Endophthalmitis Diagnosis and Treatment

Endophthalmitis

Definition: Inflammation, usually from an infection, within the anterior and posterior segments of the eye.4

Symptoms/Signs:2,5

  • Symptoms include blurry vision (93%), eye pain (75%), lid swelling (33%), and conjunctival injection (81%)

**Typically there is no fever or leukocytosis for Endophthalmitis alone**

  • Anterior Segment: Inflammation of aqueous humor. Look for cell and flare +/- hypopyon4
  • Posterior Segment: Vitreous inflammation (vitritis) – white plaque behind the lens that often obscures the retina with possible diminished red reflex4

Diagnosis:

  • Diagnosis is made clinically by your slit lamp and fundoscopic exam
  • It is supported by vitreous cultures and/or newer testing via DNA microanalysis or PCR.2,5

If etiology is unclear, a systemic evaluation is needed1

  • Cultures: Blood, Urine, CSF?
  • Imaging: Chest X-ray, cardiac ultrasound, CT/MRI Brain
  • Labs: CBC, ESR, BUN/Creatinine

 

Causes:1,2,5

Exogenous (60%): Direct inoculation of bacteria into the eye

  • Surgery, trauma, burns

Endogenous (20%): Hematogenous spread of a bacterial infection

  • Intravenous drug use, septicemia, endocarditis, abscess, indwelling catheters

Idiopathic (20%)

 

Infectious Organisms:1,2

  • Bacterial: The most common organisms are coagulase-negative Staphylococcus epidermidis, Staphylococcus aureus, and Streptococcus species; Gram negative organisms like Pseudomonas, Escherichia coli, and Enterococcus are observed in penetrating injuries.
  • Viral: Rare; they classically cause uveitis.
  • Fungal: Candida albicans (75-80% of fungal cases).

 

Treatment:

  • Systemic antibiotics are used in the treatment of Endophthalmitis, and for better penetration, intravitreal injections are often needed as well5
  • Typical treatment is with vancomycin (broad coverage for over 99% of gram-positive organisms), and Ceftazadime, which is effective against nearly 100% of gram-negative bacteria observed in Endophthalmitis3
  • Second line agents: amikacin, cefazolin, cefuroxime, clindamycin3

 

Prognosis:2,5

  • In general, the outcomes for Endophthalmitis are poor
  • Endogenous Endophthalmitis generally does worse than exogenous due to the organism profile involved. Furthermore, endogenous Endophthalmitis carries with it the risk of bilateral infection in 15-25% of cases

 

References:

  1. Durand M. Bacterial endophthalmitis. Current through Nov 2016, UpToDate.com
  2. Egan D. Peak D. Peters J. Talavera F. Lavenburg D. O’Connor E. Lavely R. Updated April 6 2015. Emedicine.medscape.com
  3. Khan A, Okhravi N, Lightman S. The eye in systemic sepsis. Clinical medicine (London, England). 2002;2(5):444-448.
  4. Ness T, Pelz K, Hansen LL. Endogenous endophthalmitis: microorganisms, disposition and prognosis. Acta ophthalmologica Scandinavica. 2007;85(8):
  5. Shildkrot Y. Eliott D. Infectious Endopthalmitis. Opthalmology, 4th edition, copyright 2015, 9, 723-728, e-book ISBN: 978-1-4557-5001-6

 

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