Endogenous endophthalmitis: Difference between revisions
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*[[Alcoholism]] | *[[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]], and ultimately permanent [[vision loss]]. | |||
===Complications=== | ===Complications=== | ||
Common complications of bacterial 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 | |||
*[[Sepsis]] (specific for endogenous endophthalmit) | |||
*[[Suprachoroidal hemorrhage]] (specific for endogenous endophthalmit) | |||
===Prognosis=== | ===Prognosis=== | ||
The prognosis of endogenouse endophthalmtis varies with the offending organism and the systemic status of the patient. | The prognosis of endogenouse endophthalmtis varies with the offending organism and the systemic status of the patient. | ||
Revision as of 13:54, 5 August 2016
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]
Overview
Endogenous endophthalmitis is caused by either the hematologic dissemination of bacterial or 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.
Historical Perspective
Classification
endogenous enophthalmitis may be classified according to causative organisms into 2 subtypes: bacterial or fungal.
Pathophysiology
Pathogenesis
Endogenous bacterial endophthalmitis is caused by either the hematologic dissemination of an infection to the eyes or direct spread from adjacent infectious sites. 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. Most common extraocular foci of infection include liver abscess, pneumonia, endocarditis, and soft tissue infection. 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:[1][2][3]
- Direct invasion (septic emboli reaches the eye through the posterior segment vasculature)
- 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 (CNS) infection via the optic nerve.
Endogenous candida endophthalmitis is commonly associated with procedures or conditions that increase the risk for blood-borne 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.
Following inhalation of the airborne organisms, the aspergilli spores enter the terminal alveoli of the lung. Under normal circumstances, the lung provides a natural resistance against invading organisms. However, in the 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 aspergillus endophthalmitis.
Gross Pathology
- On gross pathology, eyelid swelling, eyelid erythema, conjunctival injection, chemosis, and mucoprulunt dischage are characteristic findings of endogenous endophthalmitis.
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 polymorphonoclear leukocytes, lymphocytes, budding yeast, pseudohyphae) are characteristic findings of candida endophthalmitis.[4]
- On microscopic histopathological analysis, angiocentric retinal and choroidal lesion, mixed acute and chronic inflammatory cells infiltration, retinal and choroidal vessel invasion, and subretinal pigment epithelial infection are characteristic findings of aspergillus endophthalmitis.[5] [6]
Causes
Bacterial
Common causes of endogenous bacterial endophthalmitis include:[1][2][3]
- Gram-positive bacteria
- Streptococcus pneumoniae
- Staphylococcus aureus
- Bacillus cereus (primary bacterial cause in intravenous drug abusers)
- Gram-negative bacteria
- Neisseria meningitidis (pre-antibiotic era)
- Escherichia coli
- Klebsiella (in the Asian population with liver abscess)
Fungal
Common causes of endogenous fungal endophthalmitis include:[1][2][3]
Differentiating endogenous Endophthalmitis from Other Diseases
Endogenous bacterial endophthalmitis must be differentiated from:
- Aspergillus endophthalmitis
- Candida endophthalmitis
Candida endophthalmitis must be differentiated from:[7][8]
- Cytomegalvirus retinitis
- Toxoplasmosis retinochoroiditis
- Primary intraocular lymphoma
- Syphilitic choroiditis
- Aspergillus endophthalmitis
- Endogenous bacterial endophthalmaitis
Aspergillus endophthalmitis must be differentiated from:[9]
- Cytomegalvirus retinitis
- Toxoplasmosis retinochoroiditis
- Coccidiomycosis choroiditis
- Endogenous bacterial endophthalmitis
Epidemiology and Demographics
Incidence
The incidence of endogenous endophthalmitis is estimated to be 50 cases per 100,000 hospitalized patients.[2][10]
Age
Endogenous bacterial endophthalmitis affects men and women equally.[2]
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.[3]
Risk Factors
Endogenous bacterial endophthalmitis
Common risk factors in the development of endogenous bacterial endophthalmitis include:[1][2][3]
- Recent hospitalization
- Immunosuppression
- Diabetes mellitus
- Urinary tract infection
- Immunosuppression (associated with underlying malignancy, neutropenia, and HIV)
- Intravenous drug use
- Catheterization
- Long-term use of broad-spectrum antibiotics or immunosuppressive drugs
- Liver abscess
- Infective endocarditis (IE)
Endogenous candida endophthalmitis
Common risk factors in the development of endogenous fungal endophthalmitis include:
- Recent abdominal surgery
- Diabetes mellitus
- Indwelling central venous catheter.
- Chemotherapy
- Organ transplantation (cardiac and liver transplants)
- Immunosuppressive therapy for hematopoietic stem cell transplantation (HSCT)
- History of chronic pulmonary diseases
- Intravenous drug abuse
- Alcoholism
Screening
Screening for endogenous endophthalmitis is not recommended in hospitalized patients.[11]
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, and ultimately permanent vision loss.
Complications
Common complications of bacterial 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
- Sepsis (specific for endogenous endophthalmit)
- Suprachoroidal hemorrhage (specific for endogenous endophthalmit)
Prognosis
The prognosis of endogenouse endophthalmtis varies with the offending organism and the systemic status of the patient.
- Late detection and late treatment of systemic infection of endogenouse bacterial endophthalmtis is associated with a poor prognosis.[1][2][3]
- The prognosis of candida endophthalmiaits is good if prompt systemic amphotericin B treatment is received.[12]
- Despite of aggressive treatment, aspergillus endophthalmitis is associated with poor prognosis.[13]
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:
- History of diabetes mellitus
- Immunosuppression (associated with underlying malignancy, neutropenia, and HIV)
- History of cardiac disease
- History of abdominal surgery
- intravenous catheters
- Intravenous drug abuse.
- Immunosuppressive therapy
- History of chronic pulmonary diseases
Symptoms
Symptoms of endogenous endophthalmitis may include the following:
- Decreased vision
- Eyelid edema
- Conjunctival injection
- Eye pain
- Photophobia
- Presence of floaters
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:
- Decreased vision
- Conjunctival injection
- Eyelid edema
- Hypopyon
- Cloudy cornea
- Decreased red reflex
- Roth's spots and retinal periphlebitis
- White and fluffy choriodoretinal lesions (candida endophthalmitis)
- Snowball-like opacities in vitreous (candida endophthalmitis)
Laboratory Findings
Candida endophthalmitis [14]
- Positive cultures of blood, catheter tips, surgical wounds, and body fluids for Candidia
- Vitreaus cultures and biopsy (required to confirm the diagnosis)
- Vitreous polymerase chain reaction (PCR)
Aspergillus endophthalmitis
- Pars plana vitreous biopsy and cultures (Grocott or Periodic acid-Schiff)
- Anterior chamber and vitreous aspiration alone are unreliable
- Coexisting systemic aspergillosis
Imaging Findings
X Ray
CT
MRI
Ultrasound
On ocular ultrasonography, endophthalmitis may characterized by anterior vitreous haze echoes and retinochoroidal thickening.[1][2]====Ultrasound==== On ocular ultrasonography, endophthalmitis may characterized by anterior vitreous haze echoes and retinochoroidal thickening.[1][2]
Other Imaging Findings
Orbital echography is helpful for assessment of vitreous opacification, and retinal detachment in a patient with endophthalmitis.[2][15]
Other Diagnostic Studies
Other Diagnostic Studies
Other diagnostic studies for endogenous endophthalmiatis include:[1][2][3]
- Echocardiography (assessed the possibility of endocarditis).
- Testing for human immunodeficiency virus (HIV)
- Cultures of other sites (catheter tip)
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.
- Systemic antibiotics are recommended in endogenous bacterial endophthalmitis because the source of the infection is distant from the eye.
- Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
- Vitrectomy is recommended in severe cases of endogenous endophthalmitis with marked vitreous infiltration
Antimicrobial Regimens
- Infectious endophthalmitis[1]
- 1. Causative pathogens
- Staphylococcus epidermidis
- Staphylococcus aureus
- Bacillus spp.
- Escherichia coli
- Neisseria meningitidis
- 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
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.[1][16][17][18]
- 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
Primary Prevention
Effective measures for the primary prevention of endogenous endophthalmitis include:
- Effective treatment of underlining medical conditions
Secondary prevention
There are no secondary preventive measures available for posttraumaic endophthalmiatis. Endophthalmiatis is a medical emergency.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 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.
- ↑ 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.
- ↑ 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.
- ↑ Hunt, LCDR Kerry E., and Ben J. Glasgow. "Aspergillus endophthalmitis: an unrecognized endemic disease in orthotopic liver transplantation." Ophthalmology 103.5 (1996): 757-767.
- ↑ Menezes, Allison V., et al. "Mortality of hospitalized patients with Candida endophthalmitis." Archives of internal medicine 154.18 (1994): 2093-2097.
- ↑ 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.
- ↑ Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.
- ↑ 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.
- ↑ US Preventivre Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=endophthalmitis Accessed on August 5, 2016
- ↑ 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.
- ↑ Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.
- ↑ Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140.
- ↑ 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.
- ↑ 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.
- ↑ "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.
- ↑ Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140.