Endophthalmitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Moubarak, M.D. [2]

Overview

Endophthalmitis is an inflammation of the internal coats of the eye. It is a dreaded complication of all intraocular surgeries, particularly cataract surgery, with possible loss of vision and the eye itself. Infectious etiology is the most common and various bacteria and fungi have been isolated as the cause of the endophthalmitis. Other causes include penetrating trauma and retained intraocular foreign bodies.

Signs and symptoms

A history of recent intraocular surgery or penetrating ocular trauma is usually elicited. In some cases of metastatic endophthalmitis, the spread of infection may be hematogenous (via the blood-stream). That is more commonly seen in patients with immunocompromised states like AIDS and also in diabetes. The condition is usually accompanied by severe pain, loss of vision and redness of the conjunctiva and the underlying episclera. Alongside are present signs of inflammation of the various coats of the eye. Hypopyon can also be present in endophthalmitis and should be looked for on examination by a slit lamp. Progression to involve all the coats of the eye is called as panuveitis or panophthalmitis.

Causes

Drug side-effect

• Dexamethasone implant

Treatment

Overview

• 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.
• Endogenous endophthalmitis is caused by the hematologic dissemination of an infection to the eyes. Systemic antibiotics are recommended in endogenous bacterial endophthalmitis because the source of the infection is distant from the eye.
• Most common extraocular foci of infection include liver abscess, pneumonia, endocarditis, and soft tissue infection.
• Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
• Immediate vitrectomy is often necessary

Antimicrobial Regimens

• Infectious endophthalmitis

• 1. Causative pathogens

• Staphylococcus epidermidis
• Staphylococcus aureus
• Streptococci
• Enterococci
• Bacillus spp.
• Escherichia coli
• Neisseria meningitidis
• Klebsiella spp.
• Propionibacterium spp.
• Corynebacterium spp.
• Pseudomonas aeruginosa
• Candida spp.
• Aspergillus spp.
• 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

• 4. Special Considerations

• 4.1 Endogenous endophthalmitis

• 4.1.1 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

• 4.2 Bleb-related endophthalmitis

• 4.2.1 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

• 4.3 Post-operative endophthalmitis

• 4.3.1 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
• Note (1): In addition to intravitreal antibiotic therapy, vitrectomy is necessary
• Note (2): If there is no improvement in 48 h, a repeat intravitreal injection may be administered
• Note (3): Late post-operative endophthalmitis is often caused by Propionibacterium acnes (several years post-op)

• 4.3.2 Pathogen-directed antimicrobial therapy

• 4.3.2.1 Gram-positive bacteria

• Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose

• 4.3.2.2 Gram-negative bacteria

• Preferred regimen: Amikacin 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
• Note: Intravitreal amikacin is associated with the development of retinal microvasculitis

• 4.4 Post-traumatic endophthalmitis

• 4.4.1 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

External links

• Peters JR. "Endophthalmitis." eMedicine.com. Accessed September 28, 2006.
• Wu L. "Endophthalmitis, Fungal." eMedicine.com. Accessed September 28, 2006.