Endogenous endophthalmitis: Difference between revisions

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'''For the main page on endophthalmitis, please click [[endophthalmitis|here]]'''<br>
'''For more information on bacterial endophthalmitis, please click [[Bacterial endophthalmitis|here]]'''<br>
'''For more information on post-operative endophthalmitis, please click [[Post-operative endophthalmitis|here]]'''<br>
'''For more information on post-traumatic endophthalmitis, please click [[Post-traumatic endophthalmitis|here]]'''<br>
'''For more information on bleb-related endophthalmitis, please click [[Bleb-related endophthalmitis|here]]'''<br>
 
{{CMG}}; {{AE}} {{SaraM}}
{{CMG}}; {{AE}} {{SaraM}}
<br>
{{SK}} Endogenous fungal endophthalmitis; Endogenous bacterial endophthalmitis


==Overview==
==Overview==
Endogenous endophthalmitis (EE) also termed metastatic endophthalmitis, is caused by the hematologic dissemination of bacterial or fungal infection to the eyes. Most common extraocular foci of infection include [[liver abscess]], [[pneumonia]], [[endocarditis]], and soft tissue infection.
Endogenous endophthalmitis is a rare but sight-threatening complication
Endogenous endophthalmitis is less common than exogenous endophthalmitis and has been reported to account for 2–8%.
that can be caused by the [[Disseminated disease|hematologic dissemination]] of [[bacterial]]/[[fungal]] infections to the eyes or direct spread from adjacent contagious sites.  
Most common extraocular foci of infection include [[liver abscess]], [[pneumonia]], [[endocarditis]], and soft tissue infection.
Endogenous endophthalmitis is commonly associated with [[immunosuppression]] or procedures that increase the risk for blood-borne infections, such as [[diabetes]], [[HIV]], [[malignancy]], [[intravenous drug use]], [[transplantation]], [[immunosuppressive therapy]], and [[catheterization]].
Common causes of endogenous endophthalmitis include ''[[Streptococcus pneumoniae]]'', ''[[Staphylococcus aureus]]'', ''[[Bacillus cereus]]'', and [[Klebsiella|Klebsiella spp]].
Additionally, endogenous endophthalmitis may be caused by the [[Disseminated disease|hematologic dissemination]] of [[fungal]] infections into the eye commonly ''[[Candida|Candida spp]]'' (>50%) following by [[Aspergillus]], and [[Fusarium|Fusarium spp]].
Endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, [[corneal perforation]], and ultimately permanent [[vision loss]]. <ref name="pmid11115260">{{cite journal| author=Doft BM, Kelsey SF, Wisniewski SR| title=Retinal detachment in the endophthalmitis vitrectomy study. | journal=Arch Ophthalmol | year= 2000 | volume= 118 | issue= 12 | pages= 1661-5 | pmid=11115260 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11115260  }} </ref>
The prognosis of endogenouse endophthalmitis varies with the offending organism and the systemic status of the patient.
Late detection and late treatment of systemic infection of endogenouse endophthalmitis is associated with a poor prognosis.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
The diagnosis of endogenous endophthalmitis may be difficult because of the variability in the clinical signs and symptoms.
Patients with endogenous endophthalmtis usually appear extremely ill and [[lethargic]]. Therefore, eye examination in extremely ill patients, such as those in [[intensive care units|intensive care units (ICU)]], seems necessary.
Most common eye examination findings in endogenous endophthalmitis may include decreased vision, ocular pain, eyelid edema, cloudy [[cornea]], and decreased [[red reflex]].
Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
However, positive cultures from [[vitreous]] samples can be achieved much less frequently in endogenous endophthalmitis. Identification of the causative pathogen by [[blood]], [[urine]], or [[cerebrospinal fluid]] culture is successful in more than 75% of endogenous endophthalmitis cases.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref>
*The patient needs urgent examination by an expert [[ophthalmologist]] and/or vitreo-retina specialist who will usually decide for urgent intervention to provide [[intravitreal injection]] of potent antibiotics and also prepare for an urgent pars plana [[vitrectomy]] as needed.  [[Enucleation]] may be required to remove a blind and painful eye.
Systemic antimicrobial and anti-fungal agents are recommended in endogenous endophthalmitis because the source of the infection is distant from the eye.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref>


==Historical Perspective==
==Historical Perspective==
In 1916, Dr. Leonard Weakly published a case report which detailed a patient with endophthalmitis concurrent with [[meningitis]].<ref name="pmid20767965">{{cite journal| author=Weakley AL| title=METASTATIC ENDOPHTHALMITIS IN A CASE OF CEREBRO-SPINAL MENINGITIS. | journal=Br Med J | year= 1916 | volume= 1 | issue= 2871 | pages= 47-8 | pmid=20767965 | doi= | pmc=2346850 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi? </ref>


==Classification==
==Classification==
endogenous enophthalmitis may be classified according to causative organisms into 2 subtypes: bacterial or fungal.
Endogenous enophthalmitis may be classified according to causative organisms into 2 subtypes: [[bacterial]] or [[fungal]].<ref name="pmid24056527">{{cite journal| author=Lim HW, Shin JW, Cho HY, Kim HK, Kang SW, Song SJ et al.| title=Endogenous endophthalmitis in the Korean population: a six-year retrospective study. | journal=Retina | year= 2014 | volume= 34 | issue= 3 | pages= 592-602 | pmid=24056527 | doi=10.1097/IAE.0b013e3182a2e705 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24056527  }} </ref><ref name="pmid15059712">{{cite journal| author=Schiedler V, Scott IU, Flynn HW, Davis JL, Benz MS, Miller D| title=Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. | journal=Am J Ophthalmol | year= 2004 | volume= 137 | issue= 4 | pages= 725-31 | pmid=15059712 | doi=10.1016/j.ajo.2003.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15059712  }} </ref>


==Pathophysiology==
==Pathophysiology==
====Pathogenesis====
====Pathogenesis====
Endogenous endophthalmitis is caused by the hematologic dissemination of an infection to the eyes. Most common extraocular foci of infection include [[liver abscess]], [[pneumonia]], [[endocarditis]], and soft tissue infection.
Endogenous endophthalmitis is mainly caused by [[Disseminated disease|hematologic dissemination]] of the organism from a primary site of infection in the setting of [[bacteremia]] or [[fungemia]].
Endogenous endophthalmitis is commonly associated with [[immunosuppression]] or procedures that increase the risk for blood-borne infections, such as [[diabetes]], [[HIV]], [[malignancy]], [[intravenous drug use]], [[transplantation]], [[immunosuppressive therapy]], and [[catheterization]].
Endogenous endophthalmitis is commonly associated with [[immunosuppression]] or procedures that increase the risk for blood-borne infections, such as [[diabetes]], [[HIV]], [[malignancy]], [[intravenous drug use]], [[transplantation]], [[immunosuppressive therapy]], and [[catheterization]].
Under normal circumstances, the [[blood-ocular barrier]] provides a natural resistance against invading organisms.
Under normal circumstances, the [[blood-ocular barrier]] provides a natural resistance against invading organisms.
Following [[bacteremia]], the blood-borne organisms permeate the [[blood-ocular barrier]] by:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
In the high risk patients, following [[bacteremia]] the blood-borne organisms permeate the [[blood-ocular barrier]] by:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895 }} </ref><ref name="pmid3541265">{{cite journal| author=Greenwald MJ, Wohl LG, Sell CH| title=Metastatic bacterial endophthalmitis: a contemporary reappraisal. | journal=Surv Ophthalmol | year= 1986 | volume= 31 | issue= 2 | pages= 81-101 | pmid=3541265 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3541265 }} </ref>
*Direct invasion ([[septic emboli]] reaches the eye through the [[posterior segment]] vasculature)
*Direct invasion ([[septic emboli]] reaches the eye through the [[posterior segment]] vasculature)
*Change in vascular endothelium (caused by [[inflammatory mediators]] released during infection)
*Change in vascular endothelium (caused by [[inflammatory mediators]] released during infection)
Direct spread from contagious sites can also occur in cases of [[central nervous system|central nervous system (CNS)]] infection via the [[optic nerve]].
Most common extraocular foci of infection include [[liver abscess]], [[pneumonia]], [[endocarditis]], and soft tissue infection.
 
Additionally, direct spread from contagious sites can occur in cases of [[central nervous system|central nervous system (CNS)]] infection via the [[optic nerve]].<ref name="pmid8989607">{{cite journal| author=Samiy N, D'Amico DJ| title=Endogenous fungal endophthalmitis. | journal=Int Ophthalmol Clin | year= 1996 | volume= 36 | issue= 3 | pages= 147-62 | pmid=8989607 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8989607  }} </ref>


The exact pathogenesis of candida endophthalmitis is not fully understood. It is though endogenous candida endophthalmitis is commonly associated with abdominal surgery or [[diabetes mellitus]]. It is thought [[immunosuppression]] alone does not increase the risk of [[fungemia]] and subsequent fungal endophthalmitis.  
'''Endogenous fungal endophthalmitis''' is also associated with procedures or conditions that increase the risk for blood-borne fungal infections, such as [[abdominal surgery]], [[diabetes mellitus]], and indwelling [[central venous catheter]]. It is thought [[immunosuppression]] alone does not increase the risk of [[fungemia]] and subsequent fungal endophthalmitis.<ref name="pmid11476686">{{cite journal| author=Rao NA, Hidayat AA| title=Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis. | journal=Am J Ophthalmol | year= 2001 | volume= 132 | issue= 2 | pages= 244-51 | pmid=11476686 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11476686  }} </ref>


The asexual spores of aspergilli organisms are airborne.
Following inhalation of an airborne organism into the body, the aspergilli spores enter the terminal alveoli of the lung.
Under normal circumstances, the lung provides a natural resistance against invading organisms.
But in high risk patients, such as those patients with history of [[chronic pulmonary diseases]]],  history of [[organ transplant]], [[intravenous drug abuse]], [[cardiac surgery]], and [[alcoholism]], disseminated aspergillosis may result in endogenous endophthalmitis.
====Gross Pathology====
====Gross Pathology====
*On gross pathology, eyelid swelling, eyelid [[erythema]], [[conjunctival injection]], [[chemosis]], and [[mucoprulunt dischage]] are characteristic findings of endogenous endophthalmitis.  
*On gross pathology, eyelid swelling, eyelid [[erythema]], [[conjunctival injection]], [[chemosis]], and mucoprulunt dischage are characteristic findings of endogenous endophthalmitis.
 
====Microscopic histopathological analysis====
====Microscopic histopathological analysis====
*On microscopic histopathological analysis, infiltration of [[polymorphonuclear leukocytes]] and destruction of ocular structures are characteristic findings of endogeouse bacterial endophthalmitis.
*On microscopic histopathological analysis, infiltration of [[polymorphonuclear leukocytes]] and destruction of [[ocular|ocular structures]] are characteristic findings of endogeouse bacterial endophthalmitis.
*On microscopic histopathological analysis, random [[vitreouse]] and [[retinal]] lesions with polymorphonoclear leukocytes, lymphocytes, budding yeast, pseudohyphae, and  choroidal/retinal wall invasion are characteristic findings of [[candida]] endophthalmitis.<ref> Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251. </ref>  
*On microscopic histopathological analysis, random [[vitreous humour|vitreous]], [[choroid ]], and [[retinal]] lesions (which demonstrate [[polymorphonuclear leukocytes], [[lymphocytes]], [[budding yeast]], and [[pseudohyphae]]) are characteristic findings of [[candida]] endophthalmitis.<ref> Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251. </ref>  
*On microscopic histopathological analysis, angiocentric retinal and choroidal lesion, mixed acute and chronic inflammatory cells infiltration,  retinal and choroidal vessel invassion, subretinal pigment epithelial and subretinal infection are characteristic findings of [[aspergillus]] endophthalmitis.<ref> Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251. </ref> <ref>Hunt, LCDR Kerry E., and Ben J. Glasgow. "Aspergillus endophthalmitis: an unrecognized endemic disease in orthotopic liver transplantation." Ophthalmology 103.5 (1996): 757-767.</ref>
*On microscopic histopathological analysis, mixed acute and chronic inflammatory cells infiltration,  retinal and choroidal vessel invasion, and subretinal pigment epithelial infection are characteristic findings of [[aspergillus]] endophthalmitis.<ref> Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251. </ref> <ref>Hunt, LCDR Kerry E., and Ben J. Glasgow. "Aspergillus endophthalmitis: an unrecognized endemic disease in orthotopic liver transplantation." Ophthalmology 103.5 (1996): 757-767.</ref>


==Causes==
==Causes==
Common causes of endogenous endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
===Bacterial===
===Bacterial===
Common causes of endogenous bacterial endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*[[Gram-positive bacteria]]  
*[[Gram-positive bacteria]]  
**''[[Streptococcus pneumoniae]]''
**''[[Streptococcus|Streptococcus spp]]''
**''[[Staphylococcus aureus]]''
**''[[Staphylococcus aureus]]''
**''[[Bacillus cereus]]'' (primary bacterial cause in [[intravenous drug abusers]])
**''[[Bacillus cereus]]'' (primary bacterial cause in [[intravenous drug users]])
*[[Gram-negative bacteria]]
*[[Gram-negative bacteria]]
**''[[Neisseria meningitidis]]'' (pre-antibiotic era)
**''[[Neisseria meningitidis]]'' (pre-antibiotic era)
**''[[Escherichia coli]]''
**''[[Escherichia coli]]''
**[[Klebsiella]] (in the Asian population with [[liver abscess]])
**[[Klebsiella|Klebsiella spp]] (in the Asian population with [[liver abscess]])
 
===Fungal===
===Fungal===
Common causes of endogenous fungal endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*''[[Candida albicans]]''
*''[[Candida albicans]]''
*[[Aspergillus]]
*''[[Candida tropicalis]]''
*''[[Aspergillus|Aspergillus spp]]''
*''[[Fusarium|Fusarium spp]]''


==Differentiating endogenous Endophthalmitis from Other Diseases==
==Differentiating endogenous Endophthalmitis from Other Diseases==
Endogenous bacterial endophthalmitis  
Endogenous bacterial endophthalmitis must be differentiated from:<ref name="pmid22050564">{{cite journal| author=Yonekawa Y, Chan RV, Reddy AK, Pieroni CG, Lee TC, Lee S| title=Early intravitreal treatment of endogenous bacterial endophthalmitis. | journal=Clin Experiment Ophthalmol | year= 2011 | volume= 39 | issue= 8 | pages= 771-8 | pmid=22050564 | doi=10.1111/j.1442-9071.2011.02545.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22050564  }} </ref>
*Aspergillus endophthalmitis
*Aspergillus endophthalmitis
*Candida endophthalmitis  
*Candida endophthalmitis  
Candida endophthalmitis  
Candida endophthalmitis must be differentiated from:<ref> Menezes, Allison V., et al. "Mortality of hospitalized patients with Candida endophthalmitis." Archives of internal medicine 154.18 (1994): 2093-2097. </ref><ref>Hidalgo, Jose A., et al. "Fungal endophthalmitis diagnosis by detection of Candida albicans DNA in intraocular fluid by use of a species-specific polymerase chain reaction assay." Journal of Infectious Diseases 181.3 (2000): 1198-1201.</ref>
*Cytomegalvirus retinitis
*[[CMV retinitis|Cytomegalvirus retinitis]]
*Toxoplasmosis retinochoroiditis
*Toxoplasmosis retinochoroiditis
*Primary intraocular lymphoma
*[[intraocular lymphoma|Primary intraocular lymphoma]]
*Syphilitic choroiditis
*Syphilitic [[choroiditis]]
*Aspergillus endophthalmitis
*Aspergillus endophthalmitis
*Endogenous bacterial endophthalmaitis  
*Endogenous bacterial endophthalmaitis  
Aspergillus endophthalmitis  
Aspergillus endophthalmitis must be differentiated from:<ref> Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.</ref>
*Cytomegalvirus retinitis
*[[CMV retinitis|Cytomegalvirus retinitis]]
*Toxoplasmosis retinochoroiditis
*[[Toxoplasmosis]] retinochoroiditis
*Coccidiomycosis choroiditis
*[[Coccidiomycosis]] choroiditis
*Endogenous bacterial endophthalmitis  
*Endogenous bacterial endophthalmitis  


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Incidence===
The incidence of endogenous endophthalmitis is estimated to be 50 cases per 100,000 hospitalized patients.<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid15522366">{{cite journal| author=Essex RW, Yi Q, Charles PG, Allen PJ| title=Post-traumatic endophthalmitis. | journal=Ophthalmology | year= 2004 | volume= 111 | issue= 11 | pages= 2015-22 | pmid=15522366 | doi=10.1016/j.ophtha.2003.09.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15522366  }} </ref>
===Age===
Endogenous bacterial endophthalmitis affects men and women equally.<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
===Geographical Distribution===
In East Asian populations, [[liver abscess]] caused by ''[[Klebsiella pneumoniae]]'' is estimated to be the source of 60.000 cases per 100,000 individuals with endogenous endophthalmitis.<ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>


==Risk Factors==
==Risk Factors==
===Endogenous bacterial endophthalmitis===
===Endogenous bacterial endophthalmitis===
Common risk factors in the development of endogenous bacterial endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
Common risk factors in the development of endogenous bacterial endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*Recent hospitalization
*Recent hospitalization
*[[Immunosuppression]]  
*[[Immunosuppression]]  
Line 81: Line 114:
*Long-term use of [[broad-spectrum antibiotics]] or [[immunosuppressive drugs]]
*Long-term use of [[broad-spectrum antibiotics]] or [[immunosuppressive drugs]]
*[[Liver abscess]]  
*[[Liver abscess]]  
*[[Infective endocarditis|[Infective endocarditis (IE)]]  
*[[Infective endocarditis|Infective endocarditis (IE)]]  
===Endogenous fungal endophthalmitis===
===Endogenous fungal endophthalmitis===
Common risk factors in the development of endogenous fungal endophthalmitis include:
Common risk factors in the development of endogenous fungal endophthalmitis include:<ref name="pmid15059712">{{cite journal| author=Schiedler V, Scott IU, Flynn HW, Davis JL, Benz MS, Miller D| title=Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. | journal=Am J Ophthalmol | year= 2004 | volume= 137 | issue= 4 | pages= 725-31 | pmid=15059712 | doi=10.1016/j.ajo.2003.11.013 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15059712  }} </ref><ref name="pmid9076791">{{cite journal| author=Essman TF, Flynn HW, Smiddy WE, Brod RD, Murray TG, Davis JL et al.| title=Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis. | journal=Ophthalmic Surg Lasers | year= 1997 | volume= 28 | issue= 3 | pages= 185-94 | pmid=9076791 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9076791  }} </ref>
*Recent [[abdominal surgery]]
*[[Diabetes mellitus]]
*Indwelling [[central venous catheter]].
*[[Chemotherapy]]  
*[[Chemotherapy]]  
*[[Organ transplantation]] (cardiac and liver transplants)
*[[Organ transplantation]]  
*[[Immunosuppressive therapy]] for [[hematopoietic stem cell transplantation]] (HSCT)
*[[Immunosuppressive therapy]] and impaired neutrophil function
*Lung involvement by ''[[Aspergillus]]''
*History of chronic pulmonary diseases
*[[intravenous drug use|Intravenous drug abuse]]
*[[Alcoholism]]
 
==Screening==
==Screening==
Screening for endogenous endophthalmitis is not recommended in hospitalized patients.<ref name=post-traumatic>US Preventivre Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=endophthalmitis Accessed on August 5, 2016 </ref>


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
===Natural History===
===Natural History===
Exogenous endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal infiltration, [[corneal perforation]], [[retinal detachment]], and ultimately permanent [[vision loss]].<ref name="pmid11115260">{{cite journal| author=Doft BM, Kelsey SF, Wisniewski SR| title=Retinal detachment in the endophthalmitis vitrectomy study. | journal=Arch Ophthalmol | year= 2000 | volume= 118 | issue= 12 | pages= 1661-5 | pmid=11115260 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11115260  }} </ref>


===Complications===
===Complications===
 
Common complications of bacterial endophthalmitis include:<ref name="pmid11115260">{{cite journal| author=Doft BM, Kelsey SF, Wisniewski SR| title=Retinal detachment in the endophthalmitis vitrectomy study. | journal=Arch Ophthalmol | year= 2000 | volume= 118 | issue= 12 | pages= 1661-5 | pmid=11115260 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11115260  }} </ref>
*Panophthalmitis
*Decrease or loss of vision
*[[Chronic pain]]
*[[Cataract]] development
*[[Retinal detachment]]
*[[Vitreous hemorrhage]]
*Hypotony and [[phthisis bulbi]]
*[[Proptosis]] and a corneal abscess
*[[Sepsis]] (specific for endogenous endophthalmit)
*Suprachoroidal hemorrhage (specific for endogenous endophthalmit)
===Prognosis===
===Prognosis===
The prognosis of endogenouse endophthalmitis varies with the offending organism and the systemic status of the patient.
*Late detection and late treatment of systemic infection of endogenouse bacterial endophthalmitis is associated with a poor prognosis.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*The prognosis of candida endophthalmitis is good if prompt systemic [[amphotericin B]] treatment is received.<ref>Essman, Thomas F., et al. "Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis." Ophthalmic Surgery, Lasers and Imaging Retina 28.3 (1997): 185-194. </ref>
*Despite of aggressive treatment, aspergillus endophthalmitis is associated with poor prognosis.<ref>Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.</ref>


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
The diagnosis of endogenous endophthalmitis may be difficult because of the variability in the clinical signs and symptoms.
===History===
Specific areas of focus when obtaining a history from the patient with endogenous endophthalmitis include:.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*History of [[diabetes mellitus]]
*[[Immunosuppression]] (associated with underlying [[malignancy]], [[neutropenia]], and [[HIV]])
*History of [[cardiac disease]]
*History of [[abdominal surgery]]
*[[intravenous catheters]]
*[[Intravenous drug use]]
*[[Immunosuppressive therapy]]
*History of chronic pulmonary diseases


===History and Symptoms===
===Symptoms===
Symptoms of endogenous endophthalmitis may include the following:<ref name="pmid26525563">{{cite journal| author=Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK et al.| title=Endogenous endophthalmitis: diagnosis, management, and prognosis. | journal=J Ophthalmic Inflamm Infect | year= 2015 | volume= 5 | issue= 1 | pages= 32 | pmid=26525563 | doi=10.1186/s12348-015-0063-y | pmc=4630262 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26525563  }} </ref><ref name="pmid21765074">{{cite journal| author=Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C et al.| title=Ocular manifestations of candidemia. | journal=Clin Infect Dis | year= 2011 | volume= 53 | issue= 3 | pages= 262-8 | pmid=21765074 | doi=10.1093/cid/cir355 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21765074  }} </ref>
*Decreased vision
*Eyelid edema
*[[Conjunctival injection]]
*Eye pain
*[[Photophobia]]
*Presence of floaters


===Physical Examination===
===Physical Examination===
*Patients with endogenous endophthalmtis usually appear extremely ill and [[lethargic]]. Therefore, eye examination in extremely ill patients, such as those in [[intensive care units|intensive care units (ICU)]], seems necessary.
*A thorough examination seems necessary to identify the primary source of infection in patient with endogenous endophthalmitis.
====Eye examination====
Ophthalmologic examination of patients with endogenoous endophthlamitis is usually remarkable for:
*Decreased vision
*[[Conjunctival injection]]
*Eyelid edema
*Cloudy [[cornea]]
*Decreased [[red reflex]]


===Laboratory Findings===
===Laboratory Findings===
Candida endophthalmitis  
Laboratory studies consistent with the diagnosis of endogenous bacterial endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref><ref name="pmid18721702">{{cite journal| author=Seal D, Reischl U, Behr A, Ferrer C, Alió J, Koerner RJ et al.| title=Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract & Refractive Surgeons multicenter study and susceptibility testing. | journal=J Cataract Refract Surg | year= 2008 | volume= 34 | issue= 9 | pages= 1439-50 | pmid=18721702 | doi=10.1016/j.jcrs.2008.05.043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18721702  }} </ref>
*Positive cultures of blood, catheter tips, surgical wounds, and body fluids for ''[[Candidia]]
*[[Culture]] and [[gram stain]] of [[aqueous humor]] as well as the [[vitreous humor]] (not often sensitive)
*[[Vitreaus]] cultures and biopsy (required to confirm to confirm the diagnosis)
*[[polymerase chain reaction|Polymerase chain reaction (PCR)]]  of [[aqueous humor]] as well as the [[vitreous humor]]
*Blood cultures (it is positive in 75% of cases of endogenous endophthalmitis)
Laboratory studies consistent with the diagnosis of endogenous candida endophthalmitis include:<ref> Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140. </ref>
*[[Vitreaus]] cultures and biopsy (required to confirm the diagnosis)
*Vitreous [[Polymerase chain reaction|polymerase chain reaction (PCR)]]
*Vitreous [[Polymerase chain reaction|polymerase chain reaction (PCR)]]
 
*Positive cultures of blood for ''[[Candida]]
Aspergillus endophthalmitis  
Laboratory studies consistent with the diagnosis of endogenous aspergillus endophthalmitis include:
*Anterior chamber and vitreous aspiration alone are unreliable
*Vitreous biopsy and cultures (Grocott or [[Periodic acid-Schiff]])
*Pars plana vitreous biopsy and cultures (Grocott or periodic acid Schiff stains)
*[[Anterior chamber]] and [[vitreous]] aspiration (unreliable)
*Coexisting systemic aspergillosis
*Positive cultures of blood for aspergillosis (coexisting systemic aspergillosis)


===Imaging Findings===
===Imaging Findings===
====X Ray====
====X Ray====
 
There are no diagnostic x ray findings associated with endogenous endophthalmitis. X ray may be helpful in the diagnosis of underling medical conditions or source of infection.
====CT====
====CT====
 
There are no diagnostic CT scan findings associated with endogenous endophthalmitis. Ct scan may be helpful in the diagnosis of underling medical conditions or source of infection.
====MRI====
====MRI====
There are no diagnostic MRI findings associated with endogenous endophthalmitis. Abdominal and chest MRI may be helpful in the diagnosis of underling medical conditions or source of infection.
====Ultrasound====
*On ocular ultrasonography, endophthalmitis may characterized by anterior vitreous haze echoes and retinochoroidal thickening.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid3495766">{{cite journal| author=Affeldt JC, Flynn HW, Forster RK, Mandelbaum S, Clarkson JG, Jarus GD| title=Microbial endophthalmitis resulting from ocular trauma. | journal=Ophthalmology | year= 1987 | volume= 94 | issue= 4 | pages= 407-13 | pmid=3495766 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3495766  }} </ref>


====Ultrasound====
Dense and hyper-reflective echoes in the [[vitreous]] cavity suggestive of exudates (yellow arrow). The membrane-like echo in the scan marked by yellow triangles suggests presence of a total [[retinal detachment]].


====Other Imaging Findings====
====Other Imaging Findings====
*[[Echocardiography]] may be helpful (assessed the possibility of [[endocarditis]])


===Other Diagnostic Studies===
===Other Diagnostic Studies===
Other diagnostic studies for endogenous endophthalmiatis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*[[Slit lamp|Slit lamp examination]]<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref>
**Mild to moderate [[anterior chamber]] reaction
**[[Hypopyon]]
**[[Roth's spots]] and [[retinal periphlebitis]]
**White and fluffy choriodoretinal lesions (candida endophthalmitis)
**Snowball-like opacities in vitreous (candida endophthalmitis)
*Testing for [[human immunodeficiency virus|human immunodeficiency virus (HIV)]]
*Culture of [[urine]] or [[cerebrospinal fluid]] is often necessary
*Cultures of other sites ([[catheter|catheter tip]], surgical wounds, and body fluids)


==Treatment==
==Treatment==
===Medical Therapy===
The patient needs urgent examination by an expert [[ophthalmologist]] and/or vitreo-retina specialist who will usually decide for urgent intervention to provide [[intravitreal injection]] of potent antibiotics and also prepare for an urgent pars plana [[vitrectomy]] as needed.  [[Enucleation]] may be required to remove a blind and painful eye.
 
*Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
*Systemic antimicrobial and antifungal treatments are recommended in endogenous endophthalmitis because the source of the infection is distant from the eye
*[[Vitrectomy]] is recommended in severe cases of endogenous endophthalmitis with marked vitreous infiltration
===Antimicrobial Regimens===
*'''Infectious endophthalmitis'''<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=PMC3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref>
:*'''1. Causative pathogens'''
::*''[[Staphylococcus epidermidis]]''
::*''[[Staphylococcus aureus]]''
::*[[Bacillus|Bacillus spp.]]
::*''[[Escherichia coli]]''
::*''[[Neisseria meningitidis]]''
::*[[Candida|Candida spp.]]
::*[[Aspergillus|Aspergillus spp.]]
::*[[Fusarium|Fusarium spp.]]
:*'''2. Empiric antimicrobial therapy'''
::::* Preferred regimen: [[Vancomycin]] 1 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Vancomycin]] 1 g IV bid for 2 weeks {{and}} [[Ceftazidime]] 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Ceftazidime]] 1 g IV bid for 2 weeks {{and}} [[Clindamycin]] 600-1200 mg IV bid to qid for 2 weeks
::::* Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
::::* Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary
::::* Note (3): Intravitreal and intravenous [[Amphotericin B]] may be added to the regimen if fungal endophthalmitis is suspected
:*'''3. Pathogen-directed antimicrobial therapy'''
::*'''3.1 Bacillus spp.'''
:::*Preferred regimen: [[Vancomycin]] 1 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Vancomycin]] 1 g IV bid for 2 weeks {{and}} [[Clindamycin]] 600-1200 mg IV bid to qid for 2 weeks
:::* Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
::*'''3.2 Non-Bacillus gram-positive bacteria'''
:::*Preferred regimen: [[Vancomycin]] 1 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Vancomycin]] 1 g IV bid for 2 weeks
:::* Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
::*'''3.3 Gram-negative bacteria'''
:::*Preferred regimen: [[Ceftazidime]] 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Ceftazidime]] 1 g IV bid for 2 weeks
:::* Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
::*'''3.4 Candida spp.'''
:::*Preferred regimen: ([[Fluconazole]] 400-800 mg IV/PO qd for 6-12 weeks {{or}} [[Voriconazole]] 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks {{or}} [[Amphotericin B]] 0.7-1.0 mg/kg IV qd for 6-12 weeks) {{and}} [[Amphotericin B]] 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
:::* Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
::*'''3.5 Aspergillus spp.'''
:::*Preferred regimen: [[Amphotericin B]] 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Dexamethasone]] 400 microgram intravitreal injection, single dose
:::* Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
:::* Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy
===Surgery===
===Surgery===
====Vitrectomy====
[[Vitrectomy]] surgically debrides the [[vitreous humor]], similarly to draining an abscess, and is the fastest way of clearing infection in eyes with fulminant endophthalmitis.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref><ref name="pmid7487614">{{cite journal| author=| title=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. | journal=Arch Ophthalmol | year= 1995 | volume= 113 | issue= 12 | pages= 1479-96 | pmid=7487614 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7487614  }} </ref><ref> Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140. </ref>
*[[Vitrectomy]] is recommended in severe cases of endogenous endophthalmitis with marked vitreous infiltration (either fungal or bacterial)
The benefits of vitrectomy include:
*Better vitreous sample
*Rapid and complete sterilization of the [[vitreous]]
*Removal of toxic bacterial products
*Enhancement of systemic antimicrobial or antifungal penetration in to the eye


===Prevention===
===Prevention===
====Primary Prevention====
Effective measures for the primary prevention of endogenous endophthalmitis include:
*Effective treatment of underlying medical conditions
====Secondary prevention====
There are no secondary preventive measures available for endogenous endophthalmiatis. Endophthalmiatis is a medical emergency.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Ophthalmology]]
[[Category:Infectious disease]]


{{WS}}
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[[Category:Ophthalmology]]
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]
Synonyms and keywords: Endogenous fungal endophthalmitis; Endogenous bacterial endophthalmitis


Overview

Endogenous endophthalmitis is a rare but sight-threatening complication that can be caused by the hematologic dissemination of bacterial/fungal infections to the eyes or direct spread from adjacent contagious sites. Most common extraocular foci of infection include liver abscess, pneumonia, endocarditis, and soft tissue infection. Endogenous endophthalmitis is commonly associated with immunosuppression or procedures that increase the risk for blood-borne infections, such as diabetes, HIV, malignancy, intravenous drug use, transplantation, immunosuppressive therapy, and catheterization. Common causes of endogenous endophthalmitis include Streptococcus pneumoniae, Staphylococcus aureus, Bacillus cereus, and Klebsiella spp. Additionally, endogenous endophthalmitis may be caused by the hematologic dissemination of fungal infections into the eye commonly Candida spp (>50%) following by Aspergillus, and Fusarium spp. Endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal perforation, and ultimately permanent vision loss. [1] The prognosis of endogenouse endophthalmitis varies with the offending organism and the systemic status of the patient. Late detection and late treatment of systemic infection of endogenouse endophthalmitis is associated with a poor prognosis.[2][3][4] The diagnosis of endogenous endophthalmitis may be difficult because of the variability in the clinical signs and symptoms. Patients with endogenous endophthalmtis usually appear extremely ill and lethargic. Therefore, eye examination in extremely ill patients, such as those in intensive care units (ICU), seems necessary. Most common eye examination findings in endogenous endophthalmitis may include decreased vision, ocular pain, eyelid edema, cloudy cornea, and decreased red reflex. Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis However, positive cultures from vitreous samples can be achieved much less frequently in endogenous endophthalmitis. Identification of the causative pathogen by blood, urine, or cerebrospinal fluid culture is successful in more than 75% of endogenous endophthalmitis cases.[2][5]

  • The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retina specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics and also prepare for an urgent pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.

Systemic antimicrobial and anti-fungal agents are recommended in endogenous endophthalmitis because the source of the infection is distant from the eye.[2][5]

Historical Perspective

In 1916, Dr. Leonard Weakly published a case report which detailed a patient with endophthalmitis concurrent with meningitis.[6]

Classification

Endogenous enophthalmitis may be classified according to causative organisms into 2 subtypes: bacterial or fungal.[7][8]

Pathophysiology

Pathogenesis

Endogenous endophthalmitis is mainly caused by hematologic dissemination of the organism from a primary site of infection in the setting of bacteremia or fungemia. Endogenous endophthalmitis is commonly associated with immunosuppression or procedures that increase the risk for blood-borne infections, such as diabetes, HIV, malignancy, intravenous drug use, transplantation, immunosuppressive therapy, and catheterization. Under normal circumstances, the blood-ocular barrier provides a natural resistance against invading organisms. In the high risk patients, following bacteremia the blood-borne organisms permeate the blood-ocular barrier by:[2][3][4][9]

Most common extraocular foci of infection include liver abscess, pneumonia, endocarditis, and soft tissue infection.

Additionally, direct spread from contagious sites can occur in cases of central nervous system (CNS) infection via the optic nerve.[10]

Endogenous fungal endophthalmitis is also associated with procedures or conditions that increase the risk for blood-borne fungal infections, such as abdominal surgery, diabetes mellitus, and indwelling central venous catheter. It is thought immunosuppression alone does not increase the risk of fungemia and subsequent fungal endophthalmitis.[11]

Gross Pathology

Microscopic histopathological analysis

  • On microscopic histopathological analysis, infiltration of polymorphonuclear leukocytes and destruction of ocular structures are characteristic findings of endogeouse bacterial endophthalmitis.
  • On microscopic histopathological analysis, random vitreous, choroid , and retinal lesions (which demonstrate [[polymorphonuclear leukocytes], lymphocytes, budding yeast, and pseudohyphae) are characteristic findings of candida endophthalmitis.[12]
  • On microscopic histopathological analysis, mixed acute and chronic inflammatory cells infiltration, retinal and choroidal vessel invasion, and subretinal pigment epithelial infection are characteristic findings of aspergillus endophthalmitis.[13] [14]

Causes

Bacterial

Common causes of endogenous bacterial endophthalmitis include:[2][3][4]

Fungal

Common causes of endogenous fungal endophthalmitis include:[2][3][4]

Differentiating endogenous Endophthalmitis from Other Diseases

Endogenous bacterial endophthalmitis must be differentiated from:[15]

  • Aspergillus endophthalmitis
  • Candida endophthalmitis

Candida endophthalmitis must be differentiated from:[16][17]

Aspergillus endophthalmitis must be differentiated from:[18]

Epidemiology and Demographics

Incidence

The incidence of endogenous endophthalmitis is estimated to be 50 cases per 100,000 hospitalized patients.[3][19]

Age

Endogenous bacterial endophthalmitis affects men and women equally.[3]

Geographical Distribution

In East Asian populations, liver abscess caused by Klebsiella pneumoniae is estimated to be the source of 60.000 cases per 100,000 individuals with endogenous endophthalmitis.[4]

Risk Factors

Endogenous bacterial endophthalmitis

Common risk factors in the development of endogenous bacterial endophthalmitis include:[2][3][4]

Endogenous fungal endophthalmitis

Common risk factors in the development of endogenous fungal endophthalmitis include:[8][20]

Screening

Screening for endogenous endophthalmitis is not recommended in hospitalized patients.[21]

Natural History, Complications, and Prognosis

Natural History

Exogenous endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal infiltration, corneal perforation, retinal detachment, and ultimately permanent vision loss.[1]

Complications

Common complications of bacterial endophthalmitis include:[1]

Prognosis

The prognosis of endogenouse endophthalmitis varies with the offending organism and the systemic status of the patient.

  • Late detection and late treatment of systemic infection of endogenouse bacterial endophthalmitis is associated with a poor prognosis.[2][3][4]
  • The prognosis of candida endophthalmitis is good if prompt systemic amphotericin B treatment is received.[22]
  • Despite of aggressive treatment, aspergillus endophthalmitis is associated with poor prognosis.[23]

Diagnosis

The diagnosis of endogenous endophthalmitis may be difficult because of the variability in the clinical signs and symptoms.

History

Specific areas of focus when obtaining a history from the patient with endogenous endophthalmitis include:.[2][3][4]

Symptoms

Symptoms of endogenous endophthalmitis may include the following:[24][25]

Physical Examination

  • Patients with endogenous endophthalmtis usually appear extremely ill and lethargic. Therefore, eye examination in extremely ill patients, such as those in intensive care units (ICU), seems necessary.
  • A thorough examination seems necessary to identify the primary source of infection in patient with endogenous endophthalmitis.

Eye examination

Ophthalmologic examination of patients with endogenoous endophthlamitis is usually remarkable for:

Laboratory Findings

Laboratory studies consistent with the diagnosis of endogenous bacterial endophthalmitis include:[2][5][26]

Laboratory studies consistent with the diagnosis of endogenous candida endophthalmitis include:[27]

Laboratory studies consistent with the diagnosis of endogenous aspergillus endophthalmitis include:

Imaging Findings

X Ray

There are no diagnostic x ray findings associated with endogenous endophthalmitis. X ray may be helpful in the diagnosis of underling medical conditions or source of infection.

CT

There are no diagnostic CT scan findings associated with endogenous endophthalmitis. Ct scan may be helpful in the diagnosis of underling medical conditions or source of infection.

MRI

There are no diagnostic MRI findings associated with endogenous endophthalmitis. Abdominal and chest MRI may be helpful in the diagnosis of underling medical conditions or source of infection.

Ultrasound

  • On ocular ultrasonography, endophthalmitis may characterized by anterior vitreous haze echoes and retinochoroidal thickening.[2][3][28]

Dense and hyper-reflective echoes in the vitreous cavity suggestive of exudates (yellow arrow). The membrane-like echo in the scan marked by yellow triangles suggests presence of a total retinal detachment.

Other Imaging Findings

Other Diagnostic Studies

Other diagnostic studies for endogenous endophthalmiatis include:[2][3][4]

Treatment

The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retina specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics and also prepare for an urgent pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.

  • Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
  • Systemic antimicrobial and antifungal treatments are recommended in endogenous endophthalmitis because the source of the infection is distant from the eye
  • Vitrectomy is recommended in severe cases of endogenous endophthalmitis with marked vitreous infiltration

Antimicrobial Regimens

  • Infectious endophthalmitis[2]
  • 1. Causative pathogens
  • 2. Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
  • Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary
  • Note (3): Intravitreal and intravenous Amphotericin B may be added to the regimen if fungal endophthalmitis is suspected
  • 3. Pathogen-directed antimicrobial therapy
  • 3.1 Bacillus spp.
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.2 Non-Bacillus gram-positive bacteria
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.3 Gram-negative bacteria
  • Preferred regimen: Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.4 Candida spp.
  • Preferred regimen: (Fluconazole 400-800 mg IV/PO qd for 6-12 weeks OR Voriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks OR Amphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.5 Aspergillus spp.
  • Preferred regimen: Amphotericin B 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose AND Dexamethasone 400 microgram intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy

Surgery

Vitrectomy

Vitrectomy surgically debrides the vitreous humor, similarly to draining an abscess, and is the fastest way of clearing infection in eyes with fulminant endophthalmitis.[2][5][29][30]

  • Vitrectomy is recommended in severe cases of endogenous endophthalmitis with marked vitreous infiltration (either fungal or bacterial)

The benefits of vitrectomy include:

  • Better vitreous sample
  • Rapid and complete sterilization of the vitreous
  • Removal of toxic bacterial products
  • Enhancement of systemic antimicrobial or antifungal penetration in to the eye

Prevention

Primary Prevention

Effective measures for the primary prevention of endogenous endophthalmitis include:

  • Effective treatment of underlying medical conditions

Secondary prevention

There are no secondary preventive measures available for endogenous endophthalmiatis. Endophthalmiatis is a medical emergency.

References

  1. ↑ 1.0 1.1 1.2 Doft BM, Kelsey SF, Wisniewski SR (2000). "Retinal detachment in the endophthalmitis vitrectomy study". Arch Ophthalmol. 118 (12): 1661–5. PMID 11115260.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Wong JS, Chan TK, Lee HM, Chee SP (2000). "Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction". Ophthalmology. 107 (8): 1483–91. PMID 10919895.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP; et al. (1997). "Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study". Arch Ophthalmol. 115 (9): 1142–50. PMID 9298055.
  6. ↑ {{cite journal| author=Weakley AL| title=METASTATIC ENDOPHTHALMITIS IN A CASE OF CEREBRO-SPINAL MENINGITIS. | journal=Br Med J | year= 1916 | volume= 1 | issue= 2871 | pages= 47-8 | pmid=20767965 | doi= | pmc=2346850 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?
  7. ↑ Lim HW, Shin JW, Cho HY, Kim HK, Kang SW, Song SJ; et al. (2014). "Endogenous endophthalmitis in the Korean population: a six-year retrospective study". Retina. 34 (3): 592–602. doi:10.1097/IAE.0b013e3182a2e705. PMID 24056527.
  8. ↑ 8.0 8.1 Schiedler V, Scott IU, Flynn HW, Davis JL, Benz MS, Miller D (2004). "Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes". Am J Ophthalmol. 137 (4): 725–31. doi:10.1016/j.ajo.2003.11.013. PMID 15059712.
  9. ↑ Greenwald MJ, Wohl LG, Sell CH (1986). "Metastatic bacterial endophthalmitis: a contemporary reappraisal". Surv Ophthalmol. 31 (2): 81–101. PMID 3541265.
  10. ↑ Samiy N, D'Amico DJ (1996). "Endogenous fungal endophthalmitis". Int Ophthalmol Clin. 36 (3): 147–62. PMID 8989607.
  11. ↑ Rao NA, Hidayat AA (2001). "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis". Am J Ophthalmol. 132 (2): 244–51. PMID 11476686.
  12. ↑ Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251.
  13. ↑ Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251.
  14. ↑ Hunt, LCDR Kerry E., and Ben J. Glasgow. "Aspergillus endophthalmitis: an unrecognized endemic disease in orthotopic liver transplantation." Ophthalmology 103.5 (1996): 757-767.
  15. ↑ Yonekawa Y, Chan RV, Reddy AK, Pieroni CG, Lee TC, Lee S (2011). "Early intravitreal treatment of endogenous bacterial endophthalmitis". Clin Experiment Ophthalmol. 39 (8): 771–8. doi:10.1111/j.1442-9071.2011.02545.x. PMID 22050564.
  16. ↑ Menezes, Allison V., et al. "Mortality of hospitalized patients with Candida endophthalmitis." Archives of internal medicine 154.18 (1994): 2093-2097.
  17. ↑ Hidalgo, Jose A., et al. "Fungal endophthalmitis diagnosis by detection of Candida albicans DNA in intraocular fluid by use of a species-specific polymerase chain reaction assay." Journal of Infectious Diseases 181.3 (2000): 1198-1201.
  18. ↑ Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.
  19. ↑ Essex RW, Yi Q, Charles PG, Allen PJ (2004). "Post-traumatic endophthalmitis". Ophthalmology. 111 (11): 2015–22. doi:10.1016/j.ophtha.2003.09.041. PMID 15522366.
  20. ↑ Essman TF, Flynn HW, Smiddy WE, Brod RD, Murray TG, Davis JL; et al. (1997). "Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis". Ophthalmic Surg Lasers. 28 (3): 185–94. PMID 9076791.
  21. ↑ US Preventivre Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=endophthalmitis Accessed on August 5, 2016
  22. ↑ Essman, Thomas F., et al. "Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis." Ophthalmic Surgery, Lasers and Imaging Retina 28.3 (1997): 185-194.
  23. ↑ Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.
  24. ↑ Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK; et al. (2015). "Endogenous endophthalmitis: diagnosis, management, and prognosis". J Ophthalmic Inflamm Infect. 5 (1): 32. doi:10.1186/s12348-015-0063-y. PMC 4630262. PMID 26525563.
  25. ↑ Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C; et al. (2011). "Ocular manifestations of candidemia". Clin Infect Dis. 53 (3): 262–8. doi:10.1093/cid/cir355. PMID 21765074.
  26. ↑ Seal D, Reischl U, Behr A, Ferrer C, Alió J, Koerner RJ; et al. (2008). "Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract & Refractive Surgeons multicenter study and susceptibility testing". J Cataract Refract Surg. 34 (9): 1439–50. doi:10.1016/j.jcrs.2008.05.043. PMID 18721702.
  27. ↑ Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140.
  28. ↑ Affeldt JC, Flynn HW, Forster RK, Mandelbaum S, Clarkson JG, Jarus GD (1987). "Microbial endophthalmitis resulting from ocular trauma". Ophthalmology. 94 (4): 407–13. PMID 3495766.
  29. ↑ "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. 113 (12): 1479–96. 1995. PMID 7487614.
  30. ↑ Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140.

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