Fulminant gram-negative neonatal endogenous endophthalmitis. Note periorbital edema (top left), conjunctival chemosis, corneal edema, and exudates in anterior chamber (top right). Ultrasonography shows vitreous echoes, choroidal thickening, and low reflective retinal detachment (bottom left)
Ventriculoperitoneal (VP) shunt induced Fusarium endophthalmitis. Left—note leucocoria and lens abscess. Aqueous and vitreous tap under topical anaesthesia, followed by intraocular antibiotic injection, was done in this patient
The second clinical picture is of a very low-grade retinal infiltrate, diagnosed on routine retinal screening. This presents as a single or multiple yellow-white lesions varying from pinhead to few millimeter size, minimally elevated from the retinal surface or as a small subretinal abscess with indistinct borders. The most common causative organism is Candida albicans and Candida tropicalis (Fig. 12.3). Vitritis is minimal or absent to start with but gradually becomes manifested as the disease progresses. This characteristic clinical diagnosis is sufficient to start antifungals as the lesions are very classic and typical. Low-grade viral retinal infections from HSV and cytomegalovirus (CMV) also start as mild to moderate diffuse retinitis without vitritis (Fig. 12.4) and later can progress to severe vitritis and sometimes keratitis .
Non-fulminant endophthalmitis. Fungal retinitis: top and middle—presumed Candida, early and active phase showing typical retinal infiltrates. Bottom—advanced stage with vitreopathy and retinal folds that needs urgent lens-sparing vitrectomy without any subretinal treatment
Viral retinitis (CMV/HSV) always shows some chorioretinal scars in addition to retinitis
Rarely a third type of clinical picture, partially resolved bacterial endogenous endophthalmitis presents as a less severe infection, after having received parenteral antibiotics during septicemia. These present mostly as a low-grade partly organized subretinal abscess (Fig. 12.5) or vitritis or organized leucocoria (Fig. 12.6) resembling a pseudoglioma due to retinal necrosis and retinal detachment. Another rare clinical presentation is a localized anterior chamber granuloma or a very focal iris abscess (authors’ experience) that can respond to systemic antimicrobials (anterior endophthalmitis).
Partially resolved endophthalmitis. Blood culture: E coli. left panel—preoperative (Top left) and post lens-sparing vitrectomy (Bottom Left). Right panel—Preoperative (Top Right) and post-systemic antibiotics (Bottom right)
Partially resolved endophthalmitis with systemic antibiotics noted few days after an acute systemic septic episode. This child presented with leucocoria and a shrunken globe resembling a pseudoglioma (left). The child was referred as a case of retinoblastoma. The ultrasonography shows no mass but showed a degenerated retinal detachment with low-intensity echoes in vitreous and subretinally—a prephthisical stage (right)
Risk factors: Prematurity with low birth weight and hospitalization has been associated in 80% babies presenting with neonatal endophthalmitis [1–4]. Rarely, healthy and normal-weight term babies without any apparent risk factor get such infections [2–4]. The common risk factors are listed in Table 12.1. In the USA, over the years, possibly due to implementation of strict asepsis protocols and attention to the risk factors, there has been a declining incidence of neonatal endogenous endophthalmitis; it reduced from 8.7 per 100,000 babies in 1986 to 4.42 per 100,000 babies in 2006 . In a prospective case series of neonatal candidemia with a prevalence of 1.1 per 100 NICU discharges, endophthalmitis was seen in 2 of 20 babies where eye was evaluated .
• Premature and low birth weight (especially less than 1500 g)
• Compromised immune status
• Hospital admission
• Indwelling catheters, infusion pumps, ventilators, implants
• Poor handwashing and hygiene of healthcare workers not practicing good barrier nursing
• Umbilical sepsis
• Blood transfusion
• Pneumonia/septic abscesses/meningitis
• Cross contamination from other infected babies
• Nursery infection outbreaks such as Candida, Meningococcus, etc.
Diagnostic criteria: Cultures may not be always positive. Hence only laboratory-based confirmation is not adequate to identify all infected endophthalmitis cases, especially of endogenous origin [1–7]. Diagnostic criteria are given in the Table 12.2.
Diagnostic criteria for neonatal endophthalmitis
Any two of the following five clinical and laboratory features can be considered as a case of neonatal endogenous endophthalmitis:
1. Inflammation of intraocular tissues where except for an infective etiology, no other underlying cause is detected
2. Clinical involvement of retina or vitreous showing typical features of exudation and/or inflammation
3. Any intraocular sample shows significant growth on culture
4. Any of the body tissues/fluid shows significant growth or microbial organisms. Common samples include blood, urine, umbilical cord stump swab, swab from any abscess, etc. in association with ocular inflammation
5. PCR is positive for eubacterial or panfungal or specific viral DNA from ocular sample in presence of ocular inflammation
All cases suspected to have neonatal and infantile endophthalmitis should have a careful ocular ultrasonography (USG-B) scan with corresponding A-Scan. Endophthalmitis eyes in early stages may have normal USG but in most cases will show low-intensity echoes. USG helps to confirm diagnosis and identifies poor prognostic indicators like retinal detachment, choroidal detachment, membranous echoes (Fig. 12.1, 12.6), and dense echoes filling most of the vitreous cavity. In all cases careful USG including immersion scan should also be done at low gain to evaluate all areas for any mass lesions or calcifications that would suggest an underlying retinoblastoma, which can masquerade as orbital cellulitis or endophthalmitis (Fig. 12.7). If possible, this is done preferably under general anesthesia as sometimes in a crying and struggling child one may miss scanning some areas that contain a hidden underlying tumor. Intraocular cysticercosis that can masquerade as endophthalmitis is also very well diagnosed by USG in most cases. USG is much more sensitive and specific than CT scan or MRI in the diagnosis of neonatal and pediatric endophthalmitis.