Endophthalmitis

Endophthalmitis
Classification and external resources
Specialty ophthalmology
ICD-10 H44.0-H44.1
ICD-9-CM 360.0-360.1
DiseasesDB 30828
MedlinePlus 001626
eMedicine emerg/880 oph/393 oph/394 oph/706
Patient UK Endophthalmitis
MeSH D009877

Endophthalmitis is an inflammation of the internal coats of the eye. It is a possible complication of all intraocular surgeries, particularly cataract surgery, with possible loss of vision and the eye itself. Infectious aetiology is the most common and various bacteria and fungi have been isolated as the cause of the endophthalmitis. Other causes include penetrating trauma, allergic reaction, and retained intraocular foreign bodies. Intravitreal injections expose patients to the risk of endophthalmitis, but with an incidence rate usually less than .05%.

Signs and symptoms

In cases of endophthalmitis, one usually finds a history of recent intraocular surgery or penetrating ocular trauma. In some cases of endogenous endophthalmitis—particularly in immunocompromised patients or those with diabetes—the spread of infection may have been hematogenous (via the blood-stream).

Endophthalmitis is usually accompanied by severe pain, loss of vision, and redness of the conjunctiva and the underlying episclera. Hypopyon can be present in endophthalmitis and should be looked for on examination by a slit lamp.

An eye exam may be indicated in severe forms of candidiasis. 1-3% of cases of candidal blood infections include endophthalmitis.

Causative organisms

Late onset endophthalmitis is mostly caused by Proprionobacterium acne.[2]

Causative organisms are not present in all cases. Endophthalmitis can emerge by entirely sterile means, e.g. an allergic reaction to a drug administered intravitreally.

Complications

Treatment

The patient needs urgent examination by an ophthalmologist, preferably a vitreoretinal specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics. Injections of vancomycin (to kill Gram-positive bacteria) and ceftazidime (to kill Gram-negative bacteria) are routine. Even though antibiotics can have negative impacts on the retina in high concentrations, the facts that visual acuity worsens in 65% of endophthalmitis patients and prognosis gets poorer the longer an infection goes untreated make immediate intervention necessary.[4] Endophthalmitis patients may also require an urgent surgery (pars plana vitrectomy), and evisceration may be necessary to remove a severe and intractable infection which could result in a blind and painful eye.

Steroids may be injected intravitreally if the etiology is allergic.

Prevention

A Cochrane Review sought to evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery.[5] Separate studies from the research showed that a periocular injection of penicillin with chloramphenicol-suphadimidine eye drops,[6] and an intracameral cefuroxime injection with topical levofloxacin[7] resulted in a risk reduction of developing endophthalmitis following cataract surgery for subjects.

In the case of intravitreal injections, however, antibiotics are not effective. Studies have demonstrated no difference between rates of infection with and without antibiotics when intravitreal injections are performed.[8] The only consistent method of antibioprophylaxis in this instance is a solution of povidone-iodine applied pre-injection.[9]

References

  1. 1 2 3 4 Forbes BA, Sahm DF, Weissfeld AS. Bailey & Scott's Diagnostic Microbiology. 12th Edition. Mosby Elsevier, 2007. p. 834.
  2. ↑ http://www.retinalphysician.com/articleviewer.aspx?articleID=107123
  3. 1 2 3 4 Goldenberg DT, Harinandan A, Walsh MK, Hassan T (Spring 2010). "Serratia Marcescens Endophthalmitis After 20-Gauge Pars Plana Vitrectomy". RETINAL Cases & Brief Reports. 4 (2): 140–2. doi:10.1097/ICB.0b013e31819955bf.
  4. ↑ Dossarps, Denis; Bron, Alain M.; Koehrer, Philippe; Aho-Glélé, Ludwig S.; Creuzot-Garcher, Catherine (2016). "Endophthalmitis after intravitreal injections: Incidence, presentation, management, and visual outcome". Am J Ophthalmol. 160 (1): 17–25.e1. doi:10.1016/j.ajo.2015.04.013. PMID 25892127.
  5. ↑ Gower EW, Lindsley K, Nanji AA, Leyngold I, McDonnell PJ (2013). "Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery". Cochrane Database Syst Rev. 7 (7): CD006364. doi:10.1002/14651858.CD006364.pub2. PMID 23857416.
  6. ↑ Christy NE, Sommer A (1979). "Antibiotic prophylaxis of postoperative endophthalmitis". Ann Ophthalmol. 11 (8): 1261–1265. PMID 318049.
  7. ↑ Endophthalmitis Study Group; European Society of Cataract; Refractive Surgeons (2007). "Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors". J Cataract Refract Surg. 33 (6): 978–988. doi:10.1016/j.jcrs.2007.02.032. PMID 17531690.
  8. ↑ d’Azy, Cédric Benoist; Pereira, Bruno; Naughton, Geraldine; Chiambaretta, Frédéric; Dutheil, Frédéric (2016-06-03). "Antibioprophylaxis in Prevention of Endophthalmitis in Intravitreal Injection: A Systematic Review and Meta-Analysis". PLOS ONE. 11 (6): e0156431. doi:10.1371/journal.pone.0156431. ISSN 1932-6203. PMC 4892688Freely accessible. PMID 27257676.
  9. ↑ de Caro, John J.; Ta, Christopher N.; Ho, Hoai-Ky V.; Cabael, Lorella; Hu, Nan; Sanislo, Steven R.; Blumenkranz, Mark S.; Moshfeghi, Darius M.; Jack, Robert (2008-06-01). "Bacterial contamination of ocular surface and needles in patients undergoing intravitreal injections". Retina (Philadelphia, Pa.). 28 (6): 877–883. doi:10.1097/IAE.0b013e31816b3180. ISSN 0275-004X. PMID 18536606.
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