Endophthalmitis

Endophthalmitis
Other names	Endophthalmia
Hypopyon with hazy media
Specialty	Ophthalmology

Endophthalmitis, or endophthalmia, is inflammation of the interior cavity of the

Endophthalmitis requires immediate medical attention to ensure the condition is diagnosed as soon as possible and treatment is started in order to reduce the risk of the person losing vision in the eye.^[2] Treatment options depend on the cause and whether the condition is cause by an endogenous or exogenous mechanism. For people with suspected exogenous endophthalmitis, a biopsy (virtuous tap) and treatment with antibiotics (usually by injection) is usually the first line of treatment.^[2] Once the person's response to the antibiotics is assessed, different further treatment options may be considered including surgery.

Signs and symptoms

Symptoms of endophthalmitis include severe eye pain, vision loss, and intense redness of the

• Panophthalmitis — Progression to involve all the coats of the eye.^[4]
• Corneal ulcer^[4]
• Orbital cellulitis^[4]
• Impairment of vision
• Complete loss of vision
• Loss of eye architecture
• Enucleation

Cause

• Bacteria:
  S. pneumoniae, other streptococcal spp., Cutibacterium acnes, Pseudomonas aeruginosa, other gram negative organisms.^[5]
• Viruses: Herpes simplex virus.^[5]
• Fungi: Candida spp.^[5] Fusarium
• Parasites:
  Toxocara.^[5]

A recent systematic review found that the most common source of infectious transmission following cataract surgery was attributed to a contaminated intaocular solution (i.e. irrigation solution, viscoelastic, or diluted antibiotic), although there is a large diversity of exogenous microorganisms that can travel via various routes including the operating room environment, phacoemulsifcation machine, surgical instruments, topical anesthetics, intraocular lens, autoclave solution, and cotton wool swabs.^[6]

Late-onset endophthalmitis is mostly caused by Cutibacterium acnes.^[7]

Causative organisms are not present in all cases. Endophthalmitis can emerge by entirely sterile means, e.g. an allergic reaction to a drug administered intravitreally.

Exogenous endophthalmitis is estimated to occur in 0.04 to 0.1% of all cataract surgeries and intravitreal injections. Whereas 0.9 to 10% of all penetrating eye trauma is complicated by exogenous endophthalmitis.^[3] Risk factors for the development of endophthalmitis after penetrating eye trauma include a delay (usually greater than 24 hours) in closure of the wound, metal objects being involved in the trauma, disruption of the lens and a retained foreign body in the eye.^[3] Bacillus cereus associated endophthalmitis is characterized by an especially fulminant clinical course and rapid vision loss.^[3]

Endogenous endophthalmitis is estimate to comprise 2-15% of all endophthalmitis.

Different approaches have been suggested to prevent exogenous endophthalmitis after cataract surgery. Perioperative antibiotic injections into the eye, specifically cefuroxime at the end of surgery, lowers the chance of endophthalmitis.^[8] Moderate evidence also supports antibiotic eye drops (levofloxacin or chloramphenicol) with antibiotic injections (cefuroxime or penicillin) to reduce the risk of endophthalmitis after cataract surgery compared with injections or eye drops alone.^[8] Periocular injection of penicillin along with chloramphenicol-suphadimidine eye drops and an intracameral cefuroxime injection with topical levofloxacin also reduces the risk reduction of developing endophthalmitis following cataract surgery for some people.^[9][10]

For people undergoing intravitreal injections, antibiotics are not as effective at preventing this type of infection. Studies have demonstrated no difference between rates of infection with and without antibiotics when intravitreal injections are performed.^[11] There is evidence to suggest that a solution of povidone-iodine and antibiotics applied pre-injection may be effective at preventing some cases of endophthalmitis in people undergoing intravitreal injections.^[12]

Intravenous antibiotics given prophylactically in those with penetrating eye trauma has shown a reduction in the incidence of exogenous endophthalmitis.^[3]

Treatment

Urgent medical attention is required if a person has suspected endophthalmitis. Intravitreal injection of antibiotics are indicated in bacterial endophthalmitis.^[2] Intravitreal injections of vancomycin (targeted against Gram-positive bacteria) and ceftazidime (targeting Gram-negative bacteria) are routine. Even though antibiotics can have negative impacts on the retina in high concentrations, since visual acuity worsens in 65% of endophthalmitis patients and prognosis gets poorer the longer an infection goes untreated, most medical professionals make the clinical judgment decision that immediate intervention with antibiotics is necessary.^[13] Fungal pathogens are treated with intravitreal injections of amphotericin B or voriconazole.^[3] Systemic antibiotics or anti-fungals are used in those with endogenous endophthalmitis with associated bactermia or fungemia.^[3] People with endophthalmitis may also require an urgent surgery (pars plana vitrectomy).^[2] In some cases, evisceration may be necessary to remove a severe and intractable infection which could result in a blind and painful eye.

In people with acute endophthalmitis, combined steroid treatment with antibiotics have been found to improve visual outcomes, versus patients only treated with antibiotics, but any improvements on the resolution acute endophthalmitis is unknown.^[14]

References