Endophthalmitis

Endophthalmitis is inflammation of the interior cavity of the eye, usually caused by 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). 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 .05%.

Endophthalmitis
Hypopyon with hazy media
SpecialtyOphthalmology

Signs and symptoms

There is usually 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.

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.[4]

Late-onset endophthalmitis is mostly caused by Cutibacterium acnes.[5]

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

A Cochrane Review sought to evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery.[6] The review showed high-certainty evidence that antibiotic injections in the eye with cefuroxime at the end of surgery lowers the chance of endophthalmitis.[6] Also, the review showed moderate evidence that antibiotic eye drops (levofloxacin or chloramphenicol) with antibiotic injections (cefuroxime or penicillin) probably lowers the chance of endophthalmitis compared with injections or eye drops alone.[6] Separate studies from the research showed that a periocular injection of penicillin with chloramphenicol-suphadimidine eye drops,[7] and an intracameral cefuroxime injection with topical levofloxacin[8] resulted in a risk reduction of developing endophthalmitis following cataract surgery for subjects.

In the case of intravitreal injections, however, antibiotics are not effective. Studies have demonstrated no difference between rates of infection with and without antibiotics when intravitreal injections are performed.[9] The only consistent method of antibioprophylaxis in this instance is a solution of povidone-iodine applied pre-injection.[10]

Treatment

The patient needs urgent examination by an ophthalmologist, preferably a vitreoretinal specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics. 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, the facts that visual acuity worsens in 65% of endophthalmitis patients and prognosis gets poorer the longer an infection goes untreated make immediate intervention necessary.[11] Endophthalmitis patients may also require an urgent surgery (pars plana vitrectomy), and 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 patients 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.[12]

References
  1. "Endophthalmitis". The Lecturio Medical Concept Library. Retrieved 19 July 2021.
  2. 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): 140–2. doi:10.1097/ICB.0b013e31819955bf. PMID 25390387.
  3. Forbes BA, Sahm DF, Weissfeld AS. Bailey & Scott's Diagnostic Microbiology. 12th Edition. Mosby Elsevier, 2007. p. 834.
  4. Park, Jeff; Popovic, Marko M.; Balas, Michael; El-Defrawy, Sherif R.; Alaei, Ravin; Kertes, Peter J. (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. ISSN 0886-3350. PMID 34538777. S2CID 237574618.
  5. Shirodkar AR, Pathengay A, Flynn HW, Albini TA, Berrocal AM, Davis JL, Lalwani GA, Murray TG, Smiddy WE, Miller D (March 2012). "Delayed- versus acute-onset endophthalmitis after cataract surgery". Am. J. Ophthalmol. 153 (3): 391–398.e2. doi:10.1016/j.ajo.2011.08.029. PMC 3381653. PMID 22030353.
  6. Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ (February 2017). "Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery". Cochrane Database Syst Rev. 2017 (2): CD006364. doi:10.1002/14651858.CD006364.pub3. PMC 5375161. PMID 28192644.
  7. Christy NE, Sommer A (1979). "Antibiotic prophylaxis of postoperative endophthalmitis". Annals of Ophthalmology. 11 (8): 1261–1265. PMID 318049.
  8. Endophthalmitis Study Group; European Society of Cataract; Refractive Surgeons (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.
  9. d’Azy, Cédric Benoist; Pereira, Bruno; Naughton, Geraldine; Chiambaretta, Frédéric; Dutheil, Frédéric (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. ISSN 1932-6203. PMC 4892688. PMID 27257676.
  10. de Caro, John J.; Ta, Christopher N.; Ho, Hoai-Ky V.; Cabael, Lorella; Hu, Nan; Sanislo, Steven R.; Blumenkranz, Mark S.; Moshfeghi, Darius M.; Jack, Robert (2008-06-01). "Bacterial contamination of ocular surface and needles in patients undergoing intravitreal injections". Retina (Philadelphia, Pa.). 28 (6): 877–883. doi:10.1097/IAE.0b013e31816b3180. ISSN 0275-004X. PMID 18536606. S2CID 25819637.
  11. Dossarps, Denis; Bron, Alain M.; Koehrer, Philippe; Aho-Glélé, Ludwig S.; Creuzot-Garcher, Catherine (2016). "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.
  12. Emami, Sara; Kitayama, Ken; Coleman, Anne L. (2022-06-06). "Adjunctive steroid therapy versus antibiotics alone for acute endophthalmitis after intraocular procedure". The Cochrane Database of Systematic Reviews. 6: CD012131. doi:10.1002/14651858.CD012131.pub3. ISSN 1469-493X. PMC 9169535. PMID 35665485.
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