Endophthalmitis



Endophthalmitis


Stephen G. Schwartz

Harry W. Flynn Jr.

Roy D. Brod



POSTOPERATIVE ENDOPHTHALMITIS


ACUTE-ONSET POSTOPERATIVE ENDOPHTHALMITIS


Introduction

Endophthalmitis is characterized by marked inflammation of intraocular tissues and fluids. In a patient with endophthalmitis, the etiology and most likely infecting organisms may be predicted by the clinical setting. The largest category is acute-onset postoperative endophthalmitis, generally defined as presenting within 6 weeks of intraocular surgery.


Etiology and Epidemiology

• Incidence rates are variable, but are usually reported as being between about 0.03% and 0.2%.

• In a recent large single-center series, reported rates were 0.025% overall, 0.028% following cataract surgery, 0.108% following penetrating keratoplasty, and 0.011% following pars plana vitrectomy (PPV; in this series, all endophthalmitis cases followed 20-gauge PPV). In a prior series from the same institution, the reported rate following secondary intraocular lens (IOL) implantation was 0.2%.

• The Endophthalmitis Vitrectomy Study (EVS) recruited patients with acute-onset postoperative endophthalmitis following cataract surgery or secondary IOL implantation; in the EVS, 69% of patients had positive vitreous cultures, and of these, the most common etiologic organisms were coagulase-negative staphylococci.

• Preoperative risk factors include immune compromise (including diabetes mellitus), active systemic infection, active blepharitis or conjunctivitis, and disease of the lacrimal drainage system.

• Intraoperative risk factors include prolonged or complicated surgery, secondary IOL implantation, posterior capsular rupture, vitreous loss, iris prolapse, contaminated irrigating solutions or IOLs, and inferotemporal placement of clear corneal incisions.

• Postoperative risk factors include wound leak, vitreous incarceration in the incision, and contaminated eye drops.




Signs

• Marked intraocular (anterior chamber and vitreous) inflammation with anterior chamber fibrin and hypopyon (Fig. 10-1)

• Eyelid edema, conjunctival congestion, corneal edema, and retinal periphlebitis may occur to a variable degree.

• Marked vitreous opacities by echography


Differential Diagnosis

• Toxic anterior segment syndrome, which generally occurs earlier (within 1 or 2 days), usually has “wall-to-wall” corneal edema, and may be associated with little or no pain, as well as little or no posterior segment inflammation.

• Retained lens material

• Flare-up of preexisting uveitis

• Triamcinolone acetonide particles

• Long-standing (dehemoglobinized) vitreous hemorrhage


Testing

• Acute-onset postoperative endophthalmitis is a clinical diagnosis,

followed by laboratory confirmation.

• If the posterior segment cannot be visualized, B-scan echography may be helpful to rule out retinal detachment, suprachoroidal hemorrhage, or retained lens fragments.

• Aqueous and vitreous cultures: Vitreous samples are more likely to yield a positive culture than aqueous samples.

• Vitreous cultures may be obtained either with a needle (tap) or with PPV instrumentation.

• Commonly used culture media include 5% blood agar (most common organisms), chocolate agar (fastidious organisms, such as Neisseria gonorrhoeae and Haemophilus influenza), sabouraud agar (fungi), thioglycollate broth (anaerobes), and anaerobic blood agar (anaerobes).

• Blood culture bottles may also be used and are helpful in after-hours cases.

• Polymerase chain reaction (PCR) may provide more rapid identification of organisms but, at this time, is available only in some major centers.




Prognosis

• The strongest predictor of final visual outcome in the EVS was presenting visual acuity; therefore, prompt initiation of treatment is
more important than any other factor, including vitreous tap versus PPV.

• Other predictors of less favorable outcomes in the EVS included older age, diabetes mellitus, corneal infiltrate, abnormal intraocular pressure, anterior segment neovascularization, absent red reflex, and open posterior capsule.



REFERENCES

Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology. 2002;109:13-24.

Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113:1479-1496.

Garg SJ, Dollin M, Storey P, et al. Microbial spectrum and outcomes of endophthalmitis after intravitreal injection versus pars plana vitrectomy. Retina. 2016;36(2):351-359.

Grzybowski A, Schwartz SG, Matsuura K, et al. Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns around the world. Curr Pharm Des. 2017;23(4):565-573.

Javey G, Schwartz SG, Moshfeghi AA, Asrani S, Flynn HW Jr. Methicillin-resistant Staphylococcus epidermidis isolation from the vitrectomy specimen four hours after initial treatment with vancomycin and ceftazidime. Clin Ophthalmol. 2010;4:101-104.

Kuklo P, Grzybowski A, Schwartz SG, Flynn HW Jr, Pathengay A. Hot topics in perioperative antibiotics for cataract surgery. Curr Pharm Des. 2017;23(4):551-557.

Rachistskaya AV, Flynn HW Jr, Fisher YL, Ayres B. Correlation between baseline echographic features of endophthalmitis, microbiological isolates, and visual outcomes. Clin Ophthalmol. 2013;7:779-785.

Rachitskaya AV, Flynn HW Jr, Wong J, Kuriyan AE, Miller D. A 10-year study of membrane filter system versus blood culture bottles in culturing vitrectomy cassette vitreous in infectious endophthalmitis. Am J Ophthalmol. 2013;156:349-354.

Schwartz SG, Flynn HW Jr, Grzybowski A, Relhan N, Ferris FL 3rd. Intracameral antibiotics and cataract surgery: endophthalmitis rates, costs, and stewardship. Ophthalmology. 2016:123;1411-1413.

Schwartz SG, Flynn HW Jr, Scott IU. Endophthalmitis: classification and current management. Expert Review Ophthalmol. 2007;2:385-396.

Smiddy WE, Smiddy RJ, Ba-Arth B, et al. Subconjunctival antibiotics in the treatment of endophthalmitis managed without vitrectomy. Retina. 2005;25:751-758.

Sridhar J, Yonekawa Y, Kuriyan AE, et al. Microbiologic spectrum and visual outcomes of acute-onset endophthalmitis undergoing therapeutic pars plana vitrectomy. Retina. 2017;37(7):1246-1251.

Vaziri K, Schwartz SG, Kishor K, Flynn HW Jr. Endophthalmitis: state of the art. Clin Ophthalmol. 2015;9:95-108.

Wykoff CC, Parrott MB, Flynn HW Jr, et al. Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002-2009). Am J Ophthalmol. 2010;150:392-398.

Yannuzzi NA, Si N, Relhan N, et al. Endophthalmitis after clear corneal cataract surgery: outcomes over two decades. Am J Ophthalmol. 2017;174:155-159.






FIGURE 10-1. Acute endophthalmitis. Acute-onset postoperative endophthalmitis.



DELAYED-ONSET (CHRONIC) POSTOPERATIVE ENDOPHTHALMITIS


Introduction

Delayed-onset (chronic) postoperative endophthalmitis is defined as presenting more than 6 weeks after intraocular surgery, but may present months or years later.


Etiology and Epidemiology

• In one single-center series, the reported rate of delayed-onset (chronic) postoperative endophthalmitis following cataract surgery was 0.017%.

• Common causative organisms in cases of delayed-onset (chronic) postoperative endophthalmitis include Propionibacterium acnes, fungi, and various less virulent gram-positive and gram-negative organisms.



Signs

• Signs are typically less severe, and presenting visual acuity is usually better, than in patients with acute-onset postoperative endophthalmitis.

• Slowly progressive intraocular inflammation and variable occurrence of hypopyon and keratic precipitates

• A white intracapsular plaque may be present and may be indicative of P. acnes infection (Fig. 10-2).

• Eyelid edema, conjunctival congestion, corneal edema, and aqueous and vitreous inflammation may occur, but generally to a lesser degree than in acute-onset postoperative endophthalmitis.


Differential Diagnosis

• Noninfectious uveitis

• Retained lens material

• Triamcinolone acetonide particles

• Long-standing (dehemoglobinized) vitreous hemorrhage


Testing

• Delayed-onset (chronic) postoperative endophthalmitis is a clinical diagnosis, followed by laboratory confirmation.

• If the posterior segment cannot be visualized, B-scan echography may be helpful to rule out retinal detachment, suprachoroidal hemorrhage, and retained lens fragments.

• Ultrasound biomicroscopy of the anterior segment may provide additional information.

• Aqueous and vitreous cultures: Vitreous samples are more likely to yield a positive culture than aqueous samples.

• Vitreous cultures may be obtained either with a needle (tap) or with PPV instrumentation.

• Commonly used culture media include 5% blood agar (most common organisms), chocolate agar (fastidious organisms, such as N. gonorrhoeae and H. influenza), sabouraud agar (fungi), thioglycollate broth (anaerobes), and anaerobic blood agar (anaerobes).

• If delayed-onset (chronic) postoperative endophthalmitis is suspected, the laboratory should be instructed to hold the cultures for at least 2 weeks to allow isolation of fastidious organisms.

• Blood culture bottles may also be used.


May 5, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Endophthalmitis
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