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Ocular System

Endophthalmitis

Rare but severe form of inflammation of inner coats of the eye, resulting from intraocular colonization of infectious agents with exudation within intraocular fluids (vitreous and aqueous)

Rare but severe form of inflammation of inner coats of the eye, resulting from intraocular colonization of infectious agents with exudation within intraocular fluids (vitreous and aqueous)

Aetiology

Exogenous endophthalmitis:

Infecting organisms gain entry into the eye via direct inoculation
  • Intraocular surgery
  • Penetrating trauma
  • Contiguous spread from adjacent tissues
(A) A case of severe exogenous fungal endophthalmitis secondary to eyeball rupture post repair. (B) A typical case of acute postoperative endophthalmitis after phacoemulsification. (C) A case of chronic bleb-related endophthalmitis. | Sheu S. J. (2017). Endophthalmitis. Korean journal of ophthalmology : KJO, 31(4), 283–289. https://doi.org/10.3341/kjo.2017.0036

Endogenous endophthalmitis:

Infectious agents hematogenously spread into the eye from a distant focus of infection
  • Liver abscess (M/C)
(A) A 70-year-old female with diabetes developed endogenous endophthalmitis secondary to Klebsiella pneumoniae (KP) liver abscess. Clinical presentation included typical papillary hypopyon. (B) A 75-year-old diabetic male visited an ophthalmologist before the diagnosis of KP liver abscess. Clinical examination revealed severe panophthalmitis without history of ocular trauma or surgery. The eye was lost despite treatment with systemic and intravitreal antibiotics. (C) A 63-year-old male with hypertension and history of endocarditis and liver abscess treated elsewhere 3 months prior. Ocular examination showed hypopyon, lens opacity, and vitreous opacity. Inf lammation resolved after combined pars plana vitrectomy, extracapsular cataract extraction, and administration of intravitreal antibiotics. (D) A 45-year-old male with poorly controlled diabetes developed bilateral endophthalmitis secondary to KP liver abscess. Endophthalmitis resolved after systemic antibiotics and one treatment with intravitreal ceftazidime. | Sheu S. J. (2017). Endophthalmitis. Korean journal of ophthalmology : KJO, 31(4), 283–289. https://doi.org/10.3341/kjo.2017.0036

Causative organisms:

  • Staphylococcus epidermidis (30.3%)
  • Other coagulase-negative Staphylococcus (9.1%)
  • Streptococcus viridans (12.1%)
  • Staphylococcus aureus (11.1%)
  • Enterobacteriaceae (3.4%)
  • Pseudomonas aeruginosa (2.5%)
  • Klebsiella pneumoniae

Risk factors:

For endogenous endophthalmitis
  • Chronic metabolic diseases:
    • Diabetes (M/C)
  • Immunosuppression
  • Malignancy
  • IV drug abuse
  • Long-term presence of an intracorporeal foreign body
  • Invasive surgery

Clinical features

Ocular symptoms:

  • Ocular pain, redness, swelling, and discharge
  • Blurred vision and floaters

Systemic symptoms:

often non-specific
  • Malaise, nausea, loss of appetite or weight, abdominal discomfort, fever, chills, and rigor.

Complications

  • Panophthalmitis: M/extensive ocular involvement in endophthalmitis with inflammation in periocular tissues.
  • Corneal ulcer
  • Orbital cellulitis
  • Loss of vision
  • Retinal detachment

Diagnosis

The diagnosis of endophthalmitis depends mostly on the clinical findings on ophthalmological examination. Delayed diagnosis of endogenous endophthalmitis can lead to not only visual loss, but also increased risk of mortality.

Differential diagnosis:

  • Retinochoroidal infection
  • Noninfectious posterior/intermediate uveitis
  • Neoplastic conditions: Large cell lymphoma or retinoblastoma

Management

Antimicrobial therapy:

Owing to the rapid progression and poor prognosis of endophthalmitis, treatment should be started empirically without waiting for laboratory confirmation.
  • Systemic broad-spectrum antibiotics + intravitreal injection of antibiotics (ceftazidime, 2.25 mg/0.1 mL; vancomycin, 1 mg/0.1 mL) or anti-fungal agents (amphotericin B, fluconazole, voriconazole).

Adjunctive therapy:

Ameliorate inflammation and pain as well as secondary glaucoma
  • Topical cycloplegics
  • Steroids
  • Hypotensive agents

Pars plana vitrectomy (PPV):

Indicated for persistent inflammation, vitreous biopsy, or retinal complication

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