Endophthalmitis

Endophthalmitis, or endophthalmia, is inflammation of the interior cavity of the eye, usually caused by an infection. It is a possible complication of all intraocular surgeries, particularly cataract surgery, and can result in loss of vision or loss of the eye itself.[1] Infection can be caused by bacteria or fungi, and is classified as exogenous (infection introduced by direct inoculation as in surgery or penetrating trauma), or endogenous (organisms carried by blood vessels to the eye from another site of infection and is more common in people who have an immunocompromised state). Other non-infectious causes include toxins, allergic reactions, and retained intraocular foreign bodies. Intravitreal injections are a rare cause, with an incidence rate usually less than 0.05%.

Endophthalmitis
Other namesEndophthalmia
Hypopyon with hazy media
SpecialtyOphthalmology

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

People with endophthalmitis often have a history of recent eye surgery or penetrating trauma to the eye.

Symptoms include severe pain, vision loss, and intense redness of the conjunctiva.[1] Hypopyon can be present and should be looked for on examination by a slit lamp. It can first present with the 'black dot sign' (Martin-Farina sign), where patients may report a small area of loss of vision that resembles a black dot or fly. Pus is often contained in the inflamed tissue of the eye (purulent).

An eye exam should be considered in systemic candidiasis, as up to 3% of cases of candidal blood infections lead to endophthalmitis.

Complications

Cause

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.[5]

Late-onset endophthalmitis is mostly caused by Cutibacterium acnes.[6]

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.

Diagnosis

Diagnosis: Microbiology testing. PCR. TASS vs Infectious endophthalmitis.[1]

Prevention

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.[7] 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.[7] 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.[8][9]

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.[10] There is evidence to suggest that a solution of povidone-iodine applied pre-injection may be effective at preventing some cases of endophthalmitis in people undergoing introvitreal injections.[11]

Treatment

Urgent medical attention is required if a person has suspected endophthalmitis. An ophthalmologist is preferred, ideally a vitreoretinal specialist. The first step in treatment (usual care) is an intravitreal injection of potent antibiotics and a biopsy to determine the type of infection.[2] Injections of vancomycin (to kill Gram-positive bacteria) and ceftazidime (to kill 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.[12] 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.

Steroids may be injected intravitreally if the cause is allergic. 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.[13]

References
  1. Oiseth S, Jones L, Maza E, eds. (10 November 2022). "Endophthalmitis". The Lecturio Medical Concept Library. Retrieved 19 July 2021.
  2. Muqit MM, Mehat M, Bunce C, Bainbridge JW, et al. (Cochrane Eyes and Vision Group) (November 2022). "Early vitrectomy for exogenous endophthalmitis following surgery". The Cochrane Database of Systematic Reviews. 2022 (11): CD013760. doi:10.1002/14651858.CD013760.pub2. PMC 9672977. PMID 36398614.
  3. Goldenberg DT, Harinandan A, Walsh MK, Hassan T (Spring 2010). "Serratia marcescens endophthalmitis after 20-gauge pars plana vitrectomy". Retinal Cases & Brief Reports. 4 (2): 140–142. doi:10.1097/ICB.0b013e31819955bf. PMID 25390387.
  4. Forbes BA, Sahm DF, Weissfeld AS. Bailey & Scott's Diagnostic Microbiology. 12th Edition. Mosby Elsevier, 2007. p. 834.
  5. Park J, Popovic MM, Balas M, El-Defrawy SR, Alaei R, Kertes PJ (January 2022). "Clinical features of endophthalmitis clusters after cataract surgery and practical recommendations to mitigate risk: systematic review". Journal of Cataract and Refractive Surgery. 48 (1): 100–112. doi:10.1097/j.jcrs.0000000000000756. PMID 34538777. S2CID 237574618.
  6. Shirodkar AR, Pathengay A, Flynn HW, Albini TA, Berrocal AM, Davis JL, et al. (March 2012). "Delayed- versus acute-onset endophthalmitis after cataract surgery". American Journal of Ophthalmology. 153 (3): 391–398.e2. doi:10.1016/j.ajo.2011.08.029. PMC 3381653. PMID 22030353.
  7. Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ (February 2017). "Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery". The Cochrane Database of Systematic Reviews. 2017 (2): CD006364. doi:10.1002/14651858.CD006364.pub3. PMC 5375161. PMID 28192644.
  8. Christy NE, Sommer A (August 1979). "Antibiotic prophylaxis of postoperative endophthalmitis". Annals of Ophthalmology. 11 (8): 1261–1265. PMID 318049.
  9. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons (June 2007). "Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors". Journal of Cataract and Refractive Surgery. 33 (6): 978–988. doi:10.1016/j.jcrs.2007.02.032. PMID 17531690. S2CID 37697458.
  10. Benoist d'Azy C, Pereira B, Naughton G, Chiambaretta F, Dutheil F (2016-06-03). "Antibioprophylaxis in Prevention of Endophthalmitis in Intravitreal Injection: A Systematic Review and Meta-Analysis". PLOS ONE. 11 (6): e0156431. Bibcode:2016PLoSO..1156431B. doi:10.1371/journal.pone.0156431. PMC 4892688. PMID 27257676.
  11. de Caro JJ, Ta CN, Ho HK, Cabael L, Hu N, Sanislo SR, et al. (June 2008). "Bacterial contamination of ocular surface and needles in patients undergoing intravitreal injections". Retina. 28 (6): 877–883. doi:10.1097/IAE.0b013e31816b3180. PMID 18536606. S2CID 25819637.
  12. Dossarps D, Bron AM, Koehrer P, Aho-Glélé LS, Creuzot-Garcher C (July 2015). "Endophthalmitis After Intravitreal Injections: Incidence, Presentation, Management, and Visual Outcome". American Journal of Ophthalmology. 160 (1): 17–25.e1. doi:10.1016/j.ajo.2015.04.013. PMID 25892127.
  13. Emami S, Kitayama K, Coleman AL (June 2022). "Adjunctive steroid therapy versus antibiotics alone for acute endophthalmitis after intraocular procedure". The Cochrane Database of Systematic Reviews. 2022 (6): CD012131. doi:10.1002/14651858.CD012131.pub3. PMC 9169535. PMID 35665485.
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