations, risk factors for ocular complications, management changes, and outcomes. Among those who received fundoscopic exams, findings suspicious for ocular candidiasis were found in 12 patients (8%, 12/148). After independent review by ophthalmology and infectious diseases, 3 patients were found to have alternate pathologies that explained their ocular findings. Nine patients (6%, 9/148) were adjudicated as having presumed Candida chorioretinitis. Of these 9 patients, 4 (44%) were asymptomatic, and 2 (22%) were unable to declare symptoms. No patients were definitively determined to have Candida endophthalmitis. Ocular candidiasis was not found to have a statistically significant association with symptoms or comorbidities. Ocular candidiasis was more likely to be found at ophthalmology exams >7 days from first positive Candida blood culture. The number needed to screen to detect presumed Candida chorioretinitis among asymptomatic patients was 20. Based on the available evidence and high risk of morbidity of eye involvement, continued ophthalmological screens seem prudent, but a definitive consensus was found to be challenging given a lack of outcome data. Additional investigations are warranted. Ophthalmology screenings have a higher sensitivity at >7 days from positive blood culture.

Candida species are common human pathogens that cause a wide range of diseases ranging from superficial to invasive candidiasis. However, basic studies focusing on the mechanisms underlying these diseases are limited. This article reviews our previous research on the mechanisms of superficial and invasive candidiasis, the virulence of Candida species, and Candida species fitness to hosts. Regarding invasive candidiasis, we focused on two types of infections: ocular candidiasis and endogenous candidiasis from the gastrointestinal tract. Using an established ocular candidiasis mouse model, along with retrospective epidemiological research, we found a strong association between Candida albicans and ocular candidiasis. Regarding endogenous candidiasis, research using Candida auris indicated that invasive strains had a higher capability for gastrointestinal tract colonization and showed greater dissemination compared with non-invasive strains. In terms of superficial candidiasis, we focused on the defense mechanism in vulvovaginal candidiasis. The results suggested that stimulated invariant natural killer T cells played a protective role against C. albicans vaginal infection and might be a therapeutic target for vulvovaginal candidiasis. Concerning Candida species fitness, we focused on environmental factors, particularly oxygen concentration, and evaluated biofilm formation under various oxygen concentrations, revealing that each Candida species favored different oxygen concentrations. In particular, Candida tropicalis showed greater biofilm formation under hypoxic conditions. Our research revealed several insights for understanding the exact mechanisms of candidiasis, which might lead to better control of Candida species infections and appropriate treatment.

Abstract Background Candidemia can lead to hematogenous seeding of the eye resulting in chorioretinitis or endophthalmitis. IDSA recommends a screening dilated retinal examination for patients with candidemia, whilst American Academy of Ophthalmology (AAO) recently declared this a low value practice. Using an inter-disciplinary team, we evaluated ophthalmology examination for patients with candidemia. Methods We performed a retrospective study of patients with candidemia at an academic medical center and affiliated hospitals between January 2011 – June 2022. Electronic medical records were reviewed for demographics and baseline characteristics. The primary outcome was chorioretinitis and/or endophthalmitis. The study was adjudicated by independent review from infectious disease and ophthalmology providers. Results We included 308 patients with a blood culture positive for candida species. 149 patients (48%) received an ophthalmologic exam, of which 55% (82) were asymptomatic. Abnormal ocular findings concerning for presumed ocular candida complications were found in 12 patients (8%, 12/149), of which 4 had alternative diagnoses to candida choriorentinits or endophthalmitis. All of the remaining 8 patients (5%, 8/149) had presumed candida chorioretinitis with no cases of candida endophthalmitis and this led to a change in management in 88% (7/8) of patients (Table 1). Of the 8 patients, 3 patients were asymptomatic, making the number needed to screen 28 to detect presumed candida chorioretinitis amongst asymptomatic patients. We did not identify statistically significant risk factors for development of abnormal ocular findings (Table 2). Table 1 Clinical diagnosis and management of patients with candida chorioretinitis and/or endophthalmitis Table 2 Clinical features of patients with and without ocular candidiasis Conclusion IDSA and AAO recommend ophthalmologic examination in symptomatic and intubated patients with candidemia. We found a 5% incidence of presumed ocular candidiasis in patients with candidemia. Given the limitations of our study, we could not conclude for or against screening in asymptomatic patients as this did not lead to a significant change in patient outcomes. Inter-disciplinary decisions involving ophthalmology and infectious diseases can help inform best practices for screening in asymptomatic patients. Future studies should evaluate ocular photography and teleophthalmology as screening strategies. Disclosures All Authors: No reported disclosures

Corneal targeted Amorolfine HCl-mixed micelles for the management of ocular candidiasis: Preparation, in vitro characterization, ex vivo and in vivo assessments

Ocular candidiasis in a tertiary hospital in Japan: A 10-year single-center retrospective study

Infectious diseases and ophthalmology professional societies have disagreed regarding ocular screening in patients with candidemia. We aimed to summarize the current evidence on the prevalence of ocular candidiasis (OC) and Candida endophthalmitis (CE) according to the standardized definitions. A literature search was conducted from the inception date through 16 October 2022 using PubMed, Embase, and SCOPUS. Pooled prevalence of ocular complications was derived from generalized linear mixed models (PROSPERO CRD42022326610). A total of 70 and 35 studies were included in the meta-analysis for OC and concordant CE (chorioretinitis with vitreous involvement), respectively. This study represented 8599 patients with candidemia who underwent ophthalmologic examination. Pooled prevalences (95% CI) of OC, overall CE, concordant CE, and discordant CE were 10.7% (8.4-13.5%), 3.1% (2.1-4.5%), 1.8% (1.3-2.6%), and 7.4% (4.5-12%) of patients screened, respectively. Studies from Asian countries had significantly higher concordant CE prevalence (95% CI) of patients screened (3.6%; 2.9-4.6%) compared with studies from European countries (1.4%; .4-5%) and American countries (1.4%; .9-2.2%) (P <.01). Presence of total parenteral nutrition and Candida albicans was associated with CE, with pooled odds ratios (95% CI) of 6.92 (3.58-13.36) and 3.02 (1.67-5.46), respectively. Prevalence of concordant CE overall and among Asian countries was 2 and 4 times higher than the prevalence previously reported by the American Academy of Ophthalmology (AAO) of <0.9%, respectively. There is an urgent need to study optimal screening protocols and to establish joint recommendations by the Infectious Diseases Society of America and AAO.

Diagnosis and management of ocular candidiasis with choroidal neovascularization using multimodal imaging

The aim of this study was to formulate and boost ocular targeting of Fenticonazole Nitrate (FTN)-loaded olaminosomes in order to improve drug corneal permeation and candidiasis treatment. Olaminosomes were formulated by ethanol injection technique applying a central composite design. The independent variables were: span 80 amount (mg) (A), oleylamine concentration (mg%) (B) and oleic acid: drug ratio (C). The dependent responses were: percent entrapment efficiency (EE %), particle size (PS), poly-dispersity index (PDI), zeta potential (ZP) and in vitro drug release after 10 hours (Q10h). Numerical optimization by Design-Expert® software was adopted to select the optimum formula. This formula was chosen based on highest EE %, ZP (as absolute value) and Q10h and lowest PS and PDI. The optimum formula was subjected to further in vitro characterization via Differential scanning calorimetry, Transmission electron microscopy, Fourier transform infrared spectroscopy, pH determination, effect of storage, influence of terminal sterilization, detection of Minimal Inhibitory Concentration and ex vivo corneal penetration analysis. Safety and antifungal activity of the optimum formula were tested through various in vivo studies like ocular irritancy, corneal tolerance, corneal uptake and susceptibility test. The optimum formula with the maximum desirability value (0.972) revealed EE% (84.24%), PS (117.55 nm), ZP (−74.85 mV) and Q10h (91.26%) respectively. The optimum formula demonstrated ocular tolerance with enhanced corneal penetration behavior (428.66 µg/cm2) and boosted antifungal activity (56.13%) compared to FTN suspension (174.66 µg/cm2 and 30.83%). The previous results ensured the ability of olaminosomes to enhance the corneal penetration and antifungal efficacy of Fenticonazole Nitrate.