WikiDoc Resources for Endophthalmitis
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For more information on bacterial endophthalmitis, please click here
For more information on post-operative endophthalmitis, please click here
For more information on bleb-related endophthalmitis, please click here
For more information on post-traumatic endophthalmitis, please click here
For more information on endogenous endophthalmitis, please click here
Endophthalmitis is an inflammation of the internal coats of the eye. It is a dreaded complication of all intraocular surgeries, particularly cataract surgery, with possible loss of vision. The most common etiology is infectious. Various bacteria and fungi have been isolated as the cause of infectious endophthalmitis. Other causes include penetrating trauma and retained intraocular foreign bodies.
Endophthalmitis may be classified according to causative organisms into 2 subtypes:
- Bacterial endophthalmitis
- Fungal endophthalmitis
Additionally, endophthalmitis may be classified as either endogenous or exogenous based on the route of infection.
- Exogenous endophthalmitis
- Endogenous endophthalmitis
Endophthalmitis is an ocular inflammation resulting from the introduction of an infectious agent, either bacterial or fungal, into the posterior segment of the eye. Infectious agents are introduced to the anterior and posterior segments of the eye exogenously or endogenously.
Exogenous endophthalmitis occurs following a penetrating ocular injury or ocular surgery. Besides cataract (approximately 90% of all cases), nearly all other type of ocular surgery such as glaucoma, retinal, radial keratotomy, and intravitreal injections may be able to disturb the integrity of the eye globe and contaminate the aqueous humor and/or vitreous humor.
Endogenous endophthalmitis is caused by the hematologic dissemination of an infection to the eyes. The most common extraocular foci of infection include liver abscess, pneumonia, and endocarditis. Endogenous endophthalmitis is commonly associated with immunosuppression or procedures that increase the risk for blood-borne infections such as diabetes, HIV, malignancy, intravenous drug use, transplantation, immunosuppressive therapy, and catheterization.
On microscopic histopathological analysis, infiltration of polymorphonuclear leukocytes or chronic inflammatory cells (depending on the duration of the inflammation) and destruction of ocular structures are characteristic findings of endophthalmitis.
Common causes of endophthalmitis include:
Differentiating Endophthalmitis from Other Diseases
- Toxic anterior segment syndrome (TASS)
- Retained lens material
- Flare-up of pre-existing uveitis
- Dehemoglobinized vitreous hemorrhage
Bleb-related endophthalmitis must be differentiated from:
- Blebitis (bleb-related endophthalmitis is characterized by severe loss of vision, marked pain, and presence of vitritis)
- Anterior uveitis
- Uveitis-glaucoma-hyphema syndrome
Epidemiology and Demographics
In the United States, post-cataract endophthalmitis is the most common form of endophthalmitis. The incidence of post-cataract endophthalmitis is estimated to range from 80 to 360 cases per 100,000 individuals.
- Secondary intraocular lens placement
- Intra-ocular lenses (IOLs) with polypropylene
- Intracapsular cataract extraction
- Clear corneal incisions
- Retained intraocular foreign bodies
- Injury in a rural setting
- Delay in repair more than 24 hours
- Bleb related
- Recent hospitalization
There is no recommended screening guideline for endophthalmitis.
Natural History, Complications, and Prognosis
Endophthalmitis is a medical emergency. If left untreated, it may lead to panophthalmitis, corneal infiltration, corneal perforation, and permanent vision loss.
Common complications of endophthalmitis include:
- Decrease or loss of vision
- Chronic pain
- Cataract development
- Retinal detachment
- Vitreous hemorrhage
- Hypotony and phthisis bulbi
Early diagnosis and treatment with antimicrobial therapy are fundamental to optimize visual outcome.
History and Symptoms
A history of recent intraocular surgery or penetrating ocular trauma is usually elicited. Endogenous endophthalmitis is more commonly seen in patients with immunocompromised states such as AIDS and also in diabetes.
The condition is usually accompanied by severe pain, loss of vision, and redness of the conjunctiva and the underlying episclera. Hypopyon may also be observed in endophthalmitis patients by a slit lamp examination.
- Culture and gram stain of aqueous humor as well as the vitreous humor
- Polymerase chain reaction (PCR) of aqueous humor as well as the vitreous humor
Other Diagnostic Studies
Slit Lamp Examination Findings
- Hypopyon ( >80% of cases)
- Anterior chamber and vitreous inflammation
- Cloudy cornea
- Clumps of exudate in the anterior chamber (around the pupillary margin)
- Cloudy cornea
- Decreased red reflex
Exogenous fungal endophthalmitis with corneal ulcer
(A) Severe conjunctival injection, subconjunctival hemorrhage, corneal stromal edema, and hypopyon (B) Fundus photograph shows a mild pale color of optic disc & macular degeneration
Patients require urgent examination by an expert ophthalmologist and vitreo-retinal specialist who will determine the need for intravitreal injection of antibiotics and possible urgent pars plana vitrectomy. Enucleation may be required to remove a blind and painful eye. Systemic antibiotics are recommended in endogenous bacterial endophthalmitis because the source of the infection is extraocular. Immediate vitrectomy is often necessary
- Infectious endophthalmitis
- 1. Causative pathogens
- 2. Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
- Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
- Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary
- Note (3): Intravitreal and intravenous Amphotericin B may be added to the regimen if fungal endophthalmitis is suspected
- 3. Pathogen-directed antimicrobial therapy
- 3.1 Bacillus spp.
- 3.2 Non-Bacillus gram-positive bacteria
- 3.3 Gram-negative bacteria
- 3.4 Candida spp.
- Preferred regimen: (Fluconazole 400-800 mg IV/PO qd for 6-12 weeks OR Voriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks OR Amphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
- Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
- 3.5 Aspergillus spp.
- Preferred regimen: Amphotericin B 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose AND Dexamethasone 400 microgram intravitreal injection, single dose
- Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
- Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy
- 4. Special Considerations
- 4.1 Endogenous endophthalmitis
- 4.1.1 Empiric antimicrobial therapy
- 4.2 Bleb-related endophthalmitis
- 4.2.1 Empiric antimicrobial therapy
- 4.3 Post-operative endophthalmitis
- 4.3.1 Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose
- Note (1): In addition to intravitreal antibiotic therapy, vitrectomy is necessary
- Note (2): If there is no improvement in 48 h, a repeat intravitreal injection may be administered
- Note (3): Late post-operative endophthalmitis is often caused by Propionibacterium acnes (several years post-op)
- 4.3.2 Pathogen-directed antimicrobial therapy
- 22.214.171.124 Gram-positive bacteria
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose
- 126.96.36.199 Gram-negative bacteria
- Preferred regimen: Amikacin 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
- Note: Intravitreal amikacin is associated with the development of retinal microvasculitis
- 4.4 Post-traumatic endophthalmitis
- 4.4.1 Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
- Note (1): Removal of foreign bodies and debridement of necrotic tissue is necessary
- Note (2): In addition to antimicrobial therapy, vitrectomy is necessary
- Note (3): Systemic broad spectrum antibiotics are recommended in post-traumatic endophthalmitis
Common effective measures for the primary prevention of endophthalmitis include:
- Proper sterile preparation of the surgical site
- Sterile preparation of the skin surrounding the surgical eye with Povidone-Iodine 10%
- Povidone-Iodine 5% onto the ocular surface (3-5 minutes prior to surgery)
- Removal of foreign bodies and debridement of necrotic tissue after penetrating eye injury
- Intracameral or intravitreal antibiotic injection after penetrating eye injury
- Effective treatment of underlying medical conditions
There are no secondary preventive measures available for post-operative endophthalmiatis, endophthalmiatis is a medical emergency.
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