Endophthalmitis

Etiology, classification
and clinical approach

DR MAZHAR ALI PANHWER

CIVIL HOSPITAL KARACHI
 DEFINITION

Intraocular inflammation involving ocular

cavities(vitreous cavity and /or anterior
chamber) & their adjacent structures which
is either infectious or non infectious .
 CLASSIFICATION

Endophthalmitis can be classified according to the

Infectivity Infective / non infective ( sterile)

Mode of entry exogenous / endogenous

Type of etiological agent

 Classification

Infectious Sterile (Infectivity)

Exogenous Endogenous ( Mode of entry)

Post trauma Post-operative Blebitis

(PEI-IOFB)

Fulminant Acute Chronic

 Cont.

Etiological agent

Endophthalmitis

Bacterial Fungal viral Parasitic

5
Gram positive bacteria Gram negative bacteria Fungi
75%-85% 10%-15%
3%

Staphylococcus Pseudomonas (8%) Aspergillus

epidemidis (43%)
Streptococcus spp Proteus (5%) Fusarium
(20%)
Staphylococcus aureus Haemophilus Cephalosporium spp.
(15%) influenzae (1%)
Propionibacterium Klebsiella( 0-1%)
acnes
Bacillus cereus (1%) Coliform spp (0-1%)
 Exogenous Endophthalmitis

Vitreous and aqueous primary site of involvement

Retina and uvea secondary involvement

Basically 3 types
1) post operative
2) post traumatic
3) Blebitis

Source of infection is from exterior

Maily bacterial
 1)Post-op Endophthalmitis

Incidence: 0.05%
MC among all types: 49-76%
Surgery Bascom Palmer Eye Katten et al
Institute (1984-1994) (1984-1989)
ECCE with and without 0.08% 0.072%
PCIOL

Secondary PCIOL 0.37% 0.3%

PPV 0.05% 0.05%
PK 0.18% 0.11%
Glaucoma filtration 0.12% 0.06%
surgery
 Source of infection

Airborne
respiratory origin, air condition in O.T
Solution and medications
irrigating solutions, drops and ointment
skin antiseptic, viscoelastic and silicon oil
Tissue
periocular skin ,lid margin and lashes
conjuctival sac, Lacrimal sac
nasal mucosa, corneal graft
Objects and materials
surgical instruments, gloves, masks, IOL

Clinical Importance- all causes are preventable

 Risk Factors

Preoperative risk factors

blepharitis , active conjunctivitis
Lacrimal drainage system infection or obstruction ,
contaminated eye drops.

Operative risk factors

wound abnormalities, PC rent ,vitreous loss ,prolonged
surgery & contaminated irrigation solutions
 Types Of Presentations

Fulminant Acute Chronic

(<4 days) (4-7days) (>4 weeks)
-gram ve -staph.epidermidis
-staph.aureus -coag.-ve cocci
-streptococci delayed delayed
entry onset
bleb P.acne
related fungi
S.epidermids
 2)Post traumatic

Incidence-2-7%(unsterile conditions & contaminated objects)

Contributes to 17-40% of all cases
Penetrating ocular trauma is main culprit
Causative organisms

fulminant: acute: chronic:

B. cereus S.epidermidis(MC) fungi:
Streptococcus Gram.-ve fusarium

Bacillus cerus isolated in 50% of culture positive cases

causes fulminante Endophthalmitis
 Difficult to diagnose early.

Rapid worsening of symptoms and inflammation

should be suspected as Endophthalmitis until proved
otherwise.

Ring corneal infiltrate & ring abscess is typical of

Bacillus. also assoc.with proptosis,chemosis & severe
orbital pain in 24hrs

Commoner in rural setting due to retained IOFB.

Removal of IOFB with in 24 hr.reduces risk.

 3)Bleb related endophthalmitis

4-18% of all cases

After glaucoma filtration surgery
May occur at any time (months- years )after surgery
Most of the time through intact bleb via conjuctival flora
Poor prognosis as org. are more virulent
Causative organism
streptococci(MC)-faecalis,viridans,pneumoniae
H.influenzae
staph. are rare
Clinical signs
infected white bleb
Vitritis
Hypopyon
 Risk factors: use of antimitotic agents,inferior
blebs,conjunctivitis,contact lens,periocular
infections
Should be differentiated from BLEBITIS
Blebitis
- low virulence organism
- mild intraocular inflammation
- no Vitritis
 Endogenous(Metastatic) Endophthalmitis

2-15% of all cases

Hematogenous spread of organism from distant source
Retina and choroid primarily involved due to high
vascularity.
Fungi> bacteria
Candida(MC)>Aspergillus
Predisposing factors
- Diabetes
- immunosuppresion(AIDS,malignancies medications)
- recent major abdominal surgery
- prolong indwelling catheter ( intravenous , TPN)
- intravenous drug abuser
- distant infection ( endocarditis, meningitis, septicemia etc)
no structural defect in globe
 Clinical Approach

Symptoms: Decreased or blurred vision

( sudden / severe acute)
( slowly / mildchronic)
Pain
Photophobia
Redness of eyes
Swollen eyelids
Discharge
White lesion in black part of the eye
Floaters
Fever
 Signs

Initial visual acuity ( prognostic significance)

Ocular motility ( sign of orbital inflammation)
Eyelid swollen , blepharospasm
Conjunctiva
hyperemia, chemosis, bleb examination if present
Cornea
edematous, opacification , DM folds
keratic precipitate, infiltrates, occult penetration
Anterior chamber
cells, flare , fibrinous exudates and Hypopyon
Iris muddy,boggy,resistant to dilatation,post.synechiae
 Pupil-absent or sluggish reaction to light
Lens - Membrane , exudates around IOL
Vitreous - Vitritis , exudates , yellowish appearance
Fundus examination
Absent red reflex and no fundal view

Papilitis
White lesion in retina and chorioid
Retinal hemorrhage and periphlebitis
IOP- usually low,may be high in early cases
Signs of penetrating injury and Intraocular foreign
body
Wound dehiscence
 Fungal Endophthalmitis

Caused by Candida albicans, Aspergillus, Fusarium

etc.
Causes
- delayed post-operative endophthalmitis
- endogenous endophthalmitis in
immunocompromised patients

Minimal pain, mild external ocular involvement

Progressive iridocyclitis, Vitritis ( string of pearl )

Yellow white choroidal lesion single or multiple

 Diagnosis

A) Clinically
B) Laboratory
AC Tap (0.1ml)
Vitreous tap (0.2 ml)
Standard Media
Grams stain Blood agar ( most aerobic bacteria)
Giemsa stain Chocolate (aerobic , Neisssseria , Haemophilus )
Culture Thioglycolate broth ( aerobic ,anaerobic bacteria)
SDA ( fungi)
Specialized Media
Lowenstein Jensen ( mycobacterium , nocardia)
Non- nutrient agar E.coli enriched
PCR
1) Ultrasound-vitreous membrane and opacities
anatomical status of the retina
extent of inflammation
choroidal detachment
IOFB presence and localization
retained lens material

2) CT Scan not much useful

to detect IOFB
3) ERG
grossly abnormal - poor prognosis
slightly subnormal - slight better
For endogenous endoph.:
Complete blood count ( signs of infection)
ESR ( malignancy ,chronic infections, rheumatic
diseases)
Cultures ( for detection of source of infection)
blood culture
urine culture
throat swab
CSF
stool
indwelling catheters tip
Chest X-ray
Other
like HIV
 Treatment

GOALS

1) Retention of useful vision.

2) Minimize the infection with antimicrobial agents.

3) Limit the inflammation.

4) Symptomatic relief.
 For bacterial endoph.

Prompt therapy is critical

Modalities

MEDICAL
1) Antibiotics
Intravitreal, periocular, topical , systemic
2) Anti-inflammatory (steroids)
topical ,periocular , systemic
( not for chronic Endophthalmitis)
3) Supportive Cycloplegic,AGM
SURGICAL
vitrectomy
 Medical treatment

Intravitreal injection
- preferred route in all types of endophthalmitis.
- direct administration in vitreous
- by passes Blood Ocular Barrier.
Intravitreal injection
Vancomycin ( 1.0 mg in 0.1 ml )
Amikacin ( 400ug in 0.1 ml)
Or
Ceftazidime (2.25mg/0.1ml)
Subconjunctival injections
Vancomycin (25mg in 0.5ml)
Amikacin (25mg in 0.5ml)
 Systemic : 1) penetrating ocular injury from
contaminated objects.
2) Endogenous bacterial endophthalmitis.
For Post-Op Endophthalmitis:
- no role due to MIC in vitreous
-Quinolones ( ciprofloxacin) can be tried

Rapid bacterial proliferation make even the

Quinolones concentration inadequate to
prevent the growth of organisms.
Ideal duration - at least 2-4 week
Drugs Doses
Vancomycin 1 gm iv.12 hrly
(10-30 mg/kg)
Ceftazidime 2 gm iv. Bd
Amikacin 250 mg iv. Tid
(15mg/kg)
Gentamycin 80 mg iv tid
(3-5mg/kg)
Ciprofloxacin 750 mg po.bd
Ofloxacin 200 mg 12 hrly
 Role Of Steroids

Indications
recent onset after rule out of fungus.
Contraindication
Late onset endophthalmitis
fungal endophthalmitis
Mechanism- reduce inflammation clinically and
histopathologicaly

limit ocular damage

Routes - Intravitreal(dexa400mgm in 0.1ml),systemic, sub-

conjuctival(1 mg in 0.25ml), topical
 Treatment in Fungal Endoph.

Indication of Intravitreal antifungal

1) pre-existing fungal keratitis endophthalmitis
2) fungal endogenous endophthalmitis ( culture +)

Commonly used medications

intra-vitreal Amphotericin B- 5microgm/0.1ml
oral fluconazole / ketoconazole ( better vitreal penetration)

Voriconazole
Intravitreal -50 microgm/0.1ml
oral- 200 mg bd
intravenous- 6 mg/kg bd 2 doses
Steroids in any form C/I
Systemic antifungals
 Vitrectomy

Advantages ( DIAGNOSTIC / THERAPEUTIC)

1) more material for culture esp. fungus.

2) removal of inflammatory mediators /organisms /toxins.

3) removal of source of infection.

4) better dispersion of antibiotics in the vitreous

.
5) clears the media and better posterior segment visualization

6) removes vitreous membrane which may be a source of late

traction and subsequent detachment.
guided by Endophthalmitis vitrectomy study
(EVS)
 Complications

Retinal necrosis
Retinal detachment
Retinal necrosis
Vitreous tap
Vitrectomy
Increased intraocular pressure
Retinal vascular occlusion
Optic neuropathy
Panophthalmitis
Hypotony
Ciliary body shut down
Leaking wound
Retinal detachment
Cyclodialysis cleft
Medication
 Prevention

1 ) PRE-OPERATIVE
a) preexisting conditions e.g.blepharitis, conjunctivitis ,
dacryocyctitis,, infected contra- lateral socket

b) povidone iodine ( BETADINE) drops

c) meticulous draping

d) topical antibiotic
2) INTRA-OPERATIVE
irrigation of A/C with vancomycin
3) POST OPERTAIVE
anterior sub-tenon antibiotic / sub conj. antibiotic
Bleb related
1) early diagnosis and treatment of conjunctivitis.
2) wearing of contact lens should be discouraged.
3) treatment of associated periocular infections.
Traumatic
1) safety goggles.
2) timely and appropriate management of ocular
trauma.
Endogenous
1) adequate and timely management of systemic
illness.
2) intravenous drug abuse reduction.
3) control of all predisposing factors.
THANK
YOU
 Endophthalmitis Vitrectomy Study(EVS)

Multicenter randomized trial carried out at 24 centres in

U.S. (1990-1994)
Purpose : To determine
The role of IV antibiotics in the management of POE
Role of initial vitrectomy in management.
Patients : N = 420 patients having clinical evidence of POE
within 6 weeks of cataract surgery
Intervention
Random assignment to immediate vitrectomy (VIT) or
vitreous biopsy (TAP). They were also randomly assigned to
treatment with IV or no IV.
Study medications : After initial VIT or TAP, all patients
received I/V injection of amikacin (0.4 mg) + vanco(1 mg)
Vanco(25 mg in 0.5 ml), Ceftazidime (100 mg in 0.5 ml),
Dexamethasone (6 mg in 0.25 ml) administered
subconjunctivally.
IV treatment: ceftazidime (2 g every 8 hrs) + amikacin
(6mg/kg every 12 hrs) for 5-10 days
Main outcome measures
Evaluation of visual acuity and clarity of ocular
media at 3, 9, 12 months
No difference in outcome between PPV followed by I/V
group compared to vitreous tap and I/V if vision better
than light perception
No difference in final visual acuity or media clarity
whether or not EVS systemic antibiotic( Amikacin ,
Ceftazidime) were employed
Vision with light perception or worse ,much better
results in immediate PPV
 Limitations of EVS
1) only for acute post -operative endophthalmitis
after cataract surgery
2) doesnt mention the outcome of vitrectomy in
other forms of endophthalmitis like;
- post traumatic
-chronic post operative etc
-endogenous endophthalmitis