Endophthalmitis

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What is Endophthalmitis?

Endophthalmitis is the presence of inflammation in the intra-ocular cavity of the eye and involves the aqueous humor and the vitreous humor. It is mainly caused by infections by various microorganisms and in a few cases it can be due to noninfectious causes and is called Sterile Endophthalmitis. One or both eyes may be involved, and it is more common in the right eye in unilateral (one side only) cases.

Is Endophthalmitis condition a Medical emergency?

Endophthalmitis is a medical emergency and requires early intervention and management to prevent permanent vision loss.

Types

Endophthalmitis may be of the following types:

  • Endogenous Endophthalmitis: It occurs when the infection spreads to the intraocular cavity via blood when the bacteria cross the blood ocular barrier
  • Exogenous Endophthalmitis: It occurs when the microorganisms are directly introduced into the intraocular cavity through penetrating trauma, surgery, or foreign bodies

Causes

Endophthalmitis results when there is an inflammation in the intraocular cavity containing the vitreous and aqueous humor. In the endogenous type the microorganisms spread to the intraocular cavity via the blood and the inflammation can be a result of the direct action of the microorganisms, or it may be secondary to the products released into the intraocular cavity due to the inflammatory reaction outside. The microorganisms are able to cross the blood ocular barrier due to damage to the tiny blood vessels. The inflammation and infection result in a progressive damage of the aqueous and vitreous humor and other intraocular tissues.

Some known causes include:

  • Infective endocarditis
  • Cataract surgery
  • Glaucoma surgery
  • Retinal surgery
  • Radial keratotomy
  • Intravitreal injections

Microorganisms that cause Endophthalmitis include:

  • Bacteria – Neisseria meningitides, Staphylococcus aureus, Streptococcus pneumoniae, pseudomonas aeruginosa, etc.
  • Virus – Herpes simplex
  • Fungus – Candida
  • Parasites – Toxoplasma gondii

Risk factors

Factors that increase the risk of Endophthalmitis include:

  • Age: More often seen in individuals over the age of 80 years undergoing eye (cataract) surgery
  • Weaken immune system and immune system disorders
  • Taking immunosuppressive medications
  • History of recent eye surgery
  • HIV/AIDS
  • History of bone marrow transplantation
  • Diabetes
  • Chronic renal failure
  • Cardiac Valve diseases
  • Leukemia
  • SLE
  • Gastrointestinal tract cancers and abscesses
  • Alcoholic hepatitis
  • Intravenous drug abuse
  • Recent invasive procedures such as hemodialysis, bladder catheterization, endoscopy
  • Chemotherapy
  • Dental procedures

Symptoms & signs

The signs and symptoms of Endophthalmitis may develop suddenly or over a few days and include:

  • Blurred vision or vision loss
  • Eye pain and irritation
  • Lid swelling
  • Severe inflammation and redness of the eye
  • Headache
  • Fever
  • Photophobia
  • Pus filled discharge from the eye
  • White spots

Investigations

Some investigations that may be advised for the evaluation of Endophthalmitis include:

  • Laboratory tests:
    • CBP & ESR
    • Blood Urea Nitrogen (BUN) Test
    • Renal Function Tests
    • Urine Culture – if clinical signs point to urinary tract infection
    • Blood Culture - if clinical signs point to generalized infection
    • Throat Culture - if clinical signs point to throat infection as a probable cause
    • Stool Culture - if clinical signs point to gastrointestinal tract infection
    • RT PCR Tests/Gram Stain and culture of vitreous and aqueous humor samples to include aerobic, anaerobic, and fungal cultures
  • Imaging tests
    • Chest X-ray – to evaluate source of infection
    • Cardiac Ultrasound – to evaluate for endocarditis
    • CT or MRI scan of the eye orbit
    • Ocular Ultrasound
  • CSF analysis
  • Complete Ophthalmic Examination including:
    • Visual acuity
    • Slit lamp
    • Intraocular pressure
    • Dilated fundoscopy

Diagnosis

A diagnosis of Endophthalmitis is established based on medical history, clinical evaluation, and results of the investigations done.

Treatment options

The treatment of Endophthalmitis depends on the cause, type and severity of the condition present. Medical and interventional management is usually required for the treatment of this condition.

Medical management

Medical management may include:

  • Postoperative Endophthalmitis:
    • Systemic antibiotics
    • Intravitreous antibiotics
  • Traumatic Endophthalmitis:
    • Systemic antibiotics
    • Topical antibiotics
    • Intravitreal antibiotics
    • Cyclopegic drops with agents such as atropine
  • Endogenous Bacterial Endophthalmitis:
    • Broad spectrum intravenous antibiotics
    • Periocular and intravitreal antibiotics
    • Cyclopegic drops with agents such as atropine
    • Topical steroids
  • Fungal Endophthalmitis:
    • Oral antifungal such as Fluconazole
    • Intravenous and intravitreous antifungals such as amphotericin B
    • Cyclopegic drops with agents such as atropine

Interventional including surgery and indications for surgery

Interventions for the management may include:

  • Pars plana vitrectomy – for Postoperative, Traumatic, and Severe bacterial Endophthalmitis
  • Treatment of the ruptured globe – Traumatic Endophthalmitis
  • Vitreous aspiration – Postoperative Endophthalmitis

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Some measures that can be taken to prevent may include:

  • Use of perioperative antibiotics at the time of cataract and other eye surgeries
  • Use of protective gear while engaging in certain activities to prevent the risk of Traumatic Endophthalmitis
  • Maintaining a healthy lifestyle and taking a proper diet
  • Keeping diabetes and hypertension under control

Complications

Complications associated with Endophthalmitis include:

  • Reduced vision
  • Permanent and complete loss of vision
  • Loss of eye structure
  • Enucleation - complete removal of the eye

Prognosis

The prognosis for Endophthalmitis depends on the cause, severity and the overall health of the individual. Endogenous type generally has a poorer prognosis when compared to exogenous type. Streptococcal infection tends to have a poorer outcome when compared to infections due to other organisms.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek immediate medical attention if the signs and symptoms of Endophthalmitis are noticed.

Indications for hospitalization if required

Hospitalization may be required for the management of certain types of the condition. It is usually not required for the management of the postoperative type.

Suggested clinical specialist/ Department to consult for this condition

  • Ophthalmology
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