Manifestations and Treatment of Ocular Coccidioidomycosis: A Review of Literature

Nicholas A Chartrand¹, Muhammed Jaafar¹, Alexander R Shusko^2*

¹Department of Ophthalmology, The University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA
²Department of Ophthalmology, Mayo Clinic Arizona, Scottsdale, AZ, USA

*Correspondence author: Alexander R Shusko, MD, Mayo Clinic Arizona, Department of Ophthalmology, 13400 East Shea Boulevard Scottsdale, AZ 85259, USA; Email: [email protected]

Citation: Chartrand NA, et al. Manifestations and Treatment of Ocular Coccidioidomycosis: A Review of Literature. J Ophthalmol Adv Res. 2025;6(1):1-12.

Copyright^© 2025 by Chartrand NA, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Purpose of Review: This review aims to summarize the epidemiology, manifestations and treatment of ocular coccidioidomycosis, a rare yet significant fungal infection that can severely impair vision.

Recent Findings: “Recent” is misleading as cases of ocular Coccidioidomycosis are rare and not frequently reported. A comprehensive literature search was performed in PubMed, EMBASE and Medline to identify case reports and retrospective reviews about the ocular manifestations of coccidioidomycosis. We identified 52 articles encompassing 63 case reports and collected data including age, gender, presentation, diagnosis, treatment, outcome and Best Corrected Visual Acuity (BCVA) at presentation and after treatment. Articles reviewed spanned from 1948 through 2022.

Summary: Average patient age was 38.7 years old, 60.3% of patients were male, 31.7% were female and gender was not disclosed 7.9% of cases. 19.0% patients had a disseminated Coccidioides infection and 4.8% of patients were immunocompromised at the time of infection. Clinical presentations of ocular coccidioidomycosis included scleritis, granulomatous lesions of the lid and retina, uveitis and endophthalmitis. 15.9% of patients progressed to enucleation. Climate change is correlated with an increased incidence of Coccidioides infections. Clinicians must maintain a high degree of suspicion for ocular coccidioidomycosis.

Keywords: Coccidioides; Valley Fever; Uveitis; Fungal Infection; Ophthalmology

Abbreviations

BCVA: Best Corrected Visual Acuity; CF: Counting Fingers; HM: Hand Motion; LP: Light Perception; NLP: No Light Perception; SD: Standard Deviation

Introduction

Coccidioidomycosis, commonly known as Valley Fever, is an infection caused by the fungus Coccidioides immitis or Coccidioides posadasii [1]. While most cases of coccidioidomycosis are self-limited, ocular complications are a rare yet serious manifestation of the disease that can lead to permanent vision loss [2]. Unfortunately, ocular coccidioidomycosis is often under-diagnosed and under-treated outside of endemic areas, which can delay appropriate management and result in poor outcomes [1,3]. The ocular manifestations of coccidioidomycosis are diverse and can include scleritis, uveitis, granulomatous lesions of the eyelid and retina and endophthalmitis. Given the severity of these complications, it is crucial to recognize and treat them in a timely and appropriate manner. In this paper, we will review the cases of ocular coccidioidomycosis found in the literature and focus on the medical and surgical treatment options available to manage this rare and challenging condition.

Methods

A comprehensive literature review was conducted on the databases PubMed, Ovid MEDLINE and EMBASE. Keywords included coccidioidomycosis, valley fever, ocular, orbit, ophthalmology, uveitis, iritis, iridocyclitis, vitritis and chorioretinitis. A representative search strategy is included in supplement 1. Inclusion criteria consisted of peer-reviewed case reports, retrospective/prospective case studies and reviews containing ocular manifestations of coccidioidomycosis. Additional articles not indexed in searched databases were identified from citations of reviewed articles. Title and abstract review yielded 52 articles that met the stated inclusion criteria. The chronicity of coccidioidomycosis infection was determined by the authors of each respective paper. There was no general consensus on the timeframe for acute vs. chronic infection. Visual acuity was recorded only for the affected eye unless otherwise noted.

Best Corrected Visual Acuity (BCVA) for each case was converted into logMAR, with non-numerical BCVA (e.g., Counting Fingers [CF], Hand Motion [HM], Light Perception [LP] and No Light Perception [NLP]) conversion as follows based on published literature: CF – 2.1, HM – 2.4, LP – 2.7, NLP – 3.0 [4,5]. A paired t-test was used to evaluate the difference in mean BCVA at presentation and after treatment in the cases that provided data at both time points.

Results

We identified 52 articles containing 63 case reports of coccidioidomycosis with ocular involvement in the literature. Demographic data are summarized in Table 1. The average patient age was 38.7 years old (SD 18.5, range: 2 weeks – 77 years). 38/63 (60.3%) of patients were male, 20/63 (31.7%) were female and gender was not disclosed in 5 cases (7.9%). Ocular involvement was unilateral in 44/63 cases (69.8%) and bilateral in 19/63 cases (30.2%). Active coccidioidomycosis infection was present in 48/63 patients (76.2%), prior infection in 12/63 patients (19.0%) and no status of systemic infection was given for 3/63 patients (4.8%). 12/63 (19.0%) patients had a disseminated Coccidioides infection. Three patients (4.8%) were immunocompromised at the time of infection. For each case report of ocular coccidioidomycosis, supplement 1 summarizes the age, gender, location, diagnosis, laterality, time from onset of symptoms to presentation, disease dissemination, treatment, patient immune status, BCVA at presentation, BCVA after treatment and length of follow-up.

The BCVA of patients with ocular coccidioidomycosis at presentation and after treatment are plotted in Fig. 1. Among the 18 case reports that provided both initial and post-treatment BCVA values, a paired t-test revealed no significant difference between the mean initial BCVA (1.32 logMAR) and the mean post-treatment BCVA (1.51 logMAR), with a p-value of 0.33.

Table 2 shows the diagnoses associated with ocular coccidioidomycosis and the treatments used by diagnosis. The most common diagnosis was chorioretinitis, with 15 cases (23.8%) of granulomatous chorioretinitis and 12 cases (19.0%) of non-granulomatous chorioretinitis. Other diagnoses include unspecified anterior uveitis (3.2%), granulomatous anterior uveitis (14.3%), non-granulomatous anterior uveitis (1.6%), cutaneous coccidioidomycosis (17.5%), endophthalmitis (6.3%), granulomatous conjunctivitis (1.6%), panuveitis (3.2%), retinitis (1.6%) and scleritis/episcleritis (7.9%). Of medical treatments, 25 patients (39.7%) received IV amphotericin B, 4 (6.3%) received intraocular amphotericin B, 5 (7.9%) received an IV azole, 20 (31.7%) received an oral azole, 1 (1.6%) received an intraocular azole. Surgical treatments included vitrectomy in 3 patients (4.8%), cutaneous surgery in 2 patients (3.2%) and enucleation in 10 patients (15.9%).

Figure 1: BCVA at presentation and after treatment.

Table 1: Demographics.

Table 2: Summary of ocular coccidioidomycosis case presentations.

Table 3: Summary of presentations and treatments for ocular coccidioidomycosis.

Discussion

Epidemiology of Coccidioidomycosis

Coccidioidomycosis is endemic to the arid and semi-arid regions of the southwestern United States, with California and Arizona accounting for the majority of reported cases in the country [6]. Outside of the United States, Valley Fever also affects parts of Mexico, Central and South America [7,8]. Coccidioidomycosis has two species in North American: C. immitis and C. posadaii. C. immitis is predominantly found in California while C. posadasii is found in other regions of United States. Phenotypically and clinically the two species are identical and can only be distinguished by molecular methods.

The incidence of coccidioidomycosis infections is increasing, with age-adjusted incidence rates increasing nearly 8 times from 2000-2018 in California [9]. The incidence of ocular involvement of Coccidioides infections is unknown, but disseminated coccidioidomycosis is estimated to occur in 0.5-2% of cases [10].

The geographic distribution of the disease may also be expanding in the United States, as more states face drought and extreme weather due to climate change [11]. Temperature is critical in both the mutation and development of the fungi, as it is hypothesized that Coccidioides ssp. thrive in dry and hot seasons by growing in the sterilized top layer of soil without competition from other microorganisms. For example, Washington state recently reported evidence of cases of coccidioidomycosis from strains endemic to the state, where it was not previously known to occur. A new niche for the fungi was already established or is establishing in Washington state. In addition to Washington, the incidence of coccidioidomycosis has been increasing in other Southwestern states such as Utah, New Mexico and Nevada [12-16].

Clinical Presentation and Diagnosis of Ocular Coccidioidomycosis

This study describes 63 case reports of ocular manifestations of coccidioidomycosis. While chorioretinitis was the most common manifestation of ocular coccidiomycosis representing 43% of patient presentations, the fungus can present as a wide variety of pathologies including cutaneous lesions, conjunctivitis, scleritis/episcleritis, uveitis and endophthalmitis. Active infection with the fungus was present in 76.2% of patients, while 19.0% of patients had a history of chronic infection. Therefore, coccidioidomycosis should be considered as a potential etiology for any new inflammatory ocular or orbital lesion in patients with a history of coccidioidomycosis infection or concomitant systemic symptoms indicative of pulmonary or disseminated infection, particularly among individuals residing in or recently visiting endemic regions.

Ocular manifestations of coccidioidomycosis are thought to result from hematogenous spread during disseminated fungal infection. Primary infection typically occurs through inhalation of the fungus, causing an acute pulmonary infection accompanied by fever and malaise that usually resolves spontaneously. However, chronic or disseminated infection may occur, especially in immunocompromised and pregnant patients, leading to spread of the fungus to the skin and bones. Conversely, some patients may present with only ocular symptoms, such as blurriness or inflammation, without any constitutional symptoms. This fact highlights the need to consider ocular coccidioidomycosis in the differential diagnosis of patients with ocular symptoms in an endemic region, even in the absence of other symptoms or signs of disseminated infection. It is especially crucial to consider this diagnosis in patients with a recent acute pulmonary infection, chronic unexplained cough or those who have recently traveled through an endemic area.

Diagnosis of Coccidioidomycosis is difficult as the systemic systems are ambiguous and requires a high degree of suspicion and knowledge from the clinician. General symptoms include cough, fatigue and fever but over half of Coccidioides infections are asymptomatic or minimally symptomatic. Other less common signs and symptoms include night sweats, rash, weight loss and headaches. Skin manifestations should raise suspicion for Coccidioides infection such as erythema nodosum and erythema multiforme.

Laboratory testing is crucial for proper diagnosis and treatment of Coccidioidomycosis. Serological testing includes Enzyme Immunoassay (EIA) for Immunoglobulin (Ig)M and (Ig)G. If the initial EIA is positive, many commercial tests will reflex to immunodiffusion antibody tests. EIA tests are more sensitive but less specific whereas immunodiffusion tests are less sensitive but more specific. Immunodiffusion testing can be quantified and expressed as a titer. Quantifiable data is useful for monitoring treatment response. Limitations of serologic include the development of serum antibodies against Coccidioides tends to trail symptoms by a few weeks. Negative EIA testing does not exclude Coccidioidomycosis and should be re-tested later if suspicion remains high or a diagnosis is not found. A common but frustrating situation arises when the EIA are positive, but the immunodiffusion is negative. Treatment should be based on the clinical picture and degree of suspicion for Coccidioidomycosis. Complement Fixation (CF) is another method to detect the presence of Coccidioidomycosis in fluids other than serum, such as CSF. CF provides a titer result that again is useful for monitoring response to treatment. Microscopic examination of bodily fluids, such as respiratory secretions or aqueous fluid, would also provide diagnostic evidence of Coccidioides infection. Culture of fluids for coccidioidomycosis are notoriously difficult to handle in an outpatient setting and is generally reserved for patients in a hospital setting. Lastly, Polymerase Chain Reaction (PCR) can be used and is highly specific for detection of Coccidioidomycosis.

The prognosis of infection is poor, with 15.9% of patients progressing to enucleation and most patients having decreased visual acuity after treatment. Although there was no significant difference in BCVA at presentation and post treatment, Fig. 1. shows a divergence of outcomes. Nearly all patients who presented with a visual acuity of 20/200 (logMAR 1.0) or better had an improvement in BCVA after treatment. On the other hand, most patients who presented with CF or worse vision remained with non-numerical visual acuity after treatment and many progressed to enucleation.

Treatment of Ocular Coccidioidomycosis

Treatment centers on quelling the proliferation of fungal material and minimizing the inflammatory response. The most common treatment identified in case reports was Amphotericin B, which licensed in the United States in 1959 [17]. Despite poor ocular penetration requiring high doses associated with significant side effects, such as nephrotoxicity, this was the primary treatment of systemic fungal infections until the later development of azole antifungals (Around the 1980s). Currently azoles, such as fluconazole, are now preferred due to excellent penetration into the eye and a more favorable side effect profile. Intraocular injection of antifungals was used less commonly but was the second line therapy for intraocular coccidioidomycosis. Surgical intervention is used sparingly as classic teaching says disruption of the eye leads to seeding of the fungus in an area that was previously unaffected. However, some cases successfully used a combined medical and surgical approach to treat complicated cases, such as endophthalmitis [18,19].

There is no standardized treatment for ocular coccidioidomycosis. The mainstay of treatment for systemic coccidioidomycosis is fluconazole. For treatment resistant or disseminated cases of ocular coccidioidomycosis, Posaconazole, which also has excellent intraocular penetration or Amphotericin B may be required for treatment. 27 patients (42.9%) with intraocular coccidioidomycosis in the review series had parenteral antifungals in addition to intraocular or surgical treatments. Cutaneous, periorbital coccidioidomycosis is treated well with fluconazole (4 patients 6.3%). Intraocular injection of antifungals agents such as voriconazole or amphotericin B are used in treatment resistant cases; 6 patients (9.5%) with intraocular coccidioidomycosis in the review series had intravitreal antifungals.

Surgical intervention for coccidioidomycosis is not performed routinely. Some experts believe coccidioidomycosis affects either the choroid and retina or the aqueous humor, but it is rarely present in both anatomical locations at the time of diagnosis due to the blood retinal barrier. It is theorized that surgical intervention allows for inoculation of fungal particles into all structures of the eye [1]. There are cases of successful combined medical and surgical management to remove foci of suspected coccidioidomycosis or vitrectomy to remove fungal particles.

Surgical intervention for coccidioidomycosis is not performed routinely. Some experts believe coccidioidomycosis affects either the choroid and retina or the aqueous humor, but it is rarely present in both anatomical locations at the time of diagnosis due to the blood retinal barrier. It is theorized that surgical intervention allows for inoculation of fungal particles into all structures of the eye [1]. There are cases of successful combined medical and surgical management to remove foci of suspected coccidioidomycosis or vitrectomy to remove fungal particles.

Key Points

• Coccidioidomycosis area of effect is growing as climate changes increase surface temperature
• High suspicion and knowledge of Coccidioidomycosis ophthalmic pathology is needed to arcuately diagnosis this blinding fungus
• Treatment courses are varied and require frequent observation and adjustment for extended periods of time

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Acknowledgments

The authors declare they had no assistance with study design, data collection, data analysis or manuscript preparation.

Funding Details

No funding was received for this review. No other financial disclosures of all authors.

References

1. Jonna G, Agarwal A. Coccidioidomycosis. In: Gupta V, Nguyen QD, LeHoang P, Agarwal A, eds. The uveitis atlas. Springer India; 2020:263-9.
2. Rodenbiker HT, Ganley JP. Ocular coccidioidomycosis. Surv Ophthalmol. 1980;24(5):263-90.
3. Moorthy RS, Rao NA, Sidikaro Y, Foos RY. Coccidioidomycosis iridocyclitis. Ophthalmology. 1994;101(12):1923-8.
4. Moussa G, Bassilious K, Mathews N. A novel excel sheet conversion tool from Snellen fraction to LogMAR including ‘counting fingers’, ‘hand movement’, ‘light perception’ and ‘no light perception’ and focused review of literature of low visual acuity reference values. Acta Ophthalmol (Copenh). 2021;99(6):e963-5.
5. Lange C, Feltgen N, Junker B, Schulze-Bonsel K, Bach M. Resolving the clinical acuity categories “hand motion” and “counting fingers” using the Freiburg Visual Acuity Test (FrACT). Graefes Arch Clin Exp Ophthalmol. 2009;247(1):137-42.
6. Ampel NM. What’s Behind the Increasing Rates of Coccidioidomycosis in Arizona and California? Curr Infect Dis Rep. 2010;12(3):211-6.
7. Brown J, Benedict K, Park BJ, Thompson GR. Coccidioidomycosis: epidemiology. Clin Epidemiol. 2013;5:185-97.
8. Baptista-rosas RC, Catalán-dibene J, Romero-olivares AL, Hinojosa A, Cavazos T, Riquelme M. Molecular detection of Coccidioides spp. from environmental samples in Baja California: Linking VALLEY FEVER to soil and climate conditions. Fungal Ecol. 2012;5(2):177-90.
9. Cooksey GLS. Regional Analysis of Coccidioidomycosis Incidence — California, 2000-2018. MMWR Morb Mortal Wkly Rep. 2020;69.
10. Crum NF. Coccidioidomycosis: A contemporary review. Infect Dis Ther. 2022;11(2):713-42.
11. Weaver E, Kolivras KN, Thomas RQ, Thomas VA, Abbas KM. Environmental factors affecting ecological niche of Coccidioides species and spatial dynamics of valley fever in the United States. Spat Spatio-Temporal Epidemiol. 2020;32:100317.
12. Valley Fever Statistics | Coccidioidomycosis | Types of Fungal Diseases | Fungal | CDC. 2022. [Last accessed on: January 30, 2025].

https://www.cdc.gov/fungal/diseases/coccidioidomycosis/statistics.html

13. Sorensen RH. Survival characteristics of mycelia and spherules of coccidioides immitis in a simulated natural environment. Am J Hyg. 1964;80:275-85.
14. Egeberg RO, Elconin AE, Egeberg MC. Effect of salinity and temperature on coccidioides immitis and three antagonistic soil saprophytes. J Bacteriol. 1964;88(2):473-6.
15. Maddy KT. Observations on coccidioides immitis found growing naturally in soil. Ariz Med. 1965;22:281-8.
16. Marsden-Haug N, Goldoft M, Ralston C. Coccidioidomycosis acquired in Washington State. Clin Infect Dis Off Publ Infect Dis Soc Am. 2013;56(6):847-50.
17. Dutcher JD, William G, Pagano JF, John V. Amphotericin b, its production and its salts. 1959. [Last accessed on: January 30, 2025].

https://patents.google.com/patent/US2908611A/en

18. Ling JJ, Bays DJ, Thompson GR 3^rd Moshiri A, Mannis MJ. Favorable outcome in coccidioides endophthalmitis-a combined medical and surgical treatment approach. Cornea. 2017;36(11):1423-5.
19. Reed DC, Shah KH, Hubschman JP. Resolution of Coccidioides immitis endophthalmitis with an aggressive surgical and medical therapeutic approach. Semin Ophthalmol. 2013;28(4):251-2.
20. Alexander PB, Coodley EL. Disseminated coccidioidomycosis with intraocular involvement. Am J Ophthalmol. 1967;64(2):283-9.
21. Bell R, Font RL. Granulomatous anterior uveitis caused by Coccidioides immitis. Am J Ophthalmol. 1972;74(1):93-8.
22. Bittencourt CE, Okezie O, Tawansy K, Peterson EM, Minckler DS. Pediatric coccidioidal orbital granuloma. Am J Ophthalmol Case Rep. 2022;25:101302.
23. Blumenkranz MS, Stevens DA. Endogenous coccidioidal endophthalmitis. Ophthalmology. 1980;87(10):974-84.
24. Blumenkranz MS, Stevens DA. Therapy of endogenous fungal endophthalmitis: miconazole or amphotericin B for coccidioidal and candidal infection. Arch Ophthalmol Chic Ill 1960. 1980;98(7):1216-20.
25. Boyden BS, Yee DS. Bilateral coccidioidal choroiditis. A clinicopathologic case report. Trans Am Acad Ophthalmol Otolaryngol Am Acad Ophthalmol Otolaryngol. 1971;75(5):1006-10.
26. Brown WC, Kellenberger RE, Hudson KE. Granulomatous uveitis associated with disseminated coccidioidomycosis. Am J Ophthalmol. 1958;45(1):102-4.
27. Chandler JW, Kalina RE, Milam DF. Coccidioidal choroiditis following renal transplantation. Am J Ophthalmol. 1972;74(6):1080-5.
28. Char DH, Crawford JB, Bertolucci G, Cole T. Intraocular coccidioidomycosis simulating a neoplasm. Br J Ophthalmol. 2012;96(2):218-9.
29. Cheng ML, Leibowitz M, Ha E. Coccidioidal endophthalmitis in immunocompetent person, California, USA. Emerg Infect Dis. 2012;18(6):1015-6.
30. Coba AJ, Sallee PK, Dixon DO, Alkhateb R, Anstead GM. Pandora’s box: disseminated coccidioidomycosis associated with self-medication with an unregulated potent corticosteroid acquired in Mexico. Trop Med Infect Dis. 2021;6(4).
31. Conan NJ, Hyman GA. Disseminated coccidioidomycosis: Treatment with protoanemonin. Am J Med. 1950;9(3):408-13.
32. Cunningham ETJ, Seiff SR, Berger TG, Lizotte PE, Howes ELJ, Horton JC. Intraocular coccidioidomycosis diagnosed by skin biopsy. Arch Ophthalmol Chic Ill 1960. 1998;116(5):674-7.
33. Cutler JE, Binder PS, Paul TO, Beamis JF. Metastatic coccidioidal endophthalmitis. Arch Ophthalmol Chic Ill 1960. 1978;96(4):689-91.
34. Dworak DP, Kapustiak J, Ehklassi TA, Patrianakos TD. Primary cutaneous coccidioidomycosis of the eyelid: a case report. Ophthal Plast Reconstr Surg. 2016;32(2):e40-41. doi:10.1097/IOP.0000000000000224
35. Faulkner RF. Ocular coccidioidomycosis. Report of a case of coccidioidal granuloma of the conjunctiva associated with cutaneous coccidioidomycosis. Am J Ophthalmol. 1962;53:822-7.
36. Gabrielian A, Hariprasad SM. New onset of bilateral multifocal coccidioidomycosal choroiditis in a patient on oral fluconazole. Can J Ophthalmol J Can Ophtalmol. 2010;45(4):419-20.
37. Glasgow BJ, Brown HH, Foos RY. Miliary retinitis in coccidioidomycosis. Am J Ophthalmol. 1987;104(1):24-7.
38. Golden SE, Morgan CM, Bartley DL, Campo RV. Disseminated coccidioidomycosis with chorioretinitis in early infancy. Pediatr Infect Dis. 1986;5(2):272-4.
39. Green WR, Bennett JE. Coccidioidomycosis. Report of a case with clinical evidence of ocular involvement. Arch Ophthalmol Chic Ill 1960. 1967;77(3):337-40.
40. Hwang JM, Pian D. Iritis presumed as secondary to disseminated coccidioidomycosis. Optom St Louis Mo. 2006;77(11):547-53.
41. Irvine ARJ. Coccidioidal granuloma of lid. Trans -Am Acad Ophthalmol Otolaryngol. 1968;72(5):751-4.
42. Jou JR, Patel S, Yo C, Sadun AA, Jou JR. Orbital coccidioidomyosis presenting as a lacrimal gland fossa mass. Br J Ophthalmol. 1995;79(12):1145-6.
43. Lamer L, Paquin F, Lorange G, Bayardelle P, Ojeimi G. Macular coccidioidomycosis. J Can Ophtalmol. 1982;17(3):121-3.
44. Levitt JM. Ocular manifestations in coccidioidomycosis. Am J Ophthalmol. 1948;31(12):1626-8.
45. Lijo-Pavia J. Eflavescencia de retina por coccidioidomycosis. Arch Oftalmol Buenos Aires. 1949;24:239-44.
46. Lovekin LG. Coccidioidomycosis. Report of a case with intraocular involvement. Am J Ophthalmol. 1951;34(4):621-3.
47. Luttrull JK, Wan WL, Kubak BM, Smith MD, Oster HA. Treatment of ocular fungal infections with oral fluconazole. Am J Ophthalmol. 1995;119(4):477-81.
48. Magrath GN, Pulido JS, Montero J, Mason C, Wilson J. Cystoid macular edema secondary to fluconazole toxicity. Ocul Immunol Inflamm. 2010;18(6):472-4.
49. Maguire LJ, Campbell RJ, Edson RS. Coccidioidomycosis with necrotizing granulomatous conjunctivitis. Cornea. 1994;13(6):539-42.
50. Michelson JB, Belmont JB, Higginbottom P. Juxtapapillary choroiditis associated with chronic meningitis due to Coccidioides immitis. Ann Ophthalmol. 1983;15(7):666-8.
51. Mondino KM, Holland GN, Glasgow BJ. Retinal seeding from anterior segment coccidioidomycosis after vitrectomy. Br J Ophthalmol. 2007;91(6):837-8.
52. Nordstrom B, Sherpa N, Marshall M, Chawla A, Heidari A, Johnson R. Coccidioidomycosis chorioretinitis. J Investig Med High Impact Case Rep. 2019;7:2324709619881561.
53. Olavarria R, Fajardo LF. Ophthalmic coccidioidomycosis. Case report and review. Arch Pathol. 1971;92(3):191-195.
54. PERRY DM, KIRBY WMM. Acute disseminated coccidioidomycosis: two cases treated with amphotericin B. AMA Arch Intern Med. 1960;105(6):929-34.
55. Pettit TH, Learn RN, Foos RY. Intraocular coccidioidomycosis. Arch Ophthalmol Chic Ill 1960. 1967;77(5):655-61.
56. Quinlan EJ, Gill V. Initial presentation of disseminated coccidioidomycosis with ocular lesions. Case Rep Infect Dis. 2020;2020:1305193.
57. Reed DS, Kostosky N, Epstein A, Blaydon S, Durairaj V, Somogyi M. Disseminated coccidioidomycosis with orbital osteomyelitis and periorbital abscess. Ophthal Plast Reconstr Surg. 2021;37(5):e173-6.
58. Rixford E, Gilchrist TC. Two cases of protozoan (coccidioidal) infection of the skin and other organs. Johns Hopkins Hosp Rep. 1896;1:209-68.
59. Shields RA, Tang PH, Bodnar ZM, Smith SJ, Silva AR. Optical coherence tomography angiography highlights chorioretinal lesions in ocular coccidioidomycosis. Ophthalmic Surg Lasers Imaging Retina. 2019;50(3):e71-3.
60. Stone JL, Kalina RE. Ocular coccidioidomycosis. Am J Ophthalmol. 1993;116(2):249-50.
61. Toomey CB, Gross A, Lee J, Spencer DB. A case of unilateral coccidioidal chorioretinitis in a patient with hiv-associated meningoencephalitis. Case Rep Ophthalmol Med. 2019;2019(101581018):1475628.
62. Trowbridge DH. Ocular manifestations of coccidioidomycosis. Trans Pac Coast Otoophthalmol Soc Annu Meet. 1952;33:229-46.
63. Ugurlu S, de Alba Campomanes AG, Naseri A, Blair JE, McLeish WM. Coccidioidomycosis of the eyelid. Ophthal Plast Reconstr Surg. 2005;21(2):157-9.
64. Vasconcelos-Santos DV, Lim JI, Rao NA. Chronic coccidioidomycosis endophthalmitis without concomitant systemic involvement: a clinicopathological case report. Ophthalmology. 2010;117(9):1839-42.
65. Wood TR. Ocular coccidioidomycosis. Report of a case presenting as Parinaud’s oculoglandular syndrome. Am J Ophthalmol. 1967;64(3):Suppl:587-90.
66. Zakka KA, Foos RY, Brown WJ. Intraocular coccidioidomycosis. Surv Ophthalmol. 1978;22(5):313-21.