Policy for ophthalmology consultation in fungemia patients

Policy for ophthalmology consultation in fungemia patients

Department of Ophthalmology

University of Kentucky

July 1, 2021

Rationale:  To provide a guideline on appropriate circumstances to consult ophthalmology in patients with fungemia.  A recent systematic review of the literature demonstrates the incidence of endophthalmitis in fungemia is less than 1% and even fewer develop blindness, ocular involvement largely resolves with medical treatment and outcomes are not improved with invasive intervention, and ophthalmic evaluation plays a negligible role in guiding the choice of specific antifungals.  In light of this, the American Academy of Ophthalmology in July 2021 released a recommendation against routine ophthalmologic consultation following confirmed fungemia, although consultation is reasonable for patient with signs or symptoms suggestive of ocular infection.

The practice of universal ophthalmic screening in these patients is not warranted and nonophthalmologists should not fear missing ocular involvement requiring invasive treatment for patients with fungemia who do not have signs or symptoms of endophthalmitis.

Policy:  No screening exam is necessary for adult fungemic patients who are awake, alert, and asymptomatic.  For patients with persistently positive blood cultures after the initial of therapy, as defined by 72 hours or greater, ophthalmic examination may be needed.  If an initial screening exam is negative, a follow-up is not required.

References:

Breazzano MP, Day HR, Bloch KC, et al. Utility of ophthalmic screening for patients with Candida bloodstream infections:  a systematic review. JAMA Ophthalmology 2019;137(6):698-710.

Brezzano MP, Bond III JB, Bearelly S, et al, for the American Academy of Ophthalmology, American Academy of Ophthalmology recommendations on screening for endogenous Candida endophthalmitis, Ophthalmology (2021).