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The prognosis of endogenouse endophthalmtis varies with the offending organism and the systemic status of the patient.
The prognosis of endogenouse endophthalmtis varies with the offending organism and the systemic status of the patient.
*Late detection and late treatment of systemic infection of endogenouse bacterial endophthalmtis is associated with a poor prognosis.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*Late detection and late treatment of systemic infection of endogenouse bacterial endophthalmtis is associated with a poor prognosis.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid10919895">{{cite journal| author=Wong JS, Chan TK, Lee HM, Chee SP| title=Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. | journal=Ophthalmology | year= 2000 | volume= 107 | issue= 8 | pages= 1483-91 | pmid=10919895 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10919895  }} </ref>
*The prognosis of candida endophthalmiaits is good if prompt systemic [[amphotericin B]] treatment is received.
*The prognosis of candida endophthalmiaits is good if prompt systemic [[amphotericin B]] treatment is received.<ref>Essman, Thomas F., et al. "Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis." Ophthalmic Surgery, Lasers and Imaging Retina 28.3 (1997): 185-194. </ref>
*Despite of aggressive treatment, aspergillus endophthalmitis is associated with poor prognosis.  
*Despite of aggressive treatment, aspergillus endophthalmitis is associated with poor prognosis.<ref>Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.</ref>
==Diagnosis==
==Diagnosis==
The diagnosis of endogenous endophthalmitis may be difficult because of the variability in the clinical signs and symptoms.
The diagnosis of endogenous endophthalmitis may be difficult because of the variability in the clinical signs and symptoms.

Revision as of 20:43, 2 August 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Endogenous endophthalmitis is caused by either the hematologic dissemination of bacterial or fungal infections to the eyes or direct spread from adjacent contagious sites. Most common extraocular foci of infection include liver abscess, pneumonia, endocarditis, and soft tissue infection.


Historical Perspective

Classification

endogenous enophthalmitis may be classified according to causative organisms into 2 subtypes: bacterial or fungal.

Pathophysiology

Pathogenesis

Endogenous bacterial endophthalmitis is caused by either the hematologic dissemination of an infection to the eyes or direct spread from adjacent infectious sites. Endogenous endophthalmitis is commonly associated with immunosuppression or procedures that increase the risk for blood-borne infections, such as diabetes, HIV, malignancy, intravenous drug use, transplantation, immunosuppressive therapy, and catheterization. Most common extraocular foci of infection include liver abscess, pneumonia, endocarditis, and soft tissue infection. Under normal circumstances, the blood-ocular barrier provides a natural resistance against invading organisms. In the high risk patients, following bacteremia the blood-borne organisms permeate the blood-ocular barrier by:[1][2][3]

Direct spread from contagious sites can also occur in cases of central nervous system (CNS) infection via the optic nerve.

Endogenous candida endophthalmitis is commonly associated with procedures or conditions that increase the risk for blood-borne infections, such as abdominal surgery, diabetes mellitus and indwelling central venous catheter. It is thought immunosuppression alone does not increase the risk of fungemia and subsequent fungal endophthalmitis.

Following inhalation of the airborne organisms, the aspergilli spores enter the terminal alveoli of the lung. Under normal circumstances, the lung provides a natural resistance against invading organisms. However, in the high risk patients, such as those patients with history of chronic pulmonary diseases, history of organ transplant, intravenous drug abuse, cardiac surgery, and alcoholism, disseminated aspergillosis may result in endogenous aspergillus endophthalmitis.

Gross Pathology

Microscopic histopathological analysis

Causes

Bacterial

Common causes of endogenous bacterial endophthalmitis include:ref name="pmid23438028">Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028. </ref>[2][3]

Fungal

Common causes of endogenous fungal endophthalmitis include:ref name="pmid23438028">Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028. </ref>[2][3]

Differentiating endogenous Endophthalmitis from Other Diseases

Endogenous bacterial endophthalmitis must be differentiated from:

  • Aspergillus endophthalmitis
  • Candida endophthalmitis

Candida endophthalmitis must be differentiated from:[7][8]

Aspergillus endophthalmitis must be differentiated from:[9]

Epidemiology and Demographics

Incidence

The incidence of endogenous endophthalmitis is estimated to be 50 cases per 100,000 hospitalized patients.[2][10]

Age

Endogenous bacterial endophthalmitis affects men and women equally.[2]

Geographical Distribution

Risk Factors

Endogenous bacterial endophthalmitis

Common risk factors in the development of endogenous bacterial endophthalmitis include:[1][2][3]

Endogenous candida endophthalmitis

Common risk factors in the development of endogenous fungal endophthalmitis include:

Screening

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

The prognosis of endogenouse endophthalmtis varies with the offending organism and the systemic status of the patient.

  • Late detection and late treatment of systemic infection of endogenouse bacterial endophthalmtis is associated with a poor prognosis.[1][2][3]
  • The prognosis of candida endophthalmiaits is good if prompt systemic amphotericin B treatment is received.[11]
  • Despite of aggressive treatment, aspergillus endophthalmitis is associated with poor prognosis.[12]

Diagnosis

The diagnosis of endogenous endophthalmitis may be difficult because of the variability in the clinical signs and symptoms.

History

Specific areas of focus when obtaining a history from the patient with endogenous endophthalmitis include:

Symptoms

Symptoms of endogenous endophthalmitis may include the following:

  • Decreased vision
  • Eyelid edema
  • Conjunctival injection
  • Eye pain
  • Photophobia
  • Presence of floaters

Physical Examination

  • Patients with endogenous endophthalmtis usually appear extremely ill and lethargic. Therefore, eye examination in extremely ill patients, such as those in intensive care units (ICU), seems necessary.
  • A thorough examination seems necessary to identify the primary source of infection in patient with endogenous endophthalmitis.

Eye examination

Ophthalmologic examination of patients with endogenoous endophthlamitis is usually remarkable for:

Laboratory Findings

Candida endophthalmitis [13]

Aspergillus endophthalmitis


Imaging Findings

X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

  • The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retina specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics and also prepare for an urgent pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.
  • Systemic antibiotics are recommended in endogenous bacterial endophthalmitis because the source of the infection is distant from the eye.
  • Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
  • Vitrectomy is recommended in severe cases of endogenous endophthalmitis with marked vitreous infiltration

Antimicrobial Regimens

  • Infectious endophthalmitis[1]
  • 1. Causative pathogens
  • 2. Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
  • Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary::* Note (3): Intravitreal and intravenous Amphotericin B may be added to the regimen if fungal endophthalmitis is suspected
  • 3. Pathogen-directed antimicrobial therapy
  • 3.1 Bacillus spp.
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.2 Non-Bacillus gram-positive bacteria
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.3 Gram-negative bacteria
  • Preferred regimen: Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.4 Candida spp.
  • Preferred regimen: (Fluconazole 400-800 mg IV/PO qd for 6-12 weeks OR Voriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks OR Amphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.5 Aspergillus spp.
  • Preferred regimen: Amphotericin B 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose AND Dexamethasone 400 microgram intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy


Surgery

Vitrectomy

Vitrectomy surgically debrides the vitreous humor, similarly to draining an abscess, and is the fastest way of clearing infection in eyes with fulminant endophthalmitis.[1][14][15][16]

  • Vitrectomy is recommended in severe cases of endogenous endophthalmitis with marked vitreous infiltration (either fungal or bacterial)

The benefits of vitrectomy include:

  • Better vitreous sample
  • Rapid and complete sterilization of the vitreous
  • Removal of toxic bacterial products
  • Enhancement of systemic antimicrobial or antiofungal penetration in to the eye

Prevention

References

  1. 1.0 1.1 1.2 1.3 1.4 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Wong JS, Chan TK, Lee HM, Chee SP (2000). "Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction". Ophthalmology. 107 (8): 1483–91. PMID 10919895.
  4. Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251.
  5. Rao, Narsing A., and Ahmed A. Hidayat. "Endogenous mycotic endophthalmitis: variations in clinical and histopathologic changes in candidiasis compared with aspergillosis." American journal of ophthalmology 132.2 (2001): 244-251.
  6. Hunt, LCDR Kerry E., and Ben J. Glasgow. "Aspergillus endophthalmitis: an unrecognized endemic disease in orthotopic liver transplantation." Ophthalmology 103.5 (1996): 757-767.
  7. Menezes, Allison V., et al. "Mortality of hospitalized patients with Candida endophthalmitis." Archives of internal medicine 154.18 (1994): 2093-2097.
  8. Hidalgo, Jose A., et al. "Fungal endophthalmitis diagnosis by detection of Candida albicans DNA in intraocular fluid by use of a species-specific polymerase chain reaction assay." Journal of Infectious Diseases 181.3 (2000): 1198-1201.
  9. Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.
  10. Essex RW, Yi Q, Charles PG, Allen PJ (2004). "Post-traumatic endophthalmitis". Ophthalmology. 111 (11): 2015–22. doi:10.1016/j.ophtha.2003.09.041. PMID 15522366.
  11. Essman, Thomas F., et al. "Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis." Ophthalmic Surgery, Lasers and Imaging Retina 28.3 (1997): 185-194.
  12. Weishaar, Paul D., et al. "Endogenous Aspergillus endophthalmitis: clinical features and treatment outcomes." Ophthalmology 105.1 (1998): 57-65.
  13. Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140.
  14. Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP; et al. (1997). "Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study". Arch Ophthalmol. 115 (9): 1142–50. PMID 9298055.
  15. "Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group". Arch Ophthalmol. 113 (12): 1479–96. 1995. PMID 7487614.
  16. Breit, Sean M., et al. "Management of endogenous fungal endophthalmitis with voriconazole and caspofungin." American journal of ophthalmology 139.1 (2005): 135-140.


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