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Endophthalmitis

Last updated: March 26, 2021

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Endophthalmitis is a rare, potentially sight-threatening inflammation of the vitreous humor (vitritis) that may be infectious (bacterial/fungal infection) or noninfectious (sterile). Infectious endophthalmitis can have either an exogenous (following ocular surgery/penetrating trauma) or endogenous (hematogenous spread) etiology. Staphylococcal/streptococcal infection after cataract surgery is the most common cause of exogenous bacterial endophthalmitis. Fungal endophthalmitis is often caused by Candida and is more common in immunocompromised individuals. Endophthalmitis may present either acutely with sudden, deep ocular pain and rapidly progressive loss of vision or indolently (chronic endophthalmitis). Clinical features include conjunctival hyperemia, corneal haziness, hypopyon, and decreased visual acuity. Vitreous infiltrates are seen on slit lamp examination. Diagnosis is often clear on history and ocular examination. In doubtful cases, ultrasound of the eye and gram stain and culture of the vitreous humor is indicated. Infectious endophthalmitis is treated with intravitreal injection of either antibiotics (vancomycin with ceftazidime/amikacin) or antifungals (amphotericin B/voriconazole). Surgical removal of the vitreous humor (vitrectomy) is done in sight-threatening cases. Patients with noninfectious endophthalmitis usually resolve completely with topical steroids alone. Untreated infectious endophthalmitis can progress to cause panophthalmitis, corneal rupture, and permanent vision loss.

Infectious endophthalmitis

Noninfectious endophthalmitis (sterile)

References:[1][2][3][4][5]

Acute vs. chronic endophthalmitis [1][5]
Acute endophthalmitis Chronic endophthalmitis
Pathogen
  • Usually bacterial
Onset
  • Sudden (acute)
  • Insidious
Symptoms
  • Ocular pain is usually absent/appears late.
  • Gradually progressive loss of vision
  • Floaters (fungal endophthalmitis)
Signs

Slit lamp examination of the eye

Fundoscopy

  • Indicated in all patients with endophthalmitis.
  • Loss of the red reflex (due to chorioretinitis)
  • Roth spots; may be seen in patients with endogenous endophthalmitis due to infective endocarditis, and occasionally in fungal endophthalmitis.
  • Bacterial endophthalmitis: nonvisualization of retinal vessels
  • Fungal endophthalmitis: creamy white retinal nodules

Ultrasound of the eye (B-scan)

Gram-stain and culture of aqueous and/or vitreous humor

  • The aqueous and/or vitreous humor can be extracted through a fine needle and cultured.
  • Indicated in doubtful cases

Workup for primary source of infection

References:[1][6][7][8][9][10][11][12]

Early initiation of treatment (within hours) is critical to preserve eyesight.References:[13][14][15][16][17]

  • Panophthalmitis
  • Corneal perforation
  • Phthisis bulbi
  • Glaucoma
  • Permanent loss of vision

References:[18][19]

We list the most important complications. The selection is not exhaustive.

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  2. Fraunfelder FT. Roy and Fraunfelder's Current Ocular Therapy. Elsevier Health Sciences ; 2008
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  7. Marticorena J, Romano V, Gómez-Ulla F. Sterile endophthalmitis after intravitreal injections. Mediators of Inflammation. 2012; 2012 . doi: 10.1155/2012/928123 . | Open in Read by QxMD
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  9. Eye Wiki - Endophthalmitis. http://eyewiki.aao.org/Endophthalmitis. Updated: December 21, 2014. Accessed: May 16, 2017.
  10. Ophthalmology. http://projects.galter.northwestern.edu/geriatrics/chapters/ophthalmology.cfm. Updated: June 9, 1999. Accessed: May 16, 2017.
  11. Red Reflex. http://www.fpnotebook.com/Eye/Exam/RdRflx.htm. . Accessed: May 16, 2017.
  12. Sadiq MA, Hassan M, Agarwal A et al . Endogenous endophthalmitis: diagnosis, management, and prognosis. J Ophthalmic Inflamm Infect. 2015; 5 (32). doi: 10.1186/s12348-015-0063-y . | Open in Read by QxMD
  13. Pomeranz HD. Roth spots. Arch Ophthalmol. 2002; 120 (11): p.1596. doi: 10.1001/archopht.120.11.1596 . | Open in Read by QxMD
  14. Au L, Guduru K, Lipscomb G, Kelly SP. Candida endophthalmitis: A critical diagnosis in the critically ill. Clin Ophthalmol. 2007; 1 (4): p.551-554.
  15. Recent advances in Endophthalmitis Management.
  16. Radhika M, Mithal K, Bawdekar A et al. Pharmacokinetics of intravitreal antibiotics in endophthalmitis. Journal of Ophthalmic Inflammation and Infection. 2014; 4 (22). doi: 10.1186/s12348-014-0022-z . | Open in Read by QxMD
  17. Listed NA. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995; 113 (12): p.1479-1496.
  18. Steroid Role Controversial in Endophthalmitis. http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/modernmedicine/modern-medicine-feature-articles/steroid-role-controversial-e?page=full. Updated: June 15, 2012. Accessed: May 16, 2017.
  19. Orozco-Hernández A, Ortega-Larrocea X, Sánchez-Bermúdez G, García-Aguirre G, Morales Canton V, Velez-Montoya R. Acute sterile endophthalmitis following intravitreal bevacizumab: case series. Clin Ophthalmol. 2014; 2014 (8): p.1793—1799. doi: 10.2147/OPTH.S66230 . | Open in Read by QxMD