Five-year retrospective review of guideline-based management of fungal endophthalmitis

Purpose: Guidelines were introduced in 2000 at the Bristol Eye Hospital (BEH) for the management of fungal endophthalmitis. A 5-year retrospective audit re-evaluated the guidelines and monitored the management of this rare condition. Clinical effectiveness and management costs were considered in light of visual outcome. Methods: Cases were identified through a 5-year retrospective review of theatre logbooks, Patient Administration System coded admissions with primary diagnosis of purulent endophthalmitis and pharmacy logbooks of patients receiving antifungal therapy. Data correlation and review of patient management were carried out in light of the findings. Results: Twenty-three cases were included, based on clinical disease and/ or positive smears or cultures. Age range was 13-74 years, with a male : female ratio of 16 : 7 and right eye : left eye ratio of 14 : 9. Risk factors for fungal endophthalmitis included septicaemia caused by intravenous drug use (78%), presence of indwelling lines (9%), postocular surgery (9%) and post-trauma (4%). Guidelines were rigidly followed in 56% of cases, with improved visual acuity in 9/13 patients compared to 4/10 where management deviated from guidelines. Deviation from guidelines occurred with incomplete use of the recommended drug regimen for the disease severity or use of drugs that were alternative to the suggested guidelines. Treatment was initiated on clinical judgement in 91% of cases and laboratory diagnosis in 9%. Conclusion: The BEH guidelines provided a useful reference when managing this uncommon condition. Voriconazole, a newer broad-spectrum agent with good ocular penetration (used in 9%), has been added to the revised guidelines. Monitoring rare conditions over prolonged time frames supports evidence-based medicine.