BASICS

DESCRIPTION

• Endophthalmitis is a serious intraocular inflammatory reaction marked by inflammation of intraocular fluid and tissues.

– Infectious causes of endophthalmitis may be classified as postoperative, posttraumatic, or endogenous.

– Noninfectious causes of endophthalmitis may clinically mimic infectious cases (e.g., sterile endophthalmitis).

EPIDEMIOLOGY

Incidence

• Varies by cause: Postoperative 75% of cases, posttraumatic 20%, endogenous 5%.

• Postoperative endophthalmitis incidence ranges from approximately 0.05–0.16% of cataract cases.

Prevalence

Endophthalmitis occurs in approximately 1500 patients in the United States per year.

RISK FACTORS

• Postoperative: Recent ocular surgery, prolonged ocular surgery, wound leak, open posterior capsule, vitreous incarceration to wound.

• Posttraumatic: recent penetrating eye trauma, intraocular foreign body, vegetable matter in wound, delayed presentation.

• Endogenous: Immunocompromised patients, indwelling catheters, intravenous drug use

GENERAL PREVENTION

• Patient’s own external bacterial flora from conjunctiva and ocular adnexa are most likely culprits.

• Preoperative preparation with 5% povidone–iodine solution reduces risk from own bacteria flora.

• Intracameral injection of cefuroxime may reduce the incidence of postcataract endophthalmitis.

PATHOPHYSIOLOGY

• Initial infiltration of vitreous by infectious organism is followed by invasion of ocular tissue by polymorphonucleocytes within 24 h.

• Significant photoreceptor damage by 48 h.

• Experimental models of bacterial and fungal endophthalmitis have shown tissue damage continues to occur after organisms are able to be isolated from vitreous cavity; thus, implicating endotoxin in disease progression.

ETIOLOGY

Bacterial or fungal infection of vitreous cavity.

DIAGNOSIS

HISTORY

• Ocular pain.

• Loss of vision.

• Red eye.

• History of recent ocular surgery, trauma, hospitalization, IV drug use.

PHYSICAL EXAM

• Exogenous cases are typically unilateral, endogenous cases may be bilateral.

• Ocular findings may include the following:

– Adnexal swelling.

– Conjunctival chemosis and injection.

– Corneal edema.

– Hypopyon.

– Anterior chamber fibrin.

– Infiltrated conjunctival bleb.

– Vitreitis.

– Reduced view of retina.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

Blood and urine cultures may be useful in suspected cases of endogenous endophthalmitis where the underlying source in not apparent.

Follow-up & special considerations

• Careful history and physical examination important for identifying source in endogenous cases.

• Consider echocardiogram to rule out endocarditis in patients with endogenous endophthalmitis.

Imaging

B-scan ultrasound to evaluate vitreous cavity for vitreitis.

Diagnostic Procedures/Other

• Vitreous tap (0.5 cc) for gram stain, culture, KOH prep, and fungal culture.

• Consider vitrectomy with vitreous tap in patients with nondiagnostic tap.

Pathological Findings

• Coagulase negative bacteria followed by S. aureus are the most common cause of endophthalmitis.

• Endogenous cases may also be associated with fungal infection (approx 50% of cases). Candida albicans and Aspergillus are the predominant species.

DIFFERENTIAL DIAGNOSIS

• Sterile endophthalmitis.

• Noninfectious posterior uveitis: Sarcoidosis, pars planitis.

• Infectious posterior uveitis: Toxoplasmosis, Toxocara, syphilis.

– Other causes of postoperative inflammation: Sympathetic ophthalmia, Phacoanaphylactic uveitis.

TREATMENT

MEDICATION

First Line

• Intravitreal antibiotic injections to empirically treat Gram-positive and Gram-negative bacteria.

• Intravitreal antifungal medications in patients with endogenous disease.

• Intravitreal steroid injections to reduce inflammatory response.

– Ceftazidime 2.25 mg in 0.1 mL.

– Vancomycin 1.0 mg in 0.1 mL.

– Dexamethasone 0.4 mg in 0.1 mL.

Second Line

• Patients presenting with light perception vision should be treated initially with vitrectomy, vitreous tap, and intravitreal antibiotics.

• Patients who do not respond adequately to initial injection of intravitreal antibiotics with 48 h should undergo either additional injection or vitrectomy.

• Fortified topical antibiotics may be used in addition.

– Vancomycin 50 mg/mL every hour.

– Ceftazidime 100 mg/mL every hour.

ADDITIONAL TREATMENT

General Measures

Patients with endogenous endophthalmitis will need complete evaluation by infectious disease specialist to diagnose and treat underlying disease source (e.g., Abscess, endocarditis, sepsis).

Issues for Referral

• All patients require evaluation and treatment by an ophthalmologist/retinal specialist.

• Patients require close daily re-evaluation until stabilization is achieved.

Additional Therapies

Patient may require delayed vitrectomy to treat nonclearing vitreous debris.

SURGERY/OTHER PROCEDURES

• Initial treatment with vitreous tap and injection of intravitreal antibiotics is recommended for postop patients presenting with vision of hand-motions or better.

• Initial pars plana vitrectomy with injection of intravitreal antibiotics is recommended for postop patients presenting with vision of light perception.

IN-PATIENT CONSIDERATIONS

Initial Stabilization

• Complete history and examination.

• Complete eye exam including dilated ophthalmoscopy.

Admission Criteria

While most commonly treated in the outpatient setting, hospital admission should be considered for patients unable to care for their condition as outpatient or unable to comply with close daily observation.

Discharge Criteria

• Hospital discharge should be considered once clinical stabilization has occurred.

– Improving vision.

– Resolving hypopyon and vitreitis.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Patients will require close daily observation until clinical stabilization has been achieved.

PATIENT EDUCATION

Patients should be instructed to urgently contact their physician with any sign of disease progression (e.g., worsening redness, pain, or decline in vision).

PROGNOSIS

This remains a serious ocular condition with a significant possibility of vision loss and permanent blindness. However, with prompt diagnosis and treatment, vision can be saved with promising long-term visual results.

COMPLICATIONS

• Retinal detachment.

• Phthisis.

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