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Infectious Disease : Endophthalmitis
ENDOPHTHALMITIS
BASIC DESCRIPTION: Endophthalmitis is an infectious condition that affects the ocular (vitreous) cavity, while panophthalmitis is an inflammation that affects every eye structure.
The incidence of epidemiology
While the incidence of endophthalmitis following penetrating ocular trauma is reported to be between 3 and 30% and is typically higher in situations with retained intraocular foreign bodies, the rate following cataract surgery is between 0.1% and 0.3%.
RISK FACTORS • The most common risk factors include untreated blepharitis, poor surgical technique, and intraoperative complications/extended operating time.
• significant risk factors for acute endophthalmitis following surgery.
Patients who are immunocompromised, diabetic, or chronically unwell are most at risk for endogenous endophthalmitis, which has been reported to occur in 1 in 5,000 to 10,000 hospitalizations, particularly those who have indwelling intravenous catheters and/or positive blood cultures.
OVERALL PREVENTION
• Despite the absence of data showing a decrease in the incidence of post-operative endophthalmitis, routine post-operative administration of topical fluoroquinolones is thought to be the standard of care following cataract surgery.
• It has recently been demonstrated that intracameral administration of cefuroxime reduces the incidence of post-operative endophthalmitis following cataract surgery (1).
• For penetrating ocular injuries with a high risk of infection, such as intraocular foreign bodies, several authorities advise systemic intravenous prophylaxis with vancomycin (1 g i.v. b.i.d.) or moxifloxacin (400 mg p.o. each day).
• For anterior segment trauma, such as corneal laceration, topical antibiotics that are fortified (vancomycin 25–50 mg/mL, cefazolin 50 mg/mL, and/or tobramycin 15 mg/mL) or topical fluoroquinolones, as well as subconjunctival injections at the conclusion of the surgical procedure, can generate therapeutic levels of
antibiotics in the anterior chamber. Patients with infection foci, particularly those suffering from Candida spp.-caused fungemia, should be closely watched for the onset of endogenous endophthalmitis.
Pathophysiology
• Post-operative endophthalmitis can result from improper wound creation following cataract surgery, which permits conjunctival and eyelid flora to enter the anterior chamber.
• In individuals with infectious processes elsewhere, bacteria can spread through the bloodstream and initially impact the choroid, resulting in endogenous endophthalmitis.
ETIOLOGY • The causes of infectious endophthalmitis might be parasitic, bacterial, or fungal. Acinetobacter species, Actinomyces israelii, Bacillus species, Clostridium species, Corynebacterium species, Escherichia coli, Haemophilus influenzae, Klebsiella species, Listeria monocytogenes, Neisseria meningitides, Proteus species, and Propionibacterium are among the most frequent causes, listed alphabetically.
Salmonella typhimurium, Pseudomonas aeruginosa, Serratia marcescens, Streptococcus species, Staphylococcus species, acnes
- Parasites (Taenia solium, Toxocara canis, Toxoplasma gondii) - Fungi (Aspergillus species, Blastomyces dermatitidis, Candida species, Coccidioides immitis, Fusarium species, Penicillium species, Rhizopus species, and Sporothrix schenckii)
• Endophthalmitis can develop six weeks following eye surgery or an intravitreal injection (acute post-operative endophthalmitis) or months or even years following the procedure as a result of less virulent organisms (such as Propionibacterium acnes); in the latter case, it is referred to as chronic endophthalmitis. – Following penetrating ocular trauma to the globe
The thinned and stretched conjunctiva's incapacity to operate as a barrier against bacterial invasion late after a glaucoma filtering operation
Gram-positive organisms make up the majority of identified isolates in cases of acute post-operative endophthalmitis following cataract surgery. Rarely, hematogenous seeding from a distant site can cause endogenous endophthalmitis, which is caused by septic emboli from a diseased heart valve that lodge into the choroidal circulation.
• Gram-negative and streptococcal bacteria
Infections caused by organisms have a worse prognosis.
• Infections caused by mixed flora are more common following trauma; in open globe injuries from rural locations where organic materials is causing the damage, the prevalence can reach 42%.
• As seen in Uveitis-Chorioretinitis, parasites frequently result in chorioretinal lesions and a slower inflammatory response that may be more harmful than the infection itself.
COMMON CONNECTED CIRCUMSTANCES
The most frequent related condition is a history of penetrating trauma or recent eye surgery.
History of Diagnosis
• The majority of endophthalmitis patients arrive with conjunctival injection (redness) and eye pain. Light sensitivity, or photophobia, is a symptom of this condition. There may also be eyelid edema and conjunctival chemosis. Sometimes, though, the only sign is sight loss.
• In certain cases, a seemingly minor injury could not prompt the patient to seek medical attention until days or weeks later, when the signs and symptoms of an infection have emerged, exposing an occult penetrating injury, especially if the infecting organism is a fungus.
• The beginning of pain and severe sight loss are indicators of an aggressive course in some cases, particularly Bacillus cereus infections.
• One of the symptoms of panophthalmitis is pain when moving the eye.
MEDICAL EXAMINATION
• The formation of vitreous opacities is crucial for
diagnosis.
• White blood cell (WBC) layering in the anterior chamber, or hypopyon, is a typical occurrence.
• Hematogenous dissemination of infections is commonly characterized by chorioretinal infiltrates with secondary vitreous involvement.
Tests for Diagnosis and Interpretation Lab
First laboratory testing
• Although aqueous and vitreous aspiration for microbial cultures and smear should be carried out in cases of suspected endophthalmitis, this procedure can occasionally be inconclusive (cultures are positive in around 70% of suspected cases of post-operative infectious endophthalmitis).
• Smears should be cultured for aerobic and anaerobic bacteria, mycobacteria, and fungi (blood, chocolate, thioglycolate, Sabouraud, etc.) after being stained with Gram, Giemsa, and methenamine-silver.
Follow-up and Particular Points to Remember
• Although culture findings are usually positive in 48 hours, treatment shouldn't be postponed.
• Inadequate sampling may be the cause of negative outcomes.
fastidious organisms or due to sterile post-operative inflammation. • During vitrectomy, which is done for therapeutic or diagnostic purposes, vitreous aspiration material is regularly collected and can be either passed through a filter that can be stained and cultured or centrifuged and smeared.
Imagining
In cases of suspected retained intraocular foreign bodies, imaging using computer tomography or ultrasonography might be helpful, particularly when cloudy media make vision less than ideal.
Diagnostic Techniques and Other
Using a 25–30 G needle, aqueous humor should be extracted and sent for culture during a local anesthetic office procedure. A 23 G needle can be used to acquire vitreous samples through the pars plana.
Pathological Results
The presence of neutrophils is a characteristic of acute endophthalmitis.
DIFFERENTIAL DIAGNOSIS: Idiopathic or non-idiopathic uveitis, postoperative sterile inflammation brought on by intraocular pharmacologic agents (such as toxic anterior segment syndrome, or TASS), and postoperative sterile inflammation brought on by retained lens fragments in cases of complex cataract surgery are additional intraocular inflammatory syndromes that can resemble infectious endophthalmitis.
FIRST LINE TREATMENT MEDICATION
• Since acute post-operative bacterial endophthalmitis is a real ophthalmologic emergency, treatment needs to start right away.
• The current suggested treatment strategy is to provide 0.1 mL of each drug intravitreally: 1.0 mg/0.1 mL of vancomycin for Gram-positive coverage and 2.25 mg/0.1 mL of ceftazidime or 0.4 mg/0.1 mL of amikacin for Gram-negative coverage in cases of β-lactam hypersensitivity. The possible harmful effect of some drugs on the retina limits the selection of antibiotics.
In cases of exposed sutures or wound leaks, topical fluoroquinolone or fortified topical antibiotic preparations (e.g., cefazolin 50 mg/mL, vancomycin 25–50 mg/mL, and/or tobramycin 15 mg/mL) should be administered hourly to achieve adequate concentrations in the anterior chamber.
• After cataract surgery, systemic antibiotic administration
• The endophthalmitis vitrectomy study does not support infections related to surgery. The choice of aminoglycosides for the treatment of an illness primarily caused by Gram-positive isolates in this particular investigation limits the methodology of this conclusion.
Despite the lack of prospective evidence, systemic 4th-generation fluoroquinolones, such as moxifloxacin 400 mg p.o. daily, should be taken into consideration because of the high intraocular concentration that these antibiotics achieve.
• In addition to the aforesaid intravitreal vancomycin and ceftazidime, empirical systemic treatment of the presumed cause is advised in cases of bacterial endogenous endophthalmitis. The results of the culture should be used to customize the antibiotic treatment.
• The majority of treatment protocols advise intravitreal infusion of 0.1 mL of amphotericin B (5–10 μg/0.1 mL) for traumatic fungal endophthalmitis or post-operative fungal endophthalmitis. However, it is important to consider the possibility of retinal toxicity. Amphotericin B does not seem to reach adequate intraocular concentrations when administered systemically. For endogenous cases, however, systemic treatment is required.
• When intravenous drug abusers develop traumatic endophthalmitis or endogenous endophthalmitis, systemic clindamycin therapy (150–300 mg i.v. t.i.d.) or intravitreal clindamycin (0.1 mL of a 1 mg/0.1 mL) may be necessary.
Some experts advise using preparation) rather than vancomycin to provide protection against B. cereus, which is linked to a very aggressive course.
Although no comparable data are available, systemic fluconazole (400–600 mg i.v. or p.o. loading dosage per day followed by 200–400 mg p.o. or i.v. per day) may be less harmful than systemic amphotericin B for endogenous endophthalmitis caused by Candida albicans. Other alternatives include caspofungin and voriconazole.
ADDITIONAL MEDICATION
Overall Actions
Topical cycloplegic eye drops (atropine 1% daily or b.i.d.) and appropriate oral drugs are required to manage the associated pain.
Referral Issues
The patient should be sent to ophthalmology as soon as the diagnosis is suspected or confirmed.
COMPlementary and substitute Methods
It is generally acknowledged that topical (prednisolone acetate 1% eye drops) or periocular corticosteroids can alter the host immune response. It is debatable whether steroids (triamcinolone acetate 4 mg/0.1 mL [1 mL] or prednisone 60 mg p.o.) should be administered intravitreally or systemically.
OTHER PROCEDURES AND SURGERY
Pars Per the endophthalmitis vitrectomy trial, in instances related to cataract surgery, plana vitrectomy is helpful if visual acuity at presentation is light perception or worse. Early vitrectomy can clear the eye of toxins and necrotic tissue while also reducing the bacterial burden.
Considering the patient
First Stabilization
It is possible to treat post-operative endophthalmitis as an outpatient.
Getting in Criteria Hospitalization may be required because to social
factors or in patients who are monocular.
Continuing Care Follow-Up Suggestions
If the patient's health deteriorates 48 hours after starting intravitreal antibiotics, re-administration of the medication—with or without vitrectomy—should be taken into consideration.
Monitoring of Patients
The treating ophthalmologist should monitor the patient every day.
PROGNOSIS • The range of microorganisms involved and the resulting direct tissue damage contribute to the visual prognosis of traumatic endophthalmitis being poorer than postoperative endophthalmitis.
• In a recent combined series of post-traumatic endophthalmitis, only 30% of eyes were 20/400 or better after elective cataract surgery, whereas culture-proven infected eyes achieved visual acuity of 20/40 or better 50% of the time and 20/400 or better 85% of the time.
better. Seventy-four percent of participants in the endophthalmitis vitrectomy study experienced visual recovery of 20/100 or higher.
• The prognosis for endophthalmitis caused by B. cereus is nearly always poor.
COMPLICATIONS
The most frequent causes of vision loss are tissue necrosis and the inflammatory reaction to the retina. Phthisis, secondary glaucoma, and retinal detachment may ensue.
ENDOPHTHALMITIS
BASIC DESCRIPTION: Endophthalmitis is an infectious condition that affects the ocular (vitreous) cavity, while panophthalmitis is an inflammation that affects every eye structure.
The incidence of epidemiology
While the incidence of endophthalmitis following penetrating ocular trauma is reported to be between 3 and 30% and is typically higher in situations with retained intraocular foreign bodies, the rate following cataract surgery is between 0.1% and 0.3%.
RISK FACTORS • The most common risk factors include untreated blepharitis, poor surgical technique, and intraoperative complications/extended operating time.
• significant risk factors for acute endophthalmitis following surgery.
Patients who are immunocompromised, diabetic, or chronically unwell are most at risk for endogenous endophthalmitis, which has been reported to occur in 1 in 5,000 to 10,000 hospitalizations, particularly those who have indwelling intravenous catheters and/or positive blood cultures.
OVERALL PREVENTION
• Despite the absence of data showing a decrease in the incidence of post-operative endophthalmitis, routine post-operative administration of topical fluoroquinolones is thought to be the standard of care following cataract surgery.
• It has recently been demonstrated that intracameral administration of cefuroxime reduces the incidence of post-operative endophthalmitis following cataract surgery (1).
• For penetrating ocular injuries with a high risk of infection, such as intraocular foreign bodies, several authorities advise systemic intravenous prophylaxis with vancomycin (1 g i.v. b.i.d.) or moxifloxacin (400 mg p.o. each day).
• For anterior segment trauma, such as corneal laceration, topical antibiotics that are fortified (vancomycin 25–50 mg/mL, cefazolin 50 mg/mL, and/or tobramycin 15 mg/mL) or topical fluoroquinolones, as well as subconjunctival injections at the conclusion of the surgical procedure, can generate therapeutic levels of
antibiotics in the anterior chamber. Patients with infection foci, particularly those suffering from Candida spp.-caused fungemia, should be closely watched for the onset of endogenous endophthalmitis.
Pathophysiology
• Post-operative endophthalmitis can result from improper wound creation following cataract surgery, which permits conjunctival and eyelid flora to enter the anterior chamber.
• In individuals with infectious processes elsewhere, bacteria can spread through the bloodstream and initially impact the choroid, resulting in endogenous endophthalmitis.
ETIOLOGY • The causes of infectious endophthalmitis might be parasitic, bacterial, or fungal. Acinetobacter species, Actinomyces israelii, Bacillus species, Clostridium species, Corynebacterium species, Escherichia coli, Haemophilus influenzae, Klebsiella species, Listeria monocytogenes, Neisseria meningitides, Proteus species, and Propionibacterium are among the most frequent causes, listed alphabetically.
Salmonella typhimurium, Pseudomonas aeruginosa, Serratia marcescens, Streptococcus species, Staphylococcus species, acnes
- Parasites (Taenia solium, Toxocara canis, Toxoplasma gondii) - Fungi (Aspergillus species, Blastomyces dermatitidis, Candida species, Coccidioides immitis, Fusarium species, Penicillium species, Rhizopus species, and Sporothrix schenckii)
• Endophthalmitis can develop six weeks following eye surgery or an intravitreal injection (acute post-operative endophthalmitis) or months or even years following the procedure as a result of less virulent organisms (such as Propionibacterium acnes); in the latter case, it is referred to as chronic endophthalmitis. – Following penetrating ocular trauma to the globe
The thinned and stretched conjunctiva's incapacity to operate as a barrier against bacterial invasion late after a glaucoma filtering operation
Gram-positive organisms make up the majority of identified isolates in cases of acute post-operative endophthalmitis following cataract surgery. Rarely, hematogenous seeding from a distant site can cause endogenous endophthalmitis, which is caused by septic emboli from a diseased heart valve that lodge into the choroidal circulation.
• Gram-negative and streptococcal bacteria
Infections caused by organisms have a worse prognosis.
• Infections caused by mixed flora are more common following trauma; in open globe injuries from rural locations where organic materials is causing the damage, the prevalence can reach 42%.
• As seen in Uveitis-Chorioretinitis, parasites frequently result in chorioretinal lesions and a slower inflammatory response that may be more harmful than the infection itself.
COMMON CONNECTED CIRCUMSTANCES
The most frequent related condition is a history of penetrating trauma or recent eye surgery.
History of Diagnosis
• The majority of endophthalmitis patients arrive with conjunctival injection (redness) and eye pain. Light sensitivity, or photophobia, is a symptom of this condition. There may also be eyelid edema and conjunctival chemosis. Sometimes, though, the only sign is sight loss.
• In certain cases, a seemingly minor injury could not prompt the patient to seek medical attention until days or weeks later, when the signs and symptoms of an infection have emerged, exposing an occult penetrating injury, especially if the infecting organism is a fungus.
• The beginning of pain and severe sight loss are indicators of an aggressive course in some cases, particularly Bacillus cereus infections.
• One of the symptoms of panophthalmitis is pain when moving the eye.
MEDICAL EXAMINATION
• The formation of vitreous opacities is crucial for
diagnosis.
• White blood cell (WBC) layering in the anterior chamber, or hypopyon, is a typical occurrence.
• Hematogenous dissemination of infections is commonly characterized by chorioretinal infiltrates with secondary vitreous involvement.
Tests for Diagnosis and Interpretation Lab
First laboratory testing
• Although aqueous and vitreous aspiration for microbial cultures and smear should be carried out in cases of suspected endophthalmitis, this procedure can occasionally be inconclusive (cultures are positive in around 70% of suspected cases of post-operative infectious endophthalmitis).
• Smears should be cultured for aerobic and anaerobic bacteria, mycobacteria, and fungi (blood, chocolate, thioglycolate, Sabouraud, etc.) after being stained with Gram, Giemsa, and methenamine-silver.
Follow-up and Particular Points to Remember
• Although culture findings are usually positive in 48 hours, treatment shouldn't be postponed.
• Inadequate sampling may be the cause of negative outcomes.
fastidious organisms or due to sterile post-operative inflammation. • During vitrectomy, which is done for therapeutic or diagnostic purposes, vitreous aspiration material is regularly collected and can be either passed through a filter that can be stained and cultured or centrifuged and smeared.
Imagining
In cases of suspected retained intraocular foreign bodies, imaging using computer tomography or ultrasonography might be helpful, particularly when cloudy media make vision less than ideal.
Diagnostic Techniques and Other
Using a 25–30 G needle, aqueous humor should be extracted and sent for culture during a local anesthetic office procedure. A 23 G needle can be used to acquire vitreous samples through the pars plana.
Pathological Results
The presence of neutrophils is a characteristic of acute endophthalmitis.
DIFFERENTIAL DIAGNOSIS: Idiopathic or non-idiopathic uveitis, postoperative sterile inflammation brought on by intraocular pharmacologic agents (such as toxic anterior segment syndrome, or TASS), and postoperative sterile inflammation brought on by retained lens fragments in cases of complex cataract surgery are additional intraocular inflammatory syndromes that can resemble infectious endophthalmitis.
FIRST LINE TREATMENT MEDICATION
• Since acute post-operative bacterial endophthalmitis is a real ophthalmologic emergency, treatment needs to start right away.
• The current suggested treatment strategy is to provide 0.1 mL of each drug intravitreally: 1.0 mg/0.1 mL of vancomycin for Gram-positive coverage and 2.25 mg/0.1 mL of ceftazidime or 0.4 mg/0.1 mL of amikacin for Gram-negative coverage in cases of β-lactam hypersensitivity. The possible harmful effect of some drugs on the retina limits the selection of antibiotics.
In cases of exposed sutures or wound leaks, topical fluoroquinolone or fortified topical antibiotic preparations (e.g., cefazolin 50 mg/mL, vancomycin 25–50 mg/mL, and/or tobramycin 15 mg/mL) should be administered hourly to achieve adequate concentrations in the anterior chamber.
• After cataract surgery, systemic antibiotic administration
• The endophthalmitis vitrectomy study does not support infections related to surgery. The choice of aminoglycosides for the treatment of an illness primarily caused by Gram-positive isolates in this particular investigation limits the methodology of this conclusion.
Despite the lack of prospective evidence, systemic 4th-generation fluoroquinolones, such as moxifloxacin 400 mg p.o. daily, should be taken into consideration because of the high intraocular concentration that these antibiotics achieve.
• In addition to the aforesaid intravitreal vancomycin and ceftazidime, empirical systemic treatment of the presumed cause is advised in cases of bacterial endogenous endophthalmitis. The results of the culture should be used to customize the antibiotic treatment.
• The majority of treatment protocols advise intravitreal infusion of 0.1 mL of amphotericin B (5–10 μg/0.1 mL) for traumatic fungal endophthalmitis or post-operative fungal endophthalmitis. However, it is important to consider the possibility of retinal toxicity. Amphotericin B does not seem to reach adequate intraocular concentrations when administered systemically. For endogenous cases, however, systemic treatment is required.
• When intravenous drug abusers develop traumatic endophthalmitis or endogenous endophthalmitis, systemic clindamycin therapy (150–300 mg i.v. t.i.d.) or intravitreal clindamycin (0.1 mL of a 1 mg/0.1 mL) may be necessary.
Some experts advise using preparation) rather than vancomycin to provide protection against B. cereus, which is linked to a very aggressive course.
Although no comparable data are available, systemic fluconazole (400–600 mg i.v. or p.o. loading dosage per day followed by 200–400 mg p.o. or i.v. per day) may be less harmful than systemic amphotericin B for endogenous endophthalmitis caused by Candida albicans. Other alternatives include caspofungin and voriconazole.
ADDITIONAL MEDICATION
Overall Actions
Topical cycloplegic eye drops (atropine 1% daily or b.i.d.) and appropriate oral drugs are required to manage the associated pain.
Referral Issues
The patient should be sent to ophthalmology as soon as the diagnosis is suspected or confirmed.
COMPlementary and substitute Methods
It is generally acknowledged that topical (prednisolone acetate 1% eye drops) or periocular corticosteroids can alter the host immune response. It is debatable whether steroids (triamcinolone acetate 4 mg/0.1 mL [1 mL] or prednisone 60 mg p.o.) should be administered intravitreally or systemically.
OTHER PROCEDURES AND SURGERY
Pars Per the endophthalmitis vitrectomy trial, in instances related to cataract surgery, plana vitrectomy is helpful if visual acuity at presentation is light perception or worse. Early vitrectomy can clear the eye of toxins and necrotic tissue while also reducing the bacterial burden.
Considering the patient
First Stabilization
It is possible to treat post-operative endophthalmitis as an outpatient.
Getting in Criteria Hospitalization may be required because to social
factors or in patients who are monocular.
Continuing Care Follow-Up Suggestions
If the patient's health deteriorates 48 hours after starting intravitreal antibiotics, re-administration of the medication—with or without vitrectomy—should be taken into consideration.
Monitoring of Patients
The treating ophthalmologist should monitor the patient every day.
PROGNOSIS • The range of microorganisms involved and the resulting direct tissue damage contribute to the visual prognosis of traumatic endophthalmitis being poorer than postoperative endophthalmitis.
• In a recent combined series of post-traumatic endophthalmitis, only 30% of eyes were 20/400 or better after elective cataract surgery, whereas culture-proven infected eyes achieved visual acuity of 20/40 or better 50% of the time and 20/400 or better 85% of the time.
better. Seventy-four percent of participants in the endophthalmitis vitrectomy study experienced visual recovery of 20/100 or higher.
• The prognosis for endophthalmitis caused by B. cereus is nearly always poor.
COMPLICATIONS
The most frequent causes of vision loss are tissue necrosis and the inflammatory reaction to the retina. Phthisis, secondary glaucoma, and retinal detachment may ensue.
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