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Ophthalmology – Endophthalmitis
Endophthalmitis is a severe, vision-threatening intraocular inflammatory condition involving the vitreous and aqueous humors, most commonly due to infection. It is considered an ophthalmic emergency, as rapid progression can lead to permanent vision loss or blindness. The condition is broadly classified into infectious (postoperative, posttraumatic, or endogenous) and noninfectious (sterile) forms, the latter mimicking infection clinically.
Most cases are postoperative (approximately 75%), particularly following cataract surgery, with an incidence of about 0.05–0.16%. Posttraumatic cases account for about 20%, often associated with penetrating injuries or retained intraocular foreign bodies. Endogenous cases (around 5%) occur when infection spreads hematogenously from a distant systemic source, typically in immunocompromised individuals, intravenous drug users, or patients with indwelling catheters.
The pathophysiology involves rapid microbial proliferation within the vitreous cavity, followed by a robust inflammatory response. Within 24 hours, inflammatory cells infiltrate ocular tissues, and by 48 hours, irreversible photoreceptor damage may occur. Even after microbial control, inflammatory mediators and endotoxins may continue to damage intraocular structures.
Patients typically present with acute onset of eye pain, decreased vision, and redness, often with a history of recent surgery, trauma, or systemic infection. Examination findings may include conjunctival injection, corneal edema, hypopyon (layering of pus in the anterior chamber), anterior chamber inflammation, and dense vitreitis, often obscuring the view of the retina. Postoperative and traumatic cases are usually unilateral, while endogenous cases may be bilateral.
Diagnosis is primarily clinical but supported by investigations. A vitreous tap is performed to obtain samples for Gram stain, culture, and fungal studies. In suspected endogenous cases, blood and urine cultures may help identify the systemic source, and an echocardiogram may be required to rule out endocarditis. B-scan ultrasonography is useful when the retina cannot be visualized, helping detect vitreous inflammation or retinal detachment.
Management requires urgent intravitreal antibiotic therapy, targeting both Gram-positive and Gram-negative organisms. Common regimens include vancomycin and ceftazidime, often combined with intravitreal corticosteroids to reduce inflammation. In suspected fungal infections, intravitreal antifungal agents are used. Patients with very poor vision (light perception only) typically require pars plana vitrectomy, which removes infected vitreous material and improves drug penetration.
Close monitoring is essential, often requiring daily follow-up until stabilization. Additional treatments may include repeat intravitreal injections or delayed vitrectomy if response is inadequate. Endogenous cases require systemic evaluation and treatment of the underlying infection, often in collaboration with infectious disease specialists.
Despite advances in treatment, the prognosis remains guarded, with a significant risk of permanent vision impairment or blindness. Early diagnosis and prompt intervention greatly improve outcomes. Complications include retinal detachment and phthisis bulbi, both of which can lead to irreversible vision loss.
Endophthalmitis is a severe, vision-threatening intraocular inflammatory condition involving the vitreous and aqueous humors, most commonly due to infection. It is considered an ophthalmic emergency, as rapid progression can lead to permanent vision loss or blindness. The condition is broadly classified into infectious (postoperative, posttraumatic, or endogenous) and noninfectious (sterile) forms, the latter mimicking infection clinically.
Most cases are postoperative (approximately 75%), particularly following cataract surgery, with an incidence of about 0.05–0.16%. Posttraumatic cases account for about 20%, often associated with penetrating injuries or retained intraocular foreign bodies. Endogenous cases (around 5%) occur when infection spreads hematogenously from a distant systemic source, typically in immunocompromised individuals, intravenous drug users, or patients with indwelling catheters.
The pathophysiology involves rapid microbial proliferation within the vitreous cavity, followed by a robust inflammatory response. Within 24 hours, inflammatory cells infiltrate ocular tissues, and by 48 hours, irreversible photoreceptor damage may occur. Even after microbial control, inflammatory mediators and endotoxins may continue to damage intraocular structures.
Patients typically present with acute onset of eye pain, decreased vision, and redness, often with a history of recent surgery, trauma, or systemic infection. Examination findings may include conjunctival injection, corneal edema, hypopyon (layering of pus in the anterior chamber), anterior chamber inflammation, and dense vitreitis, often obscuring the view of the retina. Postoperative and traumatic cases are usually unilateral, while endogenous cases may be bilateral.
Diagnosis is primarily clinical but supported by investigations. A vitreous tap is performed to obtain samples for Gram stain, culture, and fungal studies. In suspected endogenous cases, blood and urine cultures may help identify the systemic source, and an echocardiogram may be required to rule out endocarditis. B-scan ultrasonography is useful when the retina cannot be visualized, helping detect vitreous inflammation or retinal detachment.
Management requires urgent intravitreal antibiotic therapy, targeting both Gram-positive and Gram-negative organisms. Common regimens include vancomycin and ceftazidime, often combined with intravitreal corticosteroids to reduce inflammation. In suspected fungal infections, intravitreal antifungal agents are used. Patients with very poor vision (light perception only) typically require pars plana vitrectomy, which removes infected vitreous material and improves drug penetration.
Close monitoring is essential, often requiring daily follow-up until stabilization. Additional treatments may include repeat intravitreal injections or delayed vitrectomy if response is inadequate. Endogenous cases require systemic evaluation and treatment of the underlying infection, often in collaboration with infectious disease specialists.
Despite advances in treatment, the prognosis remains guarded, with a significant risk of permanent vision impairment or blindness. Early diagnosis and prompt intervention greatly improve outcomes. Complications include retinal detachment and phthisis bulbi, both of which can lead to irreversible vision loss.
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