Endogenous Versus Exogenous Candida Endophthalmitis: Clinical Features, Risk Factors, Treatment Modalities, and Visual Outcomes.

Abstract

To characterize the clinical features, risk factors, treatment modalities, and visual outcomes of culture-proven Candida endophthalmitis at a tertiary referral center. Retrospective, single-center, consecutive case series. Forty-six eyes of 46 patients with culture-proven Candida endophthalmitis treated between October 1, 2014, and October 1, 2025. Diagnosis was confirmed by positive intraocular (aqueous or vitreous sample) cultures. Clinical records were reviewed for demographics, comorbidities, risk factors, infection type, treatment course, and visual outcomes. Candida species distribution, clinical presentation, associated risk factors, treatment modalities, complications, and visual acuity (VA) at last follow-up. C. albicans was the most common isolate (32/46, 69.6%), predominating in endogenous cases (92.3%), while non-albicans Candida species were frequent in exogenous infections (C. tropicalis 5/20, 25.0%; C. parapsilosis 4/20, 20.0%; C. glabrata 3/20, 5.0%; P < .001). Endogenous cases were associated with recent hospitalization (8/26, 30.8%), intravenous drug use (IVDU, 8/26, 30.8%), and malignancy (6/26, 23.1%), whereas exogenous infections were related to recent ocular procedure or surgery (16/20, 80.0%) or recent external ocular infection (4/20, 20.0%). Pars plana vitrectomy (PPV) was performed in 25/26 (96.1%) of endogenous and 13/20 (65.0%) of exogenous cases (P = .014). Among intravitreally injected eyes, voriconazole was the most commonly used antifungal agent (35/38, 92.1%). Among systemically treated eyes, fluconazole was the most frequently used antifungal agent (19/37, 51.4%). The most common complication was retinal detachment in both groups (9/46, 19.6%). At last follow-up, VA was significantly better in endogenous than exogenous infection (0.5 LogMAR [∼20/63] vs. 2.3 LogMAR [∼20/3990]; P = .005). Enucleation/evisceration was performed in 1/26 (3.8%) of endogenous cases and 3/20 (15.0%) of exogenous cases. Candida endophthalmitis demonstrates distinct clinical profiles and visual outcomes based on infection source. Endogenous cases, most commonly due to C. albicans, are associated with systemic comorbidities and show comparatively better visual outcomes. Exogenous cases, frequently caused by non-albicans Candida species, are more refractory despite prompt antifungal therapy, vitrectomy, and anterior segment surgeries, often resulting poor visual outcomes.