Neuro-Ophthalmology & Visual Neuroscience
ISSN (Print): 2572-7257 ISSN (Online): 2572-7281 Website: Editor-in-chief: Carlo Aleci
Open Access
Journal Browser
Neuro-Ophthalmology & Visual Neuroscience. 2020, 5(1), 4-7
DOI: 10.12691/novn-5-1-3
Open AccessCase Report

First Report of Intraocular Madurella Infection Following Phacoemulsification

Atikah A1 and Bastion MLC1,

1Department of Ophthalmology, Pusat Perubatan Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff 56000 Cheras, Kuala Lumpur

Pub. Date: November 13, 2020

Cite this paper:
Atikah A and Bastion MLC. First Report of Intraocular Madurella Infection Following Phacoemulsification. Neuro-Ophthalmology & Visual Neuroscience. 2020; 5(1):4-7. doi: 10.12691/novn-5-1-3


Purpose: To report the first case of post phacoemulsification endophthalmitis secondary to Madurella fungal infection. Method: A case report. Case Presentation: A 51-year-old female referred for post-operative chronic endophthalmitis. She complained of right painless reduced visual acuity (VA). She had undergone uneventful bilateral phacoemulsification with lens implantation four weeks earlier. Her clinical conditions were normal until after about four weeks postoperatively when she presented with signs of right eye endophthalmitis. She then underwent right eye vitreous aspiration needle tap and intravitreal antibiotics. Removal of the intraocular lens was done subsequently. Examination revealed a vision of counting fingers due to hypopyon and 4+ anterior chamber cells associated with fibrinous white exudate in capsular remnant, grade 4 vitreous inflammation with flat retina on ultrasonography. Urgent vitreous biopsy, vitrectomy, removal of the capsular bag, and intravitreal vancomycin and ceftazidime had been performed. White exudates were adherent to the capsular bag, the posterior surface of the iris, and the ciliary processes with sparing of the retina and optic nerve. Gram-positive cocci and fungus of Madurella sp were isolated via the vitreous biopsy. Initially the patient responded well to antibiotics but one month later had a recurrence. Revision vitrectomy and intravitreal voriconazole injection was performed. Oral and topical antifungals were tapered over three months with judicious steroid use. At six weeks post-operatively, her best corrected VA was 6/18, N18. Conclusions: Chronic and recurrent endophthalmitis following phacoemulsification may be due to Madurella fungus. Complete removal of the capsular bag and discrete areas behind the iris and the ciliary processes where fungal hyphae may hide is mandatory. Madurella tends to be locally invasive and spares the retina and optic nerve. It responds well to systemic itraconazole and intravitreal voriconazole.

Madurella phacoemulsification endophthalmitis infection

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Relhan V, Mahajan K, Agarwal P, Garg VK. Mycetoma: An update. Indian J Dermatol 2017; 62:332-40.
[2]  Garg P, Gopinathan U, Choudhary K, Rao GN. Keratomycosis: Clinical and microbiologic experience with dematiaceous fungi. Ophthalmology. 2000; 107: 574-80.
[3]  Sengupta S, Rajan S, Reddy PR, Thiruvengadakrishnan K, Ravindran RD, Lalitha P, et al. Comparative study on the incidence and outcomes of pigmented versus non pigmented keratomycosis. Indian J Ophthalmol. 2011; 59: 291-6.
[4]  Wilhelmus KR, Jones DB. Curvularia Keratitis. Trans Am Ophthalmol Soc. 2001; 99: 111-32.
[5]  R. E. Fintelmann and A. Naseri, “Prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions,” Drugs, vol. 70, no. 11, pp. 1395-1409, 2010.
[6]  A. Gupta, V. Gupta, A. Gupta et al., “Spectrum and clinical profile of post cataract surgery endophthalmitis in north India,” Indian Journal of Ophthalmology, vol. 51, no. 2, pp. 139-145, 2003.
[7]  Kresloff MS, Castellarin AA, Zarbin MA: Endophthalmitis. Surv Ophthalmol. 1998, 43: 193-224.
[8]  Hughes DS, Hill RJ: Infectious endophthalmitis after cataract surgery. Br J Ophthalmol. 1994, 78: 227-232.
[9]  Chakrabarti A, Shivaprakash MR, Singh R, Tarai B, George VK, Fomda BA, Gupta A: Fungal endophthalmitis: fourteen years’ experience from a center in India. Retina. 2008, 28: 1400-1407.
[10]  Anand AR, Therese KL, Madhavan HN: Spectrum of etiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol. 2000, 48: 123-128.
[11]  Theodore FH. (1978). Etiology and diagnosis of fungal postoperative endophthalmitis. Ophthalmology 85: 327-340.
[12]  Pflugfelder SC, Flynn HW, Jr, Zwickey TA, Forster R Tsiligianni A, Culbertson WW, et al. (1988) Exogenous fungal endophthalmitis. Ophthalmology 95:19-30.
[13]  Meredith, T., Drews, C., Sawant, A., Gardner, S., Wilson, L., & Grossniklaus, H. (1997). Intraocular dexamethasone produces a harmful effect on treatment of experimental Staphylococcus aureus endophthalmitis. American Journal of Ophthalmology, 123(3), 436.
[14]  Luttrull JK, Leewan W, Kubak BM, Smith MD, Oster HA. Treatment of ocular fungal infections with oral fluconazole. Am J Opthalmol 1995; 119: 477-481.
[15]  Christmas NJ, Smiddy WE. Vitrectomy and systemic flucon-azole for treatment of endogenous fungal endophthalmitis. Ophthal Surg Lasers 1996; 27: 1012-1018.
[16]  Goodman DF, Stern WH. Oral ketoconazole and intraocular amphotericin for treatment of post-operative Candida para- psilosis endophthalmitis. Arch Ophthalmol 1987; 105: 172-173.
[17]  Brandt ME, Warnock DW. Epidemiology, clinical manifestations, and therapy of infections caused by dematiaceous fungi. J Chemother. 2003; 15: 36-47.
[18]  Kumar A, Khurana A, Sharma M, Chauhan L. Causative fungi and treatment outcome of dematiaceous fungal keratitis in North India. Indian J Ophthalmol. 2019; 67(7): 1048-1053.
[19]  The integumentary system. (2014). Knottenbelt and Pascoe’s Color Atlas of Diseases and Disorders of the Horse, 305-351.
[20]  Durand ML. Bacterial and Fungal Endophthalmitis. Clin Microbiol Rev. 2017; 30(3): 597-613.
[21]  Stern Ga, Buttross M: Use of corticosteroids in combination with antimicrobial drugs in the treatment of infectious corneal disease. Ophthalmology (1991) 98(6): 847-53.
[22]  Behera, U. C., Budhwani, M., Das, T., Basu, S., Padhi, T. R., Barik, M. R., & Sharma, S. (2018). Role of Early Vitrectomy in the treatment of Fungal Endophthalmitis. Retina, 38(7), 1385-1392.
[23]  Treatment of two postoperative endophthalmitis cases due to Aspergillus flavus and Scopulariopsis spp. with local and systemic antifungal therapy Sayime Aydin, Bulent Ertugrul, Berna Gultekin, Guliz Uyar, Erkin Kir BMC Infect Dis. 2007; 7: 87. Published online 2007 Jul 31.
[24]  G.G. Müller, N. Kara-José, R.S. CastroAntifúngicos em infecções oculares: drogas e vias de administração Rev Bras Oftalmol, 72 (2013), pp. 132-141
[25]  Park, S. S., D’Amico, D. J., Paton, B., & Baker, A. S. (1995). Treatment of exogenous Candida endophthalmitis in rabbits with oral fluconazole. Antimicrobial Agents and Chemotherapy, 39(4), 958-963.
[26]  Pappas PG, Kauffman CA, Andes D, Benjamin DK, Jr, Calandra TF, Edwards JE, Jr, Filler SG, Fisher JF, Kullberg BJ, Ostrosky-Zeichner L, Reboli AC, Rex JH, Walsh TJ, Sobel JD, Infectious Diseases Society of A Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009; 48(5): 503-535.
[27]  Agarwal PK, Roy P, Das A, Banerjee A, Maity PK, Abnerjee AR. Efficacy of topical and systemic itraconazole as a broad-spectrum antifungal agent in mycotic corenal ulcer. A preliminary study. Indian J Ophthalmol 2001; 49: 173.
[28]  Sarfraz, M. H., Intisar Ul Haq, R., & Mehboob, M. A. (2017). Effect of topical nepafenac in prevention of macular edema after cataract surgery in patients with nonproliferative diabetic retinopathy. Pakistan Journal of Medical Sciences, 33(1).