Infective endophthalmitis

Endophthalmitis

• An inflammation of the inner structures of the eyeball

• Uveal tissue

• Retina

• associated with pouring of exudates in the vitreous cavity, anterior chamber and posterior chamber.

Classification

Infectivity

Infective

Non-infective

Mode of entry

Exogenous

Endogenous

Etiological agent

Bacterial

Fungal

Infective endophthalmitis

Modes of infection

Exogenous

• Perforating injuries

• Perforation of infected corneal ulcers

• Postoperative infections

Endogenous

• Bloodstream

• Caries teeth

• Generalisedsepticaemia

• Puerperal sepsis

Secondary infections

• Extension of infection

• Orbital cellulitis

• Thrombophlebitis

• Infected corneal ulcers

Causative organismsB

acte

rial

Stahpylococcus

Pseudomonas

Pneumococcus

Streptococcus

E. coliFu

nga

l - Aspegillus fumigatus

- Candida albicans

- Nocardiaasteroides

- Fusarium

• Acute postoperative endophthalmitis -complication of intraocular surgery with an incidence of about 0.1%.

• Source of infection - periocular bacterial flora of the eyelids, conjunctiva, and lacrimal sac.

• Other potential sources of infection -contaminated solutions and instruments, and environmental flora

Risk factors

• Eye trauma

• Eye surgery

– Previous presence of infection

– Poor surgical technique.

– Contaminated intraocular lens.

• Intraocular injection

• Bloodstream infection

• Ophthalmic risk factors:

– Contact lens wear (poor hygiene).

– Chronic corneal ulceration.

• Non-ophthalmic risk factors:

– Immunosuppression.

– Intravenous drug use.

– AIDS.

Post operative endophthalmitis

Clinical features

• Sudden onset

• Severe pain

• Redness of eye

• Marked visual loss

• Swollen eyelid

• Lacrimation

• Photophobia

Signs

• Visual acuity may be reduced.

• Lids → red and swollen.

• Conjunctiva → chemosis and marked circumcorneal congestion.

• Cornea → oedematous, cloudy and ring infiltration may be formed.

• Anterior chamber → hypopyon

• Iris → oedematous and muddy

• Pupil → yellow reflex , absent red reflex

• Vitreous exudation - yellowish white mass is seen through fixed dilated pupil (amauroticcat’s-eye reflex)

• Intraocular pressure → raised in early stages

• but in severe cases – hypotony

• Edges of wound → yellow and necrotic and wound may gape

Diagnosis

• Culture and sensitivity studies on aqueous and vitreous samples– Anterior chamber tap

– Vitreous tap

– Vitreous biopsy

• Full infection screen– FBC, blood cultures and culture of all indwelling lines

and catheters

• B-scan ultrasound– the degree of vitritis and integrity of retina

Management

• Medical and ophthalmological emergency

• Suspected acute endophthalmitis requires emergency admission.

• Suspected delayed postoperative endophthalmitis needs urgent referral within 24 hours.

• Most patients will be admitted for a diagnostic work-up and antimicrobial treatment

Goals of treatment

• Retention of useful vision

• Minimize the infection with antimicrobial agents

• Limit the inflammation

• Symptomatic relief

Treatment

Medical

• Antibiotics - Intravitreal , periocular , topical , systemic

• Anti-inflammatory - topical , periocular , systemic (not for chronic Endophthalmitis)

• Supportive

Surgical

• Vitrectomy

Medical treatment

Broad spectrum antibiotics

• Intravitreal – aminoglycoside & vancomycin

First choice Vancomycin 1 mg in 0.1 mlCeftazidime 2.25 mg in 0.1 m

Second choice Vancomycin 1 mg in 0.1 mlAmikacin 0.4 mg in 0.1 ml

Third choice Vancomycin 1 mg in 0.1 mlGentamycin 0.2 mg in 0.1 ml

• Perioricular / subconjunctival injection

– vancomycin 25 mg & ceftazidine 100mg daily

– Gentamycin 20mg & cefuroxime 125mg daily

• Topical therapy every 30-60 min

• Systemic

– IV ceftazidine , cefotaxime

– Oral ciprofloxacin

Corticosteroids

• Indication

– recent onset after rule out fungal infection.

• Contraindication

– Late onset endophthalmitis

– Fungal endophthalmitis

• Reduce inflammation → limit ocular damage

• Eg : dexamethasone

• Intravitreal → dexamethasone 0.4 mg in 0.1ml.

• Subconjunctival → dexamethasone 4 mg (1ml) OD for 5-7 days.

• Topical dexamethasone (0.1%) or predacetate(1%) used frequently.

• Systemic → Oral corticosteroids should preferably be started after 24 hours of intensive antibiotic therapy. A daily therapy – 60 mg prednisolone to be followed by 50, 40, 30, 20 and 10 mg for 2 days each

• Atropine and analgesic

– relieve pain

• Vitrectomy

– Severe and resistant cases

– Fungal endophthalmitis

Antifungal

• Amphotericin B

– Intravitreal

– Systemic

Complications

• Panophthalmitis

• Papillitis

• Phthisis bulbi

• Retinal necrosis

• Retinal detachment

• Increased intraocular pressure

• Retinal vascular occlusion

• Optic neuropathy

• Hypotony

Expected outcomes

• Bacterial endophthalmitis → most treatable type, but the prognosis of vision is often poor.

• Mycotic endophthalmitis → chorioretinalscarring and optic nerve atrophy from glaucoma may result in blindness.

• Endophthalmitis caused by fungus / neoplasia/ foreign bodies → not responsive to medical therapy

Failure of treatment

• Inflammation is too severe to overcome.

• The underlying infectious agent is resistant to therapy.

• The medical therapy does not penetrate the eye well.

• Therapy is not administered for an adequate duration.

• The diagnosis is incorrect.

PANOPHTHALMITIS

• intense purulent inflammation of the whole eyeball including the Tenon’s capsule

Clinical features

– Severe ocular pain and headache

– Complete loss of vision

–Profuse watering

– Purulent discharge

– Marked redness and swelling of the eyes

– Associated w. malaise and fever