Endophthalmitis

DM Ari
 Endophthalmitis
• An inflammatory condition of the intraocular
cavities  the aqueous and/or vitreous
humor
• Acute or chronic  rapidly develop (most
common), develop slowly or persist for long
period of time
• Panophthalmitis  inflammation of all coats
of the eye including intraocular structures
 Etiology
• Endogenous (metastatic)  hematogenous spread
– Endocrine  DM, CKD, alcohol hepatitis
– AID  SLE
– Hematology  Leukemia, neutropenia
– AIDS
– Cardiovasculer  cardiac valvular disorder
– Oncology  lymphoma, GIT malignancies
– Invasive procedure  HD, Bladder cath., GIT endoscopy,
dental procedures, chemotherapy, total parenteral
nutrition
– Infection  meningitis, endocarditis, UTI, wound infection,
pharyngitis, pulmonary inf., septic arthritis, pyelonephritis,
abscess
• Exogenous  direct inoculation of an
organism (bacterial, or fungal, viral or
protozoa) from the outside  ocular surgery,
foreign bodies, blunt or penetrating ocular
trauma
 Pathophysiology
• Protecting agent  blood-ocular barrier
• Endogenous  blood-borne organism permeate BOB 
direct invasion
• Infection  inflammatory response  cascade of
inflammatory products  altered vascular endothelium 
BOB breakdown  the inflammatory product enter the eye
ball  digestive enzymes and bacterial toxin release 
destruction (DM, immunosuppressed patient, or history of
positive blood cultures)
• Destruction intra ocular tissues  direct invasion by the
organism or inflammatory mediators of the immune
response
 Symptoms
• Major symptoms
– Decreased vision
– A red eye
– Deep ocular pain
• Exogenous endophthalmitis
– Acute post op (<6 weeks PO, most common 2-10 days PO) 
coagulase-negative staphylococci, Staphylococcus aureus,
Streptococcus, Enterococcus
– Delayed onset or chronic pseudophakic PO (>6 weeks) 
Propionibacterium acnes, Corynebacterium species
– Posttraumatic  history of trauma (+)  bacillus, Staphylococcus
species
– Filtering bleb associated  life-long risk
– Ocular surfaces infection
Post operative traumatic
endophthalmitis
Bleb-associated endophthalmitis
 Symptoms related
• Endogenous  major symptoms occurs in any hospitalized patient
or immunosuppressed patient, DM, sepsis  Staphylococcus
aureus, Escherichia coli, other Streptococcus species
• Other symptoms
– Headache
– Photophobia
– Ocular discharge
– Injected eye
– Intense ocular and periocular inflammation
• Absence of pain and hypopion  P. acnes
• Fungal  candida albicans (most common), aspergilosis, other
candidal species, Turolopsis, Sporotrichum, Cryptococcus,
Coccioides, Mucor species
 Physical diagnostic
• Visus
• External examination
• Funduscopic examination
• Slit lamp examination
 External examination
• Proptosis (exophthalmos)  late finding in
panophthalmitis
• Eyelid swelling and erythema
• Injected conjunctiva and sclera
• Corneal edema and infection
• Chemosis  conjunctiva edema
• Hypopyon
• Purulent discharge  prolapse
Hypopion, corneal edema, chemosis,
palpebral edema
 Slit lamp
• Chronic uveitis
• Cells and flare in the CoA
Flare
 Funduscopic examination
• Reduced or absent fundus reflex
• Papillitis
• Cotton-wool spots
• White lessions in the choroid and retina
• Vitreal mass and debris  hazy vitreous
• White centered retinal hemorrhage (Roth’s
spot)  endocarditis associated
Hazy vitreous
National institute of health grading
system
Papillitis
Roth’s spot
Cotton wool spot
 Systemic sign and symptoms
• Fever
• Correlate with underlying disease of
endogenous endophthalmitis
 Specific finding
• Symptoms
– Bacterial  pain, redness, lid swelling, dereased visual
acuity  acute
– Fungal  days to weeks  history of penetrating injury 
plant subtance, soil-contaminated foreign body
• Candidal infection  high fever after ocular symptoms
• Fever of Unknown Origin (FUO)  retinochoroidal dungal infiltrate
• Delayed onset or chronic  a white plaque within the
remaining lens capsule
• Filtering bleb associated  a purulent bleb with
necrotic areas in the sclera
• Posttraumatic  intraocular foreign body
Fungal keratitis associated
endophthalmitis
Panofthalmitis
 Investigation
• Slit lamp  initial diagnosis
• USG may also helpful
• Complete blood count  signs of infection
• ESR (erythrocyte sedimentation rate)  rheumatic causes, chronic
infection
• BUN, creatinin, FBG, PP BG  evaluating underlying disease
• Imaging studies  chest x-ray, cardiac ultrasound, ocular USG
• Urinalysis
• Vitreous culture
• Blood culture
• Other culture depending on clinical sign or symptoms : CSF, Throat
swab, Stool, indwelling IV cath., penetrating object
• PCR
 Treatment
• Diagnosed  prompt consultation to
ophthalmologist  emergency
 Treatment of P.O Endophthalmitis
• Pars plana vitrectomy or vitreous aspiration 
vitreal culture
• Administration of intravitreal Ab 
vancomycin, amikacin, ceftazidime
• Systemic Ab administration
Pars plana vitrectomy
Intravitreal injection
 Treatment of traumatic
endophthalmitis
• Hospitalize
• Treat ruptured globe (if present)
• Systemic Ab  vancomycin and an aminoglycoside
(streptomycin, kanamycin, gentamycin, neomycin, etc) or
third generation cephalosporin (ceftriaxone, ceftazidime,
cefotaxime, cefdinir, cefixime)
• Soil contaminated or suspect  clindamycin until bacillus
species can be rule out (vitreal culture)
• Topical fortified Ab
• Intravitreal Ab
• Anti tetanus
• Cycloplegic drops  atropin
 Treatment of endogenous bacterial
endophthalmitis
• Hospitalize
• Systemic Ab  vancomycin and an
aminoglycoside (streptomycin, kanamycin,
gentamycin, neomycin, etc) or third generation
cephalosporin (ceftriaxone, ceftazidime,
cefotaxime, cefdinir, cefixime)
• Intravitreal Ab
• Cyclopegic drops
• Topical steroids
• Periocular Ab  sometimes indicated
Treatment of candidal endophthalmitis
• Hospitalize
• Oral or parenteral Fluconazole
• Amphotericin B IV or Intravitreal
• Cyclopegic drops
 Complication
• Loss of vision
• Loss of the eye
• Lost of vision and chronically painful 
enucleation considered
Spontaneous globe rupture due to
bacterial endophthalmitis
 Prognosis
• Acute P.O endophthalmitis  poor prognosis
 55% of eyes managing 6/60 or less
• Chronic P.O endophthamitis  respond well
to steroids initially  refractory to treatment
• Bleb associated endophthalmitis  recuring
infection
• Endogenous worse than exogenous
endophthalmitis  DM, etc
Thankyou