case of endophthalmitis recently caused the complete loss of an eye
in a patient I had seen a few years ago. Although this struck close
to home for me, many of you also directly or indirectly know
patients who have suffered the insidious effects of endophthalmitis.
This potentially blinding intraocular inflammation can lead to an
eviscerative procedure, as was the case for my patient. It can
result from surgery, trauma, intravitreal injections or endogenous
seeding, from most to least common respectively. Although it most
commonly occurs after cataract surgery, it can manifest after any
sources cite an incidence of around 0.1 percent to 0.2 percent,
although the frequency has increased in the 21st century for unknown
reasons. A recent report shows that using a prophylaxis of
fourth-generation fluoroquino-lones prior to cataract surgery
resulted in a rate of 0.07 percent.
Causes of Endophthalmitis
cases result from a coagulase negative
Staphylococci and to a lesser extent from
Staphylococcal aureus. Traumatic causes of endophthalmitis
typically result from Staphylococci and
B cereus and occur in 3 percent to 17
last 10 years practitioners have increasingly used intravitreal
injections, which pre-sent yet another avenue for bacteria to enter.
Careful attention to aseptic technique is critical to preventing
this vector for endophthalmitis. For example, during the VEGF
Inhibition Study in Ocular Neovascularization (VISION), a protocol
change toward stricter criteria for asepsis yielded lower rates of
Endogenous seeding occurs mostly in immunocompromised individuals.
Fifty percent of such cases result from fungal organisms such as
Candida albicans. Endogenous cases occur
in only 2 percent to 8 percent of all endophthalmitis cases.
Presentation and Treatment
can appear with acute or chronic cases of endophthalmitis, the
former typically presenting with more virulent microorganisms and
thus poorer prognosis. Your patient may experience varying levels of
pain, decreased visual acuity, conjunctival hyperemia, corneal
edema, vitritis, retinal hemorrhages and periphleb-itis. The most
common objective sign (86 percent) as found in the Endophthalmitis
Vitrectomy Study is a hypopyon. Rapid identification of the
condition with prompt referral is essential to offering an
intervention that may save vision and the eye.
differential diagnosis also includes uveitis and, more recently,
toxic anterior segment syndrome. The latter also occurs in
post-surgical cases, but the etiology (noninfectious and toxic) and
treatment are different.
regimens are complicated by lack of knowledge of the particular
offending agent, thus necessitating an empirical approach.
Therapeutic options may include antibiotics such as vancomycin,
aminoglycosides (amikacin) and cephalosporins (ceftazidime), most
often delivered as an intravitreal injection. Concomitant
intravitreal steroid use as a means to decrease the inflammatory
effects of endophthalmitis remains controversial.
vitrectomy serves as a means to remove the infectious component
along with the simultaneous use of intravitreal antibiotics. This is
especially true for cases of intraocular foreign body-induced
endophthalmitis. Other modes of antibiotic treatment may include
topical, oral, subconjunctival injection and intravenous.