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Endophthalmitis is an inflammation of the interior 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.
- Bacteria: N. meningitidis, Staphylococcus aureus, S. epidermidis, S. pneumoniae, other streptococcal spp., Propionibacterium acnes, Pseudomonas aeruginosa, other gram negative organisms.
- Viruses: Herpes simplex virus.
- Fungi: Candida spp. Fusarium
- Parasites: Toxoplasma gondii, Toxocara.
Late-onset endophthalmitis is mostly caused by Proprionibacterium acnes.
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.
- Panophthalmitis — Progression to involve all the coats of the eye.
- Corneal ulcer
- Orbital cellulitis
- no light perception vision
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. 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.
In patients with acute endophthalmitis, combined steroid treatment with antibiotics have been found to improve visual outcomes, versus patients only treated with antibiotics, but any improvements on the resolution acute endophthalmitis is unknown.
A Cochrane Review sought to evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery. The review showed high-certainty evidence that antibiotic injections in the eye with cefuroxime at the end of surgery lowers the chance of endophthalmitis. Also, the review showed moderate evidence that antibiotic eye drops (levofloxacin or chloramphenicol) with antibiotic injections (cefuroxime or penicillin) probably lowers the chance of endophthalmitis compared with injections or eye drops alone. Separate studies from the research showed that a periocular injection of penicillin with chloramphenicol-suphadimidine eye drops, and an intracameral cefuroxime injection with topical levofloxacin 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. The only consistent method of antibioprophylaxis in this instance is a solution of povidone-iodine applied pre-injection.
- Forbes BA, Sahm DF, Weissfeld AS. Bailey & Scott's Diagnostic Microbiology. 12th Edition. Mosby Elsevier, 2007. p. 834.
- 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.
- 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". American Journal Ophthalmology. 160 (1): 17–25.e1. doi:10.1016/j.ajo.2015.04.013. PMID 25892127.
- Kim CH, Chen MF, Coleman AL (2017). "Adjunctive steroid therapy versus antibiotics alone for acute endophthalmitis". Cochrane Database Syst Rev (2): CD012131. doi:10.1002/14651858.CD012121.pub2. PMID 28225198.
- Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ (2017). "Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery". Cochrane Database Syst Rev (2): CD006364. doi:10.1002/14651858.CD006364.pub3. PMID 28192644.
- Christy NE, Sommer A (1979). "Antibiotic prophylaxis of postoperative endophthalmitis". Annnals of Ophthalmology. 11 (8): 1261–1265. PMID 318049.
- 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". Journal of Cataract and Refractive Surgery. 33 (6): 978–988. doi:10.1016/j.jcrs.2007.02.032. PMID 17531690.
- 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 . PMID 27257676.
- 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.