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Paper text:
a 25-year - old male was referred to us with a 10-day history of decreased vision in the left eye after cataract surgery elsewhere .
initial examination revealed a visual acuity of counting finger close to face in left eye and 20/30 in right eye .
the anterior segment in right eye revealed aphakia after being operated for steroid - induced cataract elsewhere and in left eye showed 3 mm hypopyon and intraocular lens .
he was a known case of bronchial asthma and was on irregular treatment of steroids .
he was diagnosed to be a case of allergic bronchopulmonary aspergillosis at our institute on the basis of diagnostic criteria for diagnosing abpa .
serum ig e levels were 145 iu / ml . esr was 58 mm / hr , and c - reactive protein was 1
vitreous aspirate showed moderate number of neutrophils , branching septate hyphae and no bacteria on gram stain [ fig .
septate hyphae in koh stain he was put on topical voriconazole ( 10 mg / ml ) drops one - hourly , and oral itraconazole 200 mg twice - a - day was given for 6 wks .
1 mg / kg / bodyweight and topical prednisolone 1% were started in tapering doses .
two weeks post - vitrectomy bcva in left eye was 20/50 , anterior segment showed no activity [ fig . 2 ] .
after 1 month , his vision dropped to 20/70 and fundus showed a partial rhegmatogenous retinal detachment .
anterior segment photo of the patient 2 years postoperatively posterior segment photo of the patient 2 year postoperatively
allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to a. fumigatus that occurs almost exclusively in patients with asthma or , less commonly , cystic fibrosis .
symptoms and signs are those of asthma with the addition of productive cough and , occasionally , fever and anorexia .
diagnosis is suspected based on history and imaging tests and confirmed by aspergillus skin testing and measurement of ige levels , circulating precipitins , and a. fumigatus  specific antibodies .
a review of literature revealed only 5 other cases of endogenous aspergillosis endophthalmitis in immunocompetent patients . recognized risk factors include a history of immunocompromise , malignancy , organ transplantation , long - term corticosteroid use , drug abuse , ocular surgery , trauma , endocarditis , and chronic obstructive airways disease . as in our patient , 3 of the reported immunocompetent cases had been treated with corticosteroids for their symptoms prior to the diagnosis being made .
. it would be reasonable to assume that the administration of steroids in the absence of anti - fungal agent may have worsened the condition in our case .
there are only 2 patients reported in the literature with endogenous a. flavus who recovered useful vision , from a total of 6 patients , with endogenous aspergillous spp . who received a final visual acuity of 20/200 or better .
both patients underwent an early pars plana vitrectomy with intravitreal and systemic amphotericin b and recovered vision to 20/70 . during the vitrectomy ,
it is preferred to avoid a very posterior vitrectomy as well as peeling of exudates and membranes over the retina to avoid iatrogenic retinal tears .
these can occur in endophthalmitis as the retina tends to be edematous , necrotic , and friable .
voriconazole is an effective agent for treatment of fungal endophthalmitis ; it has a broad spectrum of activity .
intravitreal dose of voriconazole up to 100 microgram / ml is considered safe for the retina .
voriconazole is superior or at least similar to amphotericin b against common and rare yeast and mould infections .
it is suggested that voriconazole should be considered as a first - line intravitreal agent for treatment of fungal endophthalmitis .
itraconazole exhibits a favorably low mic for many species of aspergillous , and in selected reports , it has shown a favorable response for the treatment of invasive aspergillosis .
the vitreous penetration of itraconazole is better than amphotericin but remains only a fraction of the serum level .
endogenous fungal endophthalmitis should be considered in the differential diagnosis of progressive intraocular inflammation of unknown cause in persons predisposed to systemic fungal infection . when the infection is isolated to the choroid and retina , systemic treatment alone
may be curative . when there is vitreous involvement , a vitrectomy and intravitreal injection of voriconazole should be considered .
while invasive aspergillosis occurs typically in severely immunocompromised patients , cases of surgical site infections have been reported in immunocompetent individuals . 
 the purpose is to report an eye with post - operative aspergillus endophthalmitis , which achieved a good visual outcome following early and aggressive treatment . a young patient , known case of allergic bronchopulmonary aspergillosis presented to us with post - cataract surgery endophthalmitis . 
 he was treated with pars plana vitrectomy and intravitreal voriconazole and systemic itraconazole . 
 the patient regained a vision of 20/30 with follow up of 2 years .