Infective endophthalmitis
Endophthalmitis
• An inflammation of the inner structures of the eyeball
• Uveal tissue
• Retina
• associated with pouring of exudates in the vitreous cavity, anterior chamber and posterior chamber.
Classification
Infectivity
Infective
Non-infective
Mode of entry
Exogenous
Endogenous
Etiological agent
Bacterial
Fungal
Infective endophthalmitis
Modes of infection
Exogenous
• Perforating injuries
• Perforation of infected corneal ulcers
• Postoperative infections
Endogenous
• Bloodstream
• Caries teeth
• Generalisedsepticaemia
• Puerperal sepsis
Secondary infections
• Extension of infection
• Orbital cellulitis
• Thrombophlebitis
• Infected corneal ulcers
Causative organismsB
acte
rial
Stahpylococcus
Pseudomonas
Pneumococcus
Streptococcus
E. coliFu
nga
l - Aspegillus fumigatus
- Candida albicans
- Nocardiaasteroides
- Fusarium
• Acute postoperative endophthalmitis -complication of intraocular surgery with an incidence of about 0.1%.
• Source of infection - periocular bacterial flora of the eyelids, conjunctiva, and lacrimal sac.
• Other potential sources of infection -contaminated solutions and instruments, and environmental flora
Risk factors
• Eye trauma
• Eye surgery
– Previous presence of infection
– Poor surgical technique.
– Contaminated intraocular lens.
• Intraocular injection
• Bloodstream infection
• Ophthalmic risk factors:
– Contact lens wear (poor hygiene).
– Chronic corneal ulceration.
• Non-ophthalmic risk factors:
– Immunosuppression.
– Intravenous drug use.
– AIDS.
Post operative endophthalmitis
Clinical features
• Sudden onset
• Severe pain
• Redness of eye
• Marked visual loss
• Swollen eyelid
• Lacrimation
• Photophobia
Signs
• Visual acuity may be reduced.
• Lids → red and swollen.
• Conjunctiva → chemosis and marked circumcorneal congestion.
• Cornea → oedematous, cloudy and ring infiltration may be formed.
• Anterior chamber → hypopyon
• Iris → oedematous and muddy
• Pupil → yellow reflex , absent red reflex
• Vitreous exudation - yellowish white mass is seen through fixed dilated pupil (amauroticcat’s-eye reflex)
• Intraocular pressure → raised in early stages
• but in severe cases – hypotony
• Edges of wound → yellow and necrotic and wound may gape
Diagnosis
• Culture and sensitivity studies on aqueous and vitreous samples– Anterior chamber tap
– Vitreous tap
– Vitreous biopsy
• Full infection screen– FBC, blood cultures and culture of all indwelling lines
and catheters
• B-scan ultrasound– the degree of vitritis and integrity of retina
Management
• Medical and ophthalmological emergency
• Suspected acute endophthalmitis requires emergency admission.
• Suspected delayed postoperative endophthalmitis needs urgent referral within 24 hours.
• Most patients will be admitted for a diagnostic work-up and antimicrobial treatment
Goals of treatment
• Retention of useful vision
• Minimize the infection with antimicrobial agents
• Limit the inflammation
• Symptomatic relief
Treatment
Medical
• Antibiotics - Intravitreal , periocular , topical , systemic
• Anti-inflammatory - topical , periocular , systemic (not for chronic Endophthalmitis)
• Supportive
Surgical
• Vitrectomy
Medical treatment
Broad spectrum antibiotics
• Intravitreal – aminoglycoside & vancomycin
First choice Vancomycin 1 mg in 0.1 mlCeftazidime 2.25 mg in 0.1 m
Second choice Vancomycin 1 mg in 0.1 mlAmikacin 0.4 mg in 0.1 ml
Third choice Vancomycin 1 mg in 0.1 mlGentamycin 0.2 mg in 0.1 ml
• Perioricular / subconjunctival injection
– vancomycin 25 mg & ceftazidine 100mg daily
– Gentamycin 20mg & cefuroxime 125mg daily
• Topical therapy every 30-60 min
• Systemic
– IV ceftazidine , cefotaxime
– Oral ciprofloxacin
Corticosteroids
• Indication
– recent onset after rule out fungal infection.
• Contraindication
– Late onset endophthalmitis
– Fungal endophthalmitis
• Reduce inflammation → limit ocular damage
• Eg : dexamethasone
• Intravitreal → dexamethasone 0.4 mg in 0.1ml.
• Subconjunctival → dexamethasone 4 mg (1ml) OD for 5-7 days.
• Topical dexamethasone (0.1%) or predacetate(1%) used frequently.
• Systemic → Oral corticosteroids should preferably be started after 24 hours of intensive antibiotic therapy. A daily therapy – 60 mg prednisolone to be followed by 50, 40, 30, 20 and 10 mg for 2 days each
• Atropine and analgesic
– relieve pain
• Vitrectomy
– Severe and resistant cases
– Fungal endophthalmitis
Antifungal
• Amphotericin B
– Intravitreal
– Systemic
Complications
• Panophthalmitis
• Papillitis
• Phthisis bulbi
• Retinal necrosis
• Retinal detachment
• Increased intraocular pressure
• Retinal vascular occlusion
• Optic neuropathy
• Hypotony
Expected outcomes
• Bacterial endophthalmitis → most treatable type, but the prognosis of vision is often poor.
• Mycotic endophthalmitis → chorioretinalscarring and optic nerve atrophy from glaucoma may result in blindness.
• Endophthalmitis caused by fungus / neoplasia/ foreign bodies → not responsive to medical therapy
Failure of treatment
• Inflammation is too severe to overcome.
• The underlying infectious agent is resistant to therapy.
• The medical therapy does not penetrate the eye well.
• Therapy is not administered for an adequate duration.
• The diagnosis is incorrect.
PANOPHTHALMITIS
• intense purulent inflammation of the whole eyeball including the Tenon’s capsule
Clinical features
– Severe ocular pain and headache
– Complete loss of vision
–Profuse watering
– Purulent discharge
– Marked redness and swelling of the eyes
– Associated w. malaise and fever