Although rare, fungal endophthalmitis remains one of ophthalmology’s most formidable adversaries — insidious in onset, difficult to diagnose, and often devastating in outcome. Now, a multinational group of 24 experts from the Asia-Pacific Vitreo-Retina Society (APVRS), the Academy of Asia-Pacific Professors of Ophthalmology (AAPPO), and the Asia-Pacific Society of Ocular Inflammation and Infection (APSOII) has come together to deliver something long overdue: an international consensus on how clinicians should diagnose and manage this uncommon but vision-threatening disease. Their work, published in Eye and Vision, synthesizes real-world evidence, expert deliberation, and systematic review into 20 consensus statements that aim to bring clarity to a field long marked by uncertainty.
While fungal endophthalmitis accounts for 15–19% of endophthalmitis cases globally, the study highlights its regional skew: exogenous infections dominate in South and Southeast Asia, whereas endogenous infections are more frequently reported in Western countries — particularly among immunocompromised patients and intravenous drug users. The panel unanimously agreed that fungal infections tend to present later than bacterial ones, often after weeks or months, with vitritis as the most consistent sign. The “string-of-pearls” vitreous deposits and "creamy white" chorioretinal lesions remain archetypal visual cues for clinical diagnosis of the infection.
Traditional culture, the bedrock of microbiological diagnosis, is simply too slow for the realities of clinical care — often requiring up to two weeks for the fungi to grow. The panel strongly supports integrating molecular diagnostics such as PCR, targeted next-generation sequencing (NGS), and fungal biomarkers (β-D-glucan and galactomannan). These tools, as demonstrated in multiple figures and tables throughout the report, markedly enhance detection in culture-negative cases and may soon redefine the diagnostic standard.
In the report, the experts deliver a clear message: early and comprehensive vitrectomy improves outcomes, with Consensus Statement 4.1 stating quite explicitly "Early and complete vitrectomy in fungal endophthalmitis results in a superior outcome." Unlike bacterial endophthalmitis, where partial vitrectomy may suffice, the report observes that fungal infections typically demand a more aggressive surgical approach to debulk organisms, infiltrates, and toxins, with extensive vitreous clearance, posterior hyaloid elevation, and even IOL–capsular bag explantation in recalcitrant cases often required.
The consensus underscores a multimodal regimen — intravitreal, systemic, and (when applicable) topical antifungals. Voriconazole and amphotericin B remain central, but the authors note emerging roles for agents such as terbinafine and olorofim in refractory filamentous infections. Treatment duration is long, typically 4–6 weeks.
The one major area of disagreement in the report? Corticosteroids— where opinions remain sharply divided and where the therapy is still considered as "a significant area of controversy."
The study’s final pages call for antifungal stewardship (AFS), improved global surveillance, and expanded use of rapid diagnostics. With fungal disease rising globally — and cases like Candida auris posing new challenges — a structured, consensus-driven approach has never been more timely.
This landmark document doesn’t eliminate the complexities of fungal endophthalmitis, but it finally gives ophthalmologists what they’ve long needed: a unified, expert-backed compass to help navigate them.
