Diagnosis: Postoperative endophthalmitis
Endophthalmitis is an inflammatory condition of the anterior and posterior chambers and is a medical emergency. Endophthalmitis can be categorized as infectious or noninfectious (sterile). Causative organisms for infectious endophthalmitis can be either bacterial or fungal. Infectious endophthalmitis can be further categorized by mode of entry as either exogenous (ie postoperative or traumatic) or endogenous.
Exogenous Endophthalmitis is a more common cause and occurs in the setting of ocular surgeries (ie cataract surgery, trabeculectomy, etc.) or intravitreal injections, or following trauma. The introduction of common organisms found in the normal flora of the skin causes postoperative endophthalmitis. S epidermidis is the most common causative organism, followed by S aureus and streptococcal species. Gram negative organisms like P aeruginosa have also been implicated in post operative endophthalmitis . Exogenous endophthalmitis usually presents 3-5 days after intraocular surgery or procodure but there is documentation of postsurgical endophthalmitis occurring months or years after surgery. Surgical wounds should be checked carefully for leaks as this a possible entry point for pathogens.
Blebitis or infection of the bleb created during a trabeculectomy can lead to bleb-associated endophthalmitis, and must be monitored closely for this type of progression. It often occurs as a result of a bleb-leak, and therefore should be Seidel tested for leak as well (see left image – image credit).
Endogenous endophthalmitis is a result of hematogenous spread of an extraocular infection. Immunocompromised patients are more susceptible to endogenous endophthalmitis. Bilateral presentation is possible in endogenous endophthalmitis because of its systemic nature and fungal etiologies are not uncommon due to immunocompromise (see right image: Candida associated endophthalmitis, image credit). Endogenous endophthalmitis may even present with features of sepsis.
Treatment for endophthalmitis includes intravitreal antibiotics, (or antifungal injection if determined to be the causative agent), and pars plana vitrectomy. In the case of hand movement or better vision, treatment consists of prompt intraocular injection of broad spectrum antibiotics. Patients with light perception (LP) vision or worse, require urgent vitrectomy.
The results of the Endophthalmitis Vitrectomy Study (EVS) found that in patients with vision of LP or worse who underwent an immediate vitrectomy had significantly improved visual outcomes, compared to treatment with intravitreal antibiotics. Therefore, patients with light perception (LP) vision or worse should undergo urgent vitrectomy.
Lab studies should include gram stain and culture of aqueous and vitreous. Alternatively, RT PCR can be used instead as studies have shown that RT PCR has improved diagnostic accuracy compared to traditional culture.
Our patient, who presents with hand motion vision, would benefit from immediate vitreous tap and intravitreal injections of broad spectrum antibiotics (commonly vancomycin and ceftazidime), with close monitoring and low threshold for vitrectomy if the infection worsens or fails to improve. Delay can result in permanent visual loss. Postoperative endophthalmitis can progress rapidly and may lead to panophthalmitis. Early diagnosis and treatment are associated with better visual outcomes.
References and Additional Resources:
- Maassen JL, Folk JC: Endophthalmitis: 82-year-old male status post phacoemulsification in the left eye with acute decrease in vision. Eyerounds.org. December 5, 2005; Available at: http://www.EyeRounds.org/cases/45-Endophthalmitis-After-Cataract-Surgery.htm.
- A T. Treating Endogenous Endophthalmitis. Reviewofophthalmology.com. Published October 6, 2014. Accessed April 21, 2019. https://www.reviewofophthalmology.com/article/treating-endogenous-endophthalmitis
- Durand ML. Endophthalmitis. Clin Microbiol Infect. 2013;19(3):227-234. doi:10.1111/1469-0691.12118
- Kabbara S., Kelkar N., Conway, MD. , & Peyman, GA. Endogenous Endophthalmitis: Etiology and Treatment. Infectious Eye Diseases – Recent Advances in Diagnosis and Treatment. IntechOpen. https://doi.org/10.5772/intechopen.96766
- Kamjoo S. “Endophthalmitis.” American Academy of Ophthalmology EyeWiki. 2022; available at: https://eyewiki.aao.org/Endophthalmitis#Exogenous.
- 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. 1995;113(12):1479-1496.
Ophtho On Call Case 7 Index
Ophtho On Call Case 7: Introduction
Ophtho On Call Case 7: Additional History
Ophtho On Call Case 7: Physical Exam