Role of Multimodal Imaging in the Diagnosis and Management of Endogenous Candida Endophthalmitis in a neonate with Aggressive Retinopathy of Prematurity

Purpose: To highlight the diagnostic and therapeutic challenges of endogenous candida endophthalmitis in a preterm neonate with aggressive retinopathy of prematurity (A-ROP) and to emphasize the role of multimodal imaging in achieving accurate diagnosis and successful management. Methods: We report a case of a preterm infant with A-ROP who presented with yellowish-white macular lesions and vitreous opacities. The initial clinical impression was ocular toxoplasmosis. However, a diagnostic dilemma arose between toxoplasmosis and fungal endogenous endophthalmitis. Optical coherence tomography (OCT) findings and systemic evaluation ultimately supported a diagnosis of Candida endophthalmitis. The infant was treated with intravitreal voriconazole and systemic antifungal therapy. Results: Multimodal imaging, including ultrawide-field fundus photography and OCT, revealed features consistent with fungal chorioretinitis. Notably, OCT demonstrated the characteristic “rain cloud sign,” supporting the diagnosis of fungal endophthalmitis. Following three doses of intravitreal voriconazole, there was marked regression of the retinal lesions and complete resolution of the vitreous haze. Conclusion: Endogenous Candida endophthalmitis should be considered in preterm infants with systemic risk factors and posterior segment involvement. Multimodal imaging especially OCT is pivotal in resolving diagnostic dilemmas, distinguishing fungal infections from other differentials such as toxoplasmosis, and monitoring therapeutic response.