Post-traumatic endophthalmitis: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{SI}} | {{SI}} | ||
{{CMG}}; {{AE}} | '''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 bleb-related endophthalmitis, please click [[Bleb-related endophthalmitis|here]]'''<br> | |||
'''For more information on endogenous endophthalmitis, please click [[Endogenous endophthalmitis|here]]'''<br> | |||
{{CMG}}; {{AE}} {{SaraM}} | |||
{{SK}} Post-traumatic bacterial endophthalmitis; Post-traumatic fungal endophthalmitis | |||
==Overview== | ==Overview== | ||
Post-traumatic bacterial endophthalmitis occurs following penetrating ocular injuries. Post-traumatic endophthalmitis is associated with a large variety of organisms. The most commonly isolated organisms include gram-positive ''[[Staphylococcus epidermidis]]'' and ''[[Streptococcus]]'' (as a part of the normal skin flora and regularly contaminate open wounds). ''[[Bacillus cereus]]'' is second most common. In some cases post-traumatic endophthalmitis is polymicrobial. The risk for developing endophthalmitis after open globe injuries is estimated at about 7% of injured eyes.<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><ref name="pmid21397289">{{cite journal| author=Bhagat N, Nagori S, Zarbin M| title=Post-traumatic Infectious Endophthalmitis. | journal=Surv Ophthalmol | year= 2011 | volume= 56 | issue= 3 | pages= 214-51 | pmid=21397289 | doi=10.1016/j.survophthal.2010.09.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21397289 }} </ref><ref name="pmid10458188">{{cite journal| author=Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U et al.| title=Microbiologic spectrum and susceptibility of isolates: part II. Posttraumatic endophthalmitis. Endophthalmitis Research Group. | journal=Am J Ophthalmol | year= 1999 | volume= 128 | issue= 2 | pages= 242-4 | pmid=10458188 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458188 }} </ref> | |||
Post-traumatic bacterial endophthalmitis occurs following penetrating ocular injuries. Post-traumatic endophthalmitis associated with a | |||
==Historical Perspective== | ==Historical Perspective== | ||
*In 1903, post-traumatic fungal endophthalmitis was first reported by Romer.<ref> Romer, P. "Eine intraoculare Schimmelpilz-infection." Klin Monatsbl Augenheilkd 40 (1902): 331-333.</ref> | |||
*In 1933, exogenous fungal endophthalmitis was first described by Rychener.<ref> Wu, Lihteh, and Guillermo Tapia-Herrera. "Fungal endophthalmitis." Current Fungal Infection Reports 3.1 (2009): 55-61.</ref> | |||
==Classification== | ==Classification== | ||
Post-traumatic endophthalmitis may be classified according to the causative organisms into 2 subtypes: [[bacterial]] or [[fungal]].<ref name="pmid10458188">{{cite journal| author=Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U et al.| title=Microbiologic spectrum and susceptibility of isolates: part II. Posttraumatic endophthalmitis. Endophthalmitis Research Group. | journal=Am J Ophthalmol | year= 1999 | volume= 128 | issue= 2 | pages= 242-4 | pmid=10458188 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458188 }} </ref> | |||
==Pathophysiology== | ==Pathophysiology== | ||
===Pathogenesis=== | ===Pathogenesis=== | ||
'''Post-traumatic | '''Post-traumatic endophthalmitis''' occurs following penetrating ocular injuries. | ||
Following penetrating injury, the eye globe integrity disturbed. Penetrating ocular injuries are accompanied by infection at a much higher rate | Following penetrating injury, the eye globe integrity disturbed. The microorganisms are often implanted via direct inoculation by the penetrating object, by a retained foreign body, or by infection of the open wound. Penetrating ocular injuries are accompanied by infection at a much higher rate compared to ocular surgery. | ||
Post-traumatic endophthalmitis is associated with a large variety of organisms. The most commonly isolated organisms include gram-positive ''[[Staphylococcus epidermidis]]'' and ''[[Streptococcus]]'' (as a part of the normal skin flora and regularly contaminate open wounds). Bacillus cereus is the second most common cause. In some cases post-traumatic endophthalmitis is polymicrobial.<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><ref name="pmid21397289">{{cite journal| author=Bhagat N, Nagori S, Zarbin M| title=Post-traumatic Infectious Endophthalmitis. | journal=Surv Ophthalmol | year= 2011 | volume= 56 | issue= 3 | pages= 214-51 | pmid=21397289 | doi=10.1016/j.survophthal.2010.09.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21397289 }} </ref><ref name="pmid10458188">{{cite journal| author=Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U et al.| title=Microbiologic spectrum and susceptibility of isolates: part II. Posttraumatic endophthalmitis. Endophthalmitis Research Group. | journal=Am J Ophthalmol | year= 1999 | volume= 128 | issue= 2 | pages= 242-4 | pmid=10458188 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458188 }} </ref> | |||
====Gross Pathology==== | |||
On gross pathology, eyelid swelling, eyelid erythema, injected conjunctiva and sclera, [[hypopyon]], [[chemosis]], and mucopurulunt discharge are characteristic findings of endophthalmitis.<ref name="pmid21397289">{{cite journal| author=Bhagat N, Nagori S, Zarbin M| title=Post-traumatic Infectious Endophthalmitis. | journal=Surv Ophthalmol | year= 2011 | volume= 56 | issue= 3 | pages= 214-51 | pmid=21397289 | doi=10.1016/j.survophthal.2010.09.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21397289 }} </ref><ref name="pmid8414406">{{cite journal| author=Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE| title=Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System. | journal=Ophthalmology | year= 1993 | volume= 100 | issue= 10 | pages= 1468-74 | pmid=8414406 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8414406 }} </ref> | |||
Post-traumatic endophthalmitis associated with a | ====Microscopic histopathological analysis==== | ||
On microscopic histopathological analysis, infiltration of [[polymorphonuclear leukocytes]] or chronic inflammatory cells (depending on the duration of the inflammation) and destruction of ocular structures are characteristic findings of post-traumatic bacterial endophthalmitis. | |||
==Causes== | ==Causes== | ||
===Post-traumatic bacterial endophthalmitis=== | ===Post-traumatic bacterial endophthalmitis=== | ||
Common causes of post-traumatic bacterial endophthalmitis include:<ref name=" | Common causes of post-traumatic bacterial endophthalmitis include:<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><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="pmid10230588">{{cite journal| author=Abu el-Asrar AM, al-Amro SA, al-Mosallam AA, al-Obeidan S| title=Post-traumatic endophthalmitis: causative organisms and visual outcome. | journal=Eur J Ophthalmol | year= 1999 | volume= 9 | issue= 1 | pages= 21-31 | pmid=10230588 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10230588 }} </ref> | ||
*[[Gram-positive bacteria| | *[[Gram-positive bacteria]] | ||
**''[[Bacillus cereus]]'' (most common | **''[[Staphylococcus|Staphylococcus species]]'' | ||
**[[ | **''[[Streptococcus|Streptococcus species]]'' | ||
**''[[ | **''[[Bacillus cereus]]'' (most common in the setting of an IOFB or soil contamination) | ||
**''[[Clostridium]]'' (fulminant endophthalmitis) | |||
*[[Gram-negative bacteria | **''[[Propionibacterium acnes]]'' | ||
**[[Klebsiella]] | *[[Gram-negative bacteria]] | ||
**[[Pseudomonas]] (fulminant endophthalmitis) | **''[[Klebsiella]]'' | ||
**''[[Pseudomonas]]'' (fulminant endophthalmitis) | |||
*Polymicrobial | *Polymicrobial | ||
===Post-traumatic fungal endophthalmitis=== | ===Post-traumatic fungal endophthalmitis=== | ||
Common causes of post-traumatic fungal endophthalmitis include: | Common causes of post-traumatic 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="pmid18486220">{{cite journal| author=Wykoff CC, Flynn HW, Miller D, Scott IU, Alfonso EC| title=Exogenous fungal endophthalmitis: microbiology and clinical outcomes. | journal=Ophthalmology | year= 2008 | volume= 115 | issue= 9 | pages= 1501-7, 1507.e1-2 | pmid=18486220 | doi=10.1016/j.ophtha.2008.02.027 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18486220 }} </ref><ref name="pmid10230588">{{cite journal| author=Abu el-Asrar AM, al-Amro SA, al-Mosallam AA, al-Obeidan S| title=Post-traumatic endophthalmitis: causative organisms and visual outcome. | journal=Eur J Ophthalmol | year= 1999 | volume= 9 | issue= 1 | pages= 21-31 | pmid=10230588 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10230588 }} </ref> | ||
*''[[Candida|Candida species]]'' | *''[[Candida|Candida species]]'' | ||
*''[[Aspergillus|Aspergillus species]]'' | *''[[Aspergillus|Aspergillus species]]'' | ||
*''[[Paecilomyces|Paecilomyces species]]'' | *''[[Paecilomyces|Paecilomyces species]]'' | ||
*''[[Fusarium|Fusarium species]]'' | *''[[Fusarium|Fusarium species]]'' | ||
*'' | *''Dematacious fungi'' | ||
==Differentiating Post-traumatic Endophthalmitis from Other Diseases== | ==Differentiating Post-traumatic Endophthalmitis from Other Diseases== | ||
Post-traumatic endophthalmitis must be differentiated from:<ref name="pmid1917323">{{cite journal| author=Thach AB, Marak GE, McLean IW, Green WR| title=Phacoanaphylactic endophthalmitis: a clinicopathologic review. | journal=Int Ophthalmol | year= 1991 | volume= 15 | issue= 4 | pages= 271-9 | pmid=1917323 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1917323 }} </ref> | |||
*Post-traumatic non-infectious inflammation | |||
*Phacoanaphylactic endophthalmitis | |||
*Sympathetic ophthalmia with bilateral anterior [[uveitis]] | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The incidence of traumatic endophthalmitis may be decreasing due to earlier wound closure and prompt initiation of antibiotics. | The incidence of traumatic endophthalmitis may be decreasing due to earlier wound closure and prompt initiation of antibiotics. | ||
Post-traumatic endophthalmitis accounts for 25,000 to 31,000 cases per 100,000 individuals with endophthalmitis. | Post-traumatic endophthalmitis accounts for 25,000 to 31,000 cases per 100,000 individuals with endophthalmitis. The incidence of post-traumatic endophthalmitis varies according to the following factors: | ||
*Presence of an intraocular foreign body | |||
*Delay primary globe repair | |||
*Location and extent of laceration of the globe | |||
===Prevalence and Incidence=== | ===Prevalence and Incidence=== | ||
*The incidence of post-traumatic endophthalmitis was estimated to range from 3.300 to 30,000 per 100,000 individuals with penetrating ocular trauma.<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> | *The incidence of post-traumatic endophthalmitis was estimated to range from 3.300 to 30,000 per 100,000 individuals with penetrating ocular trauma.<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> | ||
*The incidence of post-traumatic endophthalmitis was estimated to range from 1,300 to 61,000 per 100,000 individuals with intraocular foreign body.<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> | *The incidence of post-traumatic endophthalmitis was estimated to range from 1,300 to 61,000 per 100,000 individuals with intraocular foreign body.<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> | ||
==Risk Factors== | ==Risk Factors== | ||
Common risk factors in the development of post-traumatic bacterial endophthalmitis include:<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> | Common risk factors in the development of post-traumatic bacterial endophthalmitis include:<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><ref name="pmid8414406">{{cite journal| author=Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE| title=Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System. | journal=Ophthalmology | year= 1993 | volume= 100 | issue= 10 | pages= 1468-74 | pmid=8414406 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8414406 }} </ref><ref name="pmid21397289">{{cite journal| author=Bhagat N, Nagori S, Zarbin M| title=Post-traumatic Infectious Endophthalmitis. | journal=Surv Ophthalmol | year= 2011 | volume= 56 | issue= 3 | pages= 214-51 | pmid=21397289 | doi=10.1016/j.survophthal.2010.09.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21397289 }} </ref> | ||
*Retained intraocular foreign bodies | *Retained intraocular foreign bodies | ||
**Non-metallic intraocular foreign body (IOFB) | **Non-metallic intraocular foreign body (IOFB) | ||
| Line 58: | Line 75: | ||
*Delay in repair more than 24 hours | *Delay in repair more than 24 hours | ||
*Disruption of the lens | *Disruption of the lens | ||
*Ocular tissue prolapse | |||
*Large wound size | |||
==Screening== | ==Screening== | ||
Screening for post-traumatic endophthalmitis is not recommended after open globe injuries.<ref name=post-traumatic>US Preventivre Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=endophthalmitis Accessed on August 5, 2016 </ref> There is insufficient evidence to recommend routine aqueous culture in all cases of open globe injury.<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="pmid7832224">{{cite journal| author=Ariyasu RG, Kumar S, LaBree LD, Wagner DG, Smith RE| title=Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair. | journal=Am J Ophthalmol | year= 1995 | volume= 119 | issue= 2 | pages= 181-8 | pmid=7832224 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7832224 }} </ref> | |||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
===Natural History=== | ===Natural History=== | ||
Post-traumatic endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal infiltration, corneal perforation, and | Post-traumatic endophthalmitis may occur within hours after the trauma or up to several weeks after injury. Post-traumatic endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal ring ulceration and infiltration, [[corneal opacification]], [[corneal perforation]], and permanent [[vision loss]]. <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> | ||
===Complications=== | ===Complications=== | ||
Common complications of post-traumatic endophthalmitis include: | |||
*Panophthalmitis | |||
*Decrease or loss of vision | |||
*[[Chronic pain]] | |||
*[[Cataract]] development | |||
*[[Retinal detachment]] | |||
*[[Vitreous hemorrhage]] | |||
*Hypotony and [[phthisis bulbi]] | |||
*[[Proptosis]] and a corneal abscess | |||
===Prognosis=== | ===Prognosis=== | ||
Post-traumatic bacterial endophthalmitis is associated with particularly | Post-traumatic bacterial endophthalmitis is associated with a particularly poor visual outcome. Only 22% to 42% patients with post-traumatic bacterial endophthalmitis obtain a final [[visual acuity]] of 20/400 or better.<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> | ||
Only 22% to 42% patients with post-traumatic bacterial endophthalmitis obtain a final [[visual acuity]] of 20/400 or better.<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> | |||
==Diagnosis== | ==Diagnosis== | ||
=== | ===History & Symptoms=== | ||
====History==== | |||
=== | *A recent history of penetrating ocular trauma | ||
====Symptoms==== | |||
Symptoms of post-traumatic bacterial endophthalmitis may include the following:<ref>Packer, Andrew J., Thomas A. Weingeist, and Gary W. Abrams. "Retinal periphlebitis as an early sign of bacterial endophthalmitis." American journal of ophthalmology 96.1 (1983): 66-71.</ref><ref>Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.</ref> | |||
*Decreased vision | |||
*Disproportionate pain | |||
*Lid swelling | |||
*[[Photophobia]] | |||
*Tearing | |||
===Physical Examination=== | ===Physical Examination=== | ||
Ophthalmologic examination of patients with post-traumatic endophthalmitis is usually remarkable for:<ref>Packer, Andrew J., Thomas A. Weingeist, and Gary W. Abrams. "Retinal periphlebitis as an early sign of bacterial endophthalmitis." American journal of ophthalmology 96.1 (1983): 66-71.</ref><ref>Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.</ref> | |||
*[[Conjunctival injection]] | |||
*[[Chemosis]] | |||
*Purulent discharge | |||
*Lid [[edema]] | |||
*Periorbital [[erythema]] | |||
*[[Proptosis]] | |||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
Laboratory studies consistent with the diagnosis of post-traumatic 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> | |||
*Culture and gram stain of [[aqueous humor]] as well as the [[vitreous humor]] (often not sensitive) | |||
*[[polymerase chain reaction|Polymerase chain reaction (PCR)]] of [[aqueous humor]] as well as the [[vitreous humor]] (much more sensitive than culture) | |||
===Imaging Findings=== | ===Imaging Findings=== | ||
====X Ray==== | ====X Ray==== | ||
Plain film x ray is helpful for the detection of | Plain film x ray is helpful for the detection of intraocular foreign bodies (IOFBs). However, it may detect only about 40% of intraocular foreign bodies (IOFBs).<ref name="pmid2282949">{{cite journal| author=Bryden FM, Pyott AA, Bailey M, McGhee CN| title=Real time ultrasound in the assessment of intraocular foreign bodies. | journal=Eye (Lond) | year= 1990 | volume= 4 ( Pt 5) | issue= | pages= 727-31 | pmid=2282949 | doi=10.1038/eye.1990.103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2282949 }} </ref> | ||
====CT==== | ====CT==== | ||
Orbital CT scan is helpful for localization of metallic intra ocular foreign bodies (IOFBs) in the setting of trauma. <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> | Orbital CT scan is helpful for localization of metallic intra ocular foreign bodies (IOFBs) in the setting of trauma. <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> | ||
====MRI==== | ====MRI==== | ||
Orbital MRI scan is helpful for localization of intra ocular foreign bodies (IOFBs) that may be radiolucent on CT in the setting of trauma. However, metallic IOFB must be excluded first.<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> | Orbital MRI scan is helpful for localization of intra ocular foreign bodies (IOFBs) that may be radiolucent on CT in the setting of trauma. However, metallic IOFB must be excluded first.<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==== | ====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=" | On ocular ultrasonography, endophthalmitis may be characterized by anterior vitreous [[haze echoes]] and retinochoroidal thickening.<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="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="pmid2282949">{{cite journal| author=Bryden FM, Pyott AA, Bailey M, McGhee CN| title=Real time ultrasound in the assessment of intraocular foreign bodies. | journal=Eye (Lond) | year= 1990 | volume= 4 ( Pt 5) | issue= | pages= 727-31 | pmid=2282949 | doi=10.1038/eye.1990.103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2282949 }} </ref> | ||
====Other Imaging Findings==== | ====Other Imaging Findings==== | ||
Orbital echography is helpful for assessment of [[vitreous opacification]], presence of (IOFBs), status of the posterior hyaloid face, and retinal detachment in a patient with | Orbital echography is helpful for assessment of [[vitreous opacification]], presence of (IOFBs), status of the posterior hyaloid face, and retinal detachment in a patient with post-traumatic endophthalmitis.<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> | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
====Slit lamp examination==== | |||
On slit lamp examination, post-traumatic endophthalmitis is characterized 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="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]] | |||
*Corneal ring infiltrate | |||
*Clumps of thick white material in the [[anterior chamber]] (fungal endophthalmitis) | |||
*Filaments extending from the back of the [[cornea]] into the [[aqueous humor]] (fungal endophthalmitis) | |||
==Treatment== | ==Treatment== | ||
*The patient needs urgent examination by an expert [[ophthalmologist]] and/or vitreo-retinal specialist who will determine the need for [[intravitreal injection]] of potent antibiotics or pars plana [[vitrectomy]] as needed. [[Enucleation]] may be required to remove a blind and painful eye.<ref>Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.</ref> | |||
*Closure of the wound is the first step in management of open globe injury | |||
*Removal of intraocular foreign bodies (IOFB) and debridement of necrotic tissue is necessary | |||
*Bacterial and fungal cultures from vitreous samples are required | |||
*[[Vitrectomy]] is often indicated | |||
*Immunization against tetanus based on history is necessary | |||
===Medical Therapy=== | ===Medical Therapy=== | ||
*Systemic broad spectrum antibiotics are recommended | |||
*Systemic antifungal agents are recommended in patients with suspected fungal endophthalmitis | |||
===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. Empiric antimicrobial therapy''' | |||
::::*Preferred regimen: [[Vancomycin]] 1 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Ceftazidime]] 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Amphotericin B]] 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose | |||
::::*Note (1): Removal of foreign bodies and debridement of necrotic tissue is necessary | |||
::::*Note (2): In addition to antimicrobial therapy, vitrectomy is necessary | |||
::::*Note (3): Systemic broad spectrum antibiotics are recommended in post-traumatic endophthalmitis | |||
:*'''2. Pathogen-directed antimicrobial therapy''' | |||
::*'''2.1 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 | |||
::*'''2.2 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 | |||
::*'''2.3 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 | |||
::*'''2.4 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 | |||
::*'''2.5 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. It 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>Endophthalmitis Vitrectomy Study Group. "Microbiologic factors and visual outcome in the Endophthalmitis Vitrectomy Study." American journal of ophthalmology 122.6 (1996): 830-846.</ref><ref>Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.</ref> | |||
*Vitrectomy is recommended for all patients who develop exogenous bacterial endophthalmitis. | |||
*Vitrectomy is recommended in severe cases of endogenous bacterial endophthalmitis. | |||
The benefits of vitrectomy include: | |||
*Better vitreous sample | |||
*Rapid and complete sterilization of the vitreous | |||
*Removal of toxic bacterial products | |||
*Enhancement of systemic antimicrobial penetration in to the eye | |||
===Prevention=== | |||
====Primary prevention==== | |||
Effective measures for the primary prevention of post-traumatic endophthalmitis include:<ref name="pmid17420365">{{cite journal| author=Soheilian M, Rafati N, Mohebbi MR, Yazdani S, Habibabadi HF, Feghhi M et al.| title=Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2. | journal=Arch Ophthalmol | year= 2007 | volume= 125 | issue= 4 | pages= 460-5 | pmid=17420365 | doi=10.1001/archopht.125.4.460 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17420365 }} </ref> | |||
*Primary globe repair within 24 h | |||
*Removal of foreign bodies and debridement of [[necrotic tissue]] | |||
*Intracameral or intravitreal antibiotic injection after penetrating eye injury | |||
*Systemic antimicrobial prophylaxis is recommended | |||
*Systemic antifungal prophylaxis is recommended with the suspicion of fungal infection. | |||
=== | ====Secondary prevention==== | ||
There are no secondary preventive measures available for post-traumatic endophthalmitis. | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
{{WS}} | {{WS}} | ||
{{WH}} | {{WH}} | ||
[[Category:Ophthalmology]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
Latest revision as of 23:48, 29 July 2020
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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: Post-traumatic bacterial endophthalmitis; Post-traumatic fungal endophthalmitis
Overview
Post-traumatic bacterial endophthalmitis occurs following penetrating ocular injuries. Post-traumatic endophthalmitis is associated with a large variety of organisms. The most commonly isolated organisms include gram-positive Staphylococcus epidermidis and Streptococcus (as a part of the normal skin flora and regularly contaminate open wounds). Bacillus cereus is second most common. In some cases post-traumatic endophthalmitis is polymicrobial. The risk for developing endophthalmitis after open globe injuries is estimated at about 7% of injured eyes.[1][2][3][4]
Historical Perspective
- In 1903, post-traumatic fungal endophthalmitis was first reported by Romer.[5]
- In 1933, exogenous fungal endophthalmitis was first described by Rychener.[6]
Classification
Post-traumatic endophthalmitis may be classified according to the causative organisms into 2 subtypes: bacterial or fungal.[4]
Pathophysiology
Pathogenesis
Post-traumatic endophthalmitis occurs following penetrating ocular injuries. Following penetrating injury, the eye globe integrity disturbed. The microorganisms are often implanted via direct inoculation by the penetrating object, by a retained foreign body, or by infection of the open wound. Penetrating ocular injuries are accompanied by infection at a much higher rate compared to ocular surgery.
Post-traumatic endophthalmitis is associated with a large variety of organisms. The most commonly isolated organisms include gram-positive Staphylococcus epidermidis and Streptococcus (as a part of the normal skin flora and regularly contaminate open wounds). Bacillus cereus is the second most common cause. In some cases post-traumatic endophthalmitis is polymicrobial.[1][2][3][4]
Gross Pathology
On gross pathology, eyelid swelling, eyelid erythema, injected conjunctiva and sclera, hypopyon, chemosis, and mucopurulunt discharge are characteristic findings of endophthalmitis.[3][7]
Microscopic histopathological analysis
On microscopic histopathological analysis, infiltration of polymorphonuclear leukocytes or chronic inflammatory cells (depending on the duration of the inflammation) and destruction of ocular structures are characteristic findings of post-traumatic bacterial endophthalmitis.
Causes
Post-traumatic bacterial endophthalmitis
Common causes of post-traumatic bacterial endophthalmitis include:[1][2][8][9]
- Gram-positive bacteria
- Staphylococcus species
- Streptococcus species
- Bacillus cereus (most common in the setting of an IOFB or soil contamination)
- Clostridium (fulminant endophthalmitis)
- Propionibacterium acnes
- Gram-negative bacteria
- Klebsiella
- Pseudomonas (fulminant endophthalmitis)
- Polymicrobial
Post-traumatic fungal endophthalmitis
Common causes of post-traumatic fungal endophthalmitis include:[8][10][9]
- Candida species
- Aspergillus species
- Paecilomyces species
- Fusarium species
- Dematacious fungi
Differentiating Post-traumatic Endophthalmitis from Other Diseases
Post-traumatic endophthalmitis must be differentiated from:[11]
- Post-traumatic non-infectious inflammation
- Phacoanaphylactic endophthalmitis
- Sympathetic ophthalmia with bilateral anterior uveitis
Epidemiology and Demographics
The incidence of traumatic endophthalmitis may be decreasing due to earlier wound closure and prompt initiation of antibiotics. Post-traumatic endophthalmitis accounts for 25,000 to 31,000 cases per 100,000 individuals with endophthalmitis. The incidence of post-traumatic endophthalmitis varies according to the following factors:
- Presence of an intraocular foreign body
- Delay primary globe repair
- Location and extent of laceration of the globe
Prevalence and Incidence
- The incidence of post-traumatic endophthalmitis was estimated to range from 3.300 to 30,000 per 100,000 individuals with penetrating ocular trauma.[1][2]
- The incidence of post-traumatic endophthalmitis was estimated to range from 1,300 to 61,000 per 100,000 individuals with intraocular foreign body.[1][2]
Risk Factors
Common risk factors in the development of post-traumatic bacterial endophthalmitis include:[1][2][7][3]
- Retained intraocular foreign bodies
- Non-metallic intraocular foreign body (IOFB)
- Injury in a rural setting
- Delay in repair more than 24 hours
- Disruption of the lens
- Ocular tissue prolapse
- Large wound size
Screening
Screening for post-traumatic endophthalmitis is not recommended after open globe injuries.[12] There is insufficient evidence to recommend routine aqueous culture in all cases of open globe injury.[1][13]
Natural History, Complications, and Prognosis
Natural History
Post-traumatic endophthalmitis may occur within hours after the trauma or up to several weeks after injury. Post-traumatic endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal ring ulceration and infiltration, corneal opacification, corneal perforation, and permanent vision loss. [8][14]
Complications
Common complications of post-traumatic endophthalmitis include:
- Panophthalmitis
- Decrease or loss of vision
- Chronic pain
- Cataract development
- Retinal detachment
- Vitreous hemorrhage
- Hypotony and phthisis bulbi
- Proptosis and a corneal abscess
Prognosis
Post-traumatic bacterial endophthalmitis is associated with a particularly poor visual outcome. Only 22% to 42% patients with post-traumatic bacterial endophthalmitis obtain a final visual acuity of 20/400 or better.[1][15]
Diagnosis
History & Symptoms
History
- A recent history of penetrating ocular trauma
Symptoms
Symptoms of post-traumatic bacterial endophthalmitis may include the following:[16][17]
- Decreased vision
- Disproportionate pain
- Lid swelling
- Photophobia
- Tearing
Physical Examination
Ophthalmologic examination of patients with post-traumatic endophthalmitis is usually remarkable for:[18][19]
- Conjunctival injection
- Chemosis
- Purulent discharge
- Lid edema
- Periorbital erythema
- Proptosis
Laboratory Findings
Laboratory studies consistent with the diagnosis of post-traumatic endophthalmitis include:[8][14][20]
- Culture and gram stain of aqueous humor as well as the vitreous humor (often not sensitive)
- Polymerase chain reaction (PCR) of aqueous humor as well as the vitreous humor (much more sensitive than culture)
Imaging Findings
X Ray
Plain film x ray is helpful for the detection of intraocular foreign bodies (IOFBs). However, it may detect only about 40% of intraocular foreign bodies (IOFBs).[21]
CT
Orbital CT scan is helpful for localization of metallic intra ocular foreign bodies (IOFBs) in the setting of trauma. [1][15]
MRI
Orbital MRI scan is helpful for localization of intra ocular foreign bodies (IOFBs) that may be radiolucent on CT in the setting of trauma. However, metallic IOFB must be excluded first.[1][15]
Ultrasound
On ocular ultrasonography, endophthalmitis may be characterized by anterior vitreous haze echoes and retinochoroidal thickening.[1][8][21]
Other Imaging Findings
Orbital echography is helpful for assessment of vitreous opacification, presence of (IOFBs), status of the posterior hyaloid face, and retinal detachment in a patient with post-traumatic endophthalmitis.[1][15]
Other Diagnostic Studies
Slit lamp examination
On slit lamp examination, post-traumatic endophthalmitis is characterized by:[8][14]
- Mild to moderate anterior chamber reaction
- Hypopyon
- Corneal ring infiltrate
- Clumps of thick white material in the anterior chamber (fungal endophthalmitis)
- Filaments extending from the back of the cornea into the aqueous humor (fungal endophthalmitis)
Treatment
- The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retinal specialist who will determine the need for intravitreal injection of potent antibiotics or pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.[22]
- Closure of the wound is the first step in management of open globe injury
- Removal of intraocular foreign bodies (IOFB) and debridement of necrotic tissue is necessary
- Bacterial and fungal cultures from vitreous samples are required
- Vitrectomy is often indicated
- Immunization against tetanus based on history is necessary
Medical Therapy
- Systemic broad spectrum antibiotics are recommended
- Systemic antifungal agents are recommended in patients with suspected fungal endophthalmitis
Antimicrobial Regimens
- Infectious endophthalmitis[8]
- 1. Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
- Note (1): Removal of foreign bodies and debridement of necrotic tissue is necessary
- Note (2): In addition to antimicrobial therapy, vitrectomy is necessary
- Note (3): Systemic broad spectrum antibiotics are recommended in post-traumatic endophthalmitis
- 2. Pathogen-directed antimicrobial therapy
- 2.1 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
- 2.2 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
- 2.3 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
- 2.4 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
- 2.5 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. It is the fastest way of clearing infection in eyes with fulminant endophthalmitis.[8][14][23][24][25]
- Vitrectomy is recommended for all patients who develop exogenous bacterial endophthalmitis.
- Vitrectomy is recommended in severe cases of endogenous bacterial endophthalmitis.
The benefits of vitrectomy include:
- Better vitreous sample
- Rapid and complete sterilization of the vitreous
- Removal of toxic bacterial products
- Enhancement of systemic antimicrobial penetration in to the eye
Prevention
Primary prevention
Effective measures for the primary prevention of post-traumatic endophthalmitis include:[26]
- Primary globe repair within 24 h
- Removal of foreign bodies and debridement of necrotic tissue
- Intracameral or intravitreal antibiotic injection after penetrating eye injury
- Systemic antimicrobial prophylaxis is recommended
- Systemic antifungal prophylaxis is recommended with the suspicion of fungal infection.
Secondary prevention
There are no secondary preventive measures available for post-traumatic endophthalmitis.
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 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.
- ↑ 3.0 3.1 3.2 3.3 Bhagat N, Nagori S, Zarbin M (2011). "Post-traumatic Infectious Endophthalmitis". Surv Ophthalmol. 56 (3): 214–51. doi:10.1016/j.survophthal.2010.09.002. PMID 21397289.
- ↑ 4.0 4.1 4.2 Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U; et al. (1999). "Microbiologic spectrum and susceptibility of isolates: part II. Posttraumatic endophthalmitis. Endophthalmitis Research Group". Am J Ophthalmol. 128 (2): 242–4. PMID 10458188.
- ↑ Romer, P. "Eine intraoculare Schimmelpilz-infection." Klin Monatsbl Augenheilkd 40 (1902): 331-333.
- ↑ Wu, Lihteh, and Guillermo Tapia-Herrera. "Fungal endophthalmitis." Current Fungal Infection Reports 3.1 (2009): 55-61.
- ↑ 7.0 7.1 Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE (1993). "Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System". Ophthalmology. 100 (10): 1468–74. PMID 8414406.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
- ↑ 9.0 9.1 Abu el-Asrar AM, al-Amro SA, al-Mosallam AA, al-Obeidan S (1999). "Post-traumatic endophthalmitis: causative organisms and visual outcome". Eur J Ophthalmol. 9 (1): 21–31. PMID 10230588.
- ↑ Wykoff CC, Flynn HW, Miller D, Scott IU, Alfonso EC (2008). "Exogenous fungal endophthalmitis: microbiology and clinical outcomes". Ophthalmology. 115 (9): 1501–7, 1507.e1–2. doi:10.1016/j.ophtha.2008.02.027. PMID 18486220.
- ↑ Thach AB, Marak GE, McLean IW, Green WR (1991). "Phacoanaphylactic endophthalmitis: a clinicopathologic review". Int Ophthalmol. 15 (4): 271–9. PMID 1917323.
- ↑ US Preventivre Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=endophthalmitis Accessed on August 5, 2016
- ↑ Ariyasu RG, Kumar S, LaBree LD, Wagner DG, Smith RE (1995). "Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair". Am J Ophthalmol. 119 (2): 181–8. PMID 7832224.
- ↑ 14.0 14.1 14.2 14.3 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.
- ↑ 15.0 15.1 15.2 15.3 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.
- ↑ Packer, Andrew J., Thomas A. Weingeist, and Gary W. Abrams. "Retinal periphlebitis as an early sign of bacterial endophthalmitis." American journal of ophthalmology 96.1 (1983): 66-71.
- ↑ Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.
- ↑ Packer, Andrew J., Thomas A. Weingeist, and Gary W. Abrams. "Retinal periphlebitis as an early sign of bacterial endophthalmitis." American journal of ophthalmology 96.1 (1983): 66-71.
- ↑ Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.
- ↑ 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.
- ↑ 21.0 21.1 Bryden FM, Pyott AA, Bailey M, McGhee CN (1990). "Real time ultrasound in the assessment of intraocular foreign bodies". Eye (Lond). 4 ( Pt 5): 727–31. doi:10.1038/eye.1990.103. PMID 2282949.
- ↑ Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.
- ↑ "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.
- ↑ Endophthalmitis Vitrectomy Study Group. "Microbiologic factors and visual outcome in the Endophthalmitis Vitrectomy Study." American journal of ophthalmology 122.6 (1996): 830-846.
- ↑ Endophthalmitis Vitrectomy Study Group. "Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis." Archives of Ophthalmology 113.12 (1995): 1479.
- ↑ Soheilian M, Rafati N, Mohebbi MR, Yazdani S, Habibabadi HF, Feghhi M; et al. (2007). "Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2". Arch Ophthalmol. 125 (4): 460–5. doi:10.1001/archopht.125.4.460. PMID 17420365.