Endophthalmitis: Difference between revisions

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==Signs and symptoms==
==Signs and symptoms==
A history of recent intraocular surgery or penetrating ocular trauma is usually elicited. In some cases of metastatic endophthalmitis, the spread of infection may be hematogenous (via the blood-stream). That is more commonly seen in patients with immunocompromised states like [[AIDS]] and also in [[diabetes]]. The condition is usually accompanied by severe pain, loss of vision and redness of the [[conjunctiva]] and the underlying [[episclera]]. Alongside are present signs of inflammation of the various coats of the eye. [[Hypopyon]] can also be present in endophthalmitis and should be looked for on examination by a [[slit lamp]]. Progression to involve all the coats of the eye is called as [[uveitis|panuveitis]] or ophthalmitis|panophthalmitis.
A history of recent intraocular surgery or penetrating ocular trauma is usually elicited. In some cases of metastatic endophthalmitis, the spread of infection may be hematogenous (via the blood-stream). That is more commonly seen in patients with immunocompromised states like [[AIDS]] and also in [[diabetes]]. The condition is usually accompanied by severe pain, loss of vision and redness of the [[conjunctiva]] and the underlying [[episclera]]. Alongside are present signs of inflammation of the various coats of the eye. [[Hypopyon]] can also be present in endophthalmitis and should be looked for on examination by a [[slit lamp]]. Progression to involve all the coats of the eye is called as [[uveitis|panuveitis]] or panophthalmitis.


==Treatment==
==Treatment==

Revision as of 16:42, 13 February 2014

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

Overview

Endophthalmitis is an inflammation of the internal coats of the eye. It is a dreaded complication of all intraocular surgeries, particularly cataract surgery, with possible loss of vision and the eye itself. Infectious etiology is the most common and various bacteria and fungi have been isolated as the cause of the endophthalmitis. Other causes include penetrating trauma and retained intraocular foreign bodies.

Signs and symptoms

A history of recent intraocular surgery or penetrating ocular trauma is usually elicited. In some cases of metastatic endophthalmitis, the spread of infection may be hematogenous (via the blood-stream). That is more commonly seen in patients with immunocompromised states like AIDS and also in diabetes. The condition is usually accompanied by severe pain, loss of vision and redness of the conjunctiva and the underlying episclera. Alongside are present signs of inflammation of the various coats of the eye. Hypopyon can also be present in endophthalmitis and should be looked for on examination by a slit lamp. Progression to involve all the coats of the eye is called as panuveitis or panophthalmitis.

Treatment

Overview

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.

Bacterial Endophthalmitis

Bacterial Endophthalmitis
Preferred Regimen
Vancomycin 1 mg intravitreal
PLUS
Ceftazidime 2.25 mg intravitreal
PLUS
Vancomycin 1 gm IV q12h
PLUS
Cefotaxime 1 gm IV q4h
OR
Ceftriaxone 1 gm IV q4h
OR
Ceftazidime 1 gm IV q8h
  • Vitrectomy is very important in sever cases for better visual outcomes.[1]
  • Systemic antibiotics may shows a benefit as an adjunctive therapy to intravitreal antibiotics.[2]
  • Antibiotics are adjusted after sensitivity results.
  • Clindamycin is added, in cases of intravenous drug users until Bacillus infection is ruled out.

Post-traumatic Endophthalmitis

Post-traumatic Endophthalmitis
Preferred Regimen
Vancomycin 1 mg intravitreal
PLUS
Ceftazidime 2.25 mg intravitreal
PLUS
Vancomycin 1 gm IV q12h
PLUS
Ciprofloxacin 400 mg IV/po q12h
OR
Ceftazidime 1 gm IV q8h
  • Topical antibiotics, or subconjunctival antibiotics often used in conjunction with intravitreal antibiotics post-operatively.[3]

Post Cataract Endophthalmitis

In early acute cases

  • Immediate vitrectomy may be needed, and intravitreal injection of Vancomycin 1 mg, and Ceftazidime 2.25 mg.
  • Intravitreal antibiotics may be repeated in 2–3 days.
  • Lens can be left without removal.

In chronic cases:

Post Glaucoma Surgery Endophthalmitis

Post Glaucoma Surgery Endophthalmitis
Preferred Regimen
Vancomycin 1 mg intravitreal
PLUS
Ceftazidime 2.25 mg intravitreal
  • Topical ophthalmic antibiotics usually added to the above regimen.[5]

Fungal Endophthalmitis

Fungal Endophthalmitis
Preferred Regimen
Amphotericin B 5–10 μg in 0.1 mL sterile water intravitreal
OR
Voriconazole 100 μg in 0.1 mL sterile water intravitreal
PLUS
Fluconazole 6-12 mg/kg daily
OR
Flucytosine 25 mg/kg qid
  • Duration of therapy is 4-6 weeks or longer based on the case improvement.[6]

References

  1. "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.
  2. Hooper CY, Lightman SL, Pacheco P, Tam PM, Khan A, Taylor SR (2012). "Adjunctive antibiotics in the treatment of acute bacterial endophthalmitis following cataract surgery". Acta Ophthalmol. 90 (7): e572–3. doi:10.1111/j.1755-3768.2011.02365.x. PMID 22429465.
  3. Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  4. Hanscom TA (2004). "Postoperative endophthalmitis". Clin Infect Dis. 38 (4): 542–6. doi:10.1086/381262. PMID 14765348.
  5. Leng T, Miller D, Flynn HW, Jacobs DJ, Gedde SJ (2011). "Delayed-onset bleb-associated endophthalmitis (1996-2008): causative organisms and visual acuity outcomes". Retina. 31 (2): 344–52. doi:10.1097/IAE.0b013e3181e09810. PMID 20838358.
  6. Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C; et al. (2011). "Ocular manifestations of candidemia". Clin Infect Dis. 53 (3): 262–8. doi:10.1093/cid/cir355. PMID 21765074.

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