Bleb-related endophthalmitis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]
Overview
Bleb-related endophthalmitis (BRE) is the second most frequent cause of postoperative endophthalmitis after acute and chronic post-cataract surgery endophthalmitis.
Historical Perspective
Classification
Depending on the timing of presentation and duration, bleb-related endophthalmitis (BAE) can be classified into either early onset (<6wks) or late onset(>6wks).
Pathophysiology
Causes
- Early onset BAE
- Late onset BAE
- Streptoccous species (31%)
- Staphylococcus species (7%-22%)
- Gram-negatives such as (Haemophilus influenzae 23%, Enterococcus 7%, Pseudomonas 7%)
Epidemiology and Demographics
The incidence of bleb-related endophthalmitis is approximately range from 200 to 1300 per 100,000 individuals with . It's incidence is reported to be between 0.2% to 1.3%,2,3 and is more common with the use of antiproliferative agent (up to 3%) and even higher when the bleb is placed inferiorly (up to 9.4%).
Risk Factors
- Late onset bleb leakage (increase the risk of bleb infection 26 fold)
- Inappropriate use of of The antifibrotic agents (such as 5-fluorouracil (5-FU) and Mitomycn-C (MMC))
- Reduce mucin production (secondry to loss of gablet cell)
- General conjunctival thinning
- Reduced cellularity
- Avascular bleb
- Epithelial irregularities, basement membrane breaks, and hypocellularity
- Inappropriate use of of The antifibrotic agents (such as 5-fluorouracil (5-FU) and Mitomycn-C (MMC))
- Inferior and nasal placement of bleb
- Conjunctivitis,
- Upper respiratory infection,
- Blepharitis
- Diabetes
- Trabeculectomy alone compared to combined procedure
- Chronic antibiotic use
Screening
Natural History, Complications, and Prognosis
Natural History
Complications
Prognosis
A single-center retrospective review from the 1990s showed that the 5 year risk of blebitis and that of BAE is 6.3% and 7.5%, respectively.
Diagnosis
Diagnostic Criteria
History and Symptoms
=Symptoms
- Ocular pain and discomfort
- Redness
- Blurred vision
Eyebrow ache Headache, External ocular inflammation
Physical Examination
Eye examination
- Whitened bleb surrounded by intense conjunctival injection
- A mucopurulent infiltrate,
- Precipitates similar to keratic precipitates
- Hypopyon within the bleb (often avascular with thin walls)
- Anterior chamber reaction and/or a hypopyon, depending on the duration of the blebitis. Frequently, there is a
- Bleb leak and consequent hypotony
Laboratory Findings
Imaging Findings
X Ray
CT
MRI
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Prevention
Primary Prevention
- Assessment of bleb leakage following tabeculectomy surgery in every vist
- Aggressive treatment of blebitis
- Bleb revision with conjunctival advancement to manage avascular leaking blebs (100% success rate)
- Amiotic membrane grafting as a possible alternative to conjunctival advancement (45% success rate)
Secondary prevention
- Bleb revision with conjunctival advancement to manage avascular leaking blebs (100% success rate)
- Amiotic membrane grafting as a possible alternative to conjunctival advancement (45% success rate)