DEFINISI

Endophthalmitis is an inflammatory condition of the intraocular cavities (ie, the aqueous

and/or vitreous humor) usually caused by infection. Noninfectious (sterile) endophthalmitis
may result from various causes such as retained native lens material after an operation or
from toxic agents. Panophthalmitis is inflammation of all coats of the eye including
intraocular structures.
Endoftalmitis adalah inflamasi dari ruang intraokular (termasuk aquos humor dan vitrous)
yang disebabkan oleh infeksi. Noninfeksi endoftalmitis dapat disebabkan oleh inflamasi yang
disebabkan oleh material lensa yang bocor selama prosedur operasi dan disebabkan oleh
agen toksik. Panoftalmitis adalah inflamasi dari seluruh lapisan mata termasuk strukturstruktur intraokular.

Severe endophthalmitis. Courtesy of Ron Afshari Adelman MD, MPH, MBA, FACS, Yale Medical
Group.

the 2 types of endophthalmitis are endogenous (ie, metastatic) and exogenous. Endogenous
endophthalmitis results from the hematogenous spread of organisms from a distant source
of infection (eg, endocarditis). Exogenous endophthalmitis results from direct inoculation of
an organism from the outside as a complication of ocular surgery, foreign bodies, and/or
blunt or penetrating ocular trauma.
Secara umum, endoftalmitis dibagi menjadi 2 jenis yaitu endogenous dan eksogenous
endoftalmitis. Endogenous endoftalmitis disebabkan oleh persebaran sumber infeksi melalui
peredaran darah yang disebabkan sumber infeksi diluar orbita (yang sering endokartitis).
Eksogenous endoftalmitis disebabkan oleh inokulasi langsung organisme ke orbita yang
berasal dari paparan luar seperti komplikasi dari operasi mata, benda asing, dan/atau
penetrating okular trauma.
Patofisiologi

Under normal circumstances, the blood-ocular barrier provides a natural resistance

against invading organisms.

In endogenous endophthalmitis, blood-borne organisms (seen in patients who are

bacteremic in situations such as endocarditis) permeate the blood-ocular barrier
either by direct invasion (eg, septic emboli) or by changes in vascular endothelium
caused by substrates released during infection. Destruction of intraocular tissues
may be due to direct invasion by the organism and/or from inflammatory mediators of
the immune response.
Dalam kondisi normal, bloood-ocular barrier memberikan perlindungan terhadap
invasi organism. Pada endogenous endoftalmitis, bakteri yang ada dalam darah
dapat melewati blood-ocular barrier melalui invasi langsung.
Endophthalmitis may be as subtle as white nodules on the lens capsule, iris, retina,
or choroid. It can also be as ubiquitous as inflammation of all the ocular tissues,
leading to a globe full of purulent exudate. In addition, inflammation can spread to
involve the orbital soft tissue.
Any surgical procedure that disrupts the integrity of the globe can lead to exogenous
endophthalmitis (eg, cataract, glaucoma, retinal, radial keratotomy, intravitreal
injections).

Epidemiologi
Endogenous endophthalmitis is rare, occurring in only 2-15% of all cases of
endophthalmitis. Average annual incidence is about 5 per 10,000 hospitalized
patients. In unilateral cases, the right eye is twice as likely to become infected as the
left eye, probably because of its more proximal location to direct arterial blood flow
from the right innominate artery to the right carotid artery. Since 1980, candidal
infections reported in IV drug users have increased. The number of people at risk
may be increasing because of the spread of AIDS, more frequent use of
immunosuppressive agents, and more invasive procedures (eg, bone marrow
transplantation).
Most cases of exogenous endophthalmitis (about 60%) occur after intraocular
surgery. When surgery is implicated in the cause, endophthalmitis usually begins
within 1 week after surgery. In the United States, postcataract endophthalmitis is the
most common form, with approximately 0.1-0.3% of operations having this
complication, which has increased over the last 3 years. [1] Although this is a small
percentage, large numbers of cataract operations are performed each year making
the chances that physicians may encounter this infection higher. Endophthalmitis
may also occur after intravitreal injections, although this risk in an analysis of over
10,000 injections is estimated at 0.029% per injection. [2]
Posttraumatic endophthalmitis occurs in 4-13% of all penetrating ocular injuries.
Incidence of endophthalmitis with perforating injuries in rural settings is higher when

compared with nonrural settings.[3] Delay in the repair of a penetrating globe injury is
correlated with increased risk of developing endophthalmitis. [4] Incidence of
endophthalmitis with retained intraocular foreign bodies is 7-31%.

Mortality/Morbidity
Decreased vision and permanent loss of vision are common complications of
endophthalmitis. Patients may require enucleation to eradicate a blind and painful
eye.
Mortality is related to the patient's comorbidities and the underlying medical problem,
especially when considering the etiology of hematogenous spread in endogenous
infections.

Age
An association appears to exist between the development of endophthalmitis in
cataract surgery and age greater than or equal to 85 years. [5]
History should be focused toward practices or procedures that would increase risk of
endogenous or exogenous endophthalmitis (eg, intravenous drug use, other risks for
sepsis or endocarditis, recent invasive ophthalmologic procedure). See discussion
below in Causes.
Bacterial endophthalmitis usually presents acutely with pain, redness, lid swelling,
and decreased visual acuity. Also, some bacteria (eg, Propionibacterium acnes) may
cause chronic inflammation with mild symptoms. This organism is typical skin flora
and usually is inoculated at the time of intraocular surgery.
Fungal endophthalmitis may present with an indolent course over days to weeks.
Symptoms are often blurred vision, pain, and decreased visual acuity. A history of
penetrating injury with a plant substance or soil-contaminated foreign body may often
be elicited.
Individuals with candidal infection may present with high fever, followed several days
later by ocular symptoms. Persistent fever of unknown origin (FUO) may be
associated with an occult retinochoroidal fungal infiltrate.
History of ocular surgery, ocular trauma, hammering steel with steel, working with
baling wire, or working in an industrial setting may be elicited.
In cases of postsurgical endophthalmitis, infection most often occurs approximately 1
week after surgery but may occur months or years later as in the case of P acnes.
Symptoms may include the following:

Visual symptoms in any hospitalized patient or patient taking

immunosuppressive therapy
Visual loss
Eye pain and irritation
Headache
Photophobia

Ocular discharge
Intense ocular and periocular inflammation
Injected eye
Physical findings correlate with structures involved and degree of infection or
inflammation. A thorough eye examination should be performed to include acuity,
external examination, funduscopic examination, and slit lamp examination. Seek
signs of uveitis and other findings as described below. Emergent referral to an
ophthalmologist for further evaluation, including more exhaustive physical
examination, is indicated if endophthalmitis is seriously considered.

Eyelid swelling and erythema

Injected conjunctiva and sclera
Hypopyon (layering of inflammatory cells and exudate [pus] in the anterior
chamber)

Vitreitis

Chemosis

Reduced or absent red reflex

Proptosis (a late finding in panophthalmitis)

Papillitis

Cotton-wool spots

Corneal edema and infection

White lesions in the choroid and retina

Chronic uveitis

Vitreal mass and debris

Purulent discharge

Fever

Cells and flare in the anterior chamber on slit lamp examination

Note: Absence of pain and hypopyon do not rule out endophthalmitis,

particularly in the chronic indolent form of P acnes infection.
In cases of endogenous endophthalmitis, the emergency physician needs to further
evaluate the patient for the underlying source of infection
In most clinical series, gram-positive organisms are the most common causative
organisms of endophthalmitis. The most common organisms are coagulasenegative Staphylococcus epidermidis, Staphylococcus
aureus, and Streptococcusspecies. Gram-negative organisms like Pseudomonas,
Escherichia coli, andEnterococcus are observed in penetrating injuries. However,
when endogenous endophthalmitis is considered alone, the percentage of bacterial
organisms drops markedly because of a greater proportion of fungal infections. [6] It is
very rare for endophthalmitis to be caused by viral infections. Classically, viruses are
responsible for uveitis.

Endogenous endophthalmitis
Individuals at risk for developing endogenous endophthalmitis usually have
comorbidities that predispose them to infection. [6] These include conditions such as

diabetes mellitus, chronic renal failure, cardiac valvular disorders, systemic lupus
erythematosus, AIDS, leukemia, gastrointestinal malignancies, neutropenia,
lymphoma, alcoholic hepatitis, and bone marrow transplantation.
Invasive procedures, which may result in bacteremia, such as hemodialysis, bladder
catheterization, gastrointestinal endoscopy, total parenteral nutrition, chemotherapy,
and dental procedures, also can lead to endophthalmitis.
Recent nonocular trauma or surgery, prosthetic heart valves, immunosuppression,
and intravenous drug abuse may predispose to endogenous endophthalmitis. [7]
Sources for endophthalmitis include meningitis, endocarditis, urinary tract infection,
and wound infection. Additionally, pharyngitis, pulmonary infection, septic arthritis,
pyelonephritis, and intra-abdominal abscess also have been implicated as sources of
infection.
Fungal organisms can occur in up to 50% of all cases of endogenous
endophthalmitis.[6] Candida albicans is by far the most frequent cause (75-80% of
fungal cases). Aspergillosis is the second most common cause of fungal
endophthalmitis, especially in IV drug users. Less frequent are other candidal
species and Torulopsis, Sporotrichum, Cryptococcus,
Coccidioides, and Mucorspecies.
The single most commonly involved gram positive organism is S. aureus, which
often is implicated with skin infections or chronic systemic disease, such as diabetes
mellitus or renal failure. Streptococcal species including Streptococcus pneumoniae,
Streptococcus viridans, and group A streptococci also are common. Other
streptococcal species, eg, group B in newborns with meningitis or group G in elderly
patients with wound infections or malignancies, also have been isolated.Bacillus
cereus has been implicated in intravenous drug abuse and intravenous
injections. Clostridium species have been implicated in association with bowel
carcinomas.
Gram-negative bacteria are other bacterial etiologies. E coli is the most common
among the gram-negative bacteria. Haemophilus influenzae, Neisseria meningitidis,
Klebsiella pneumoniae, Serratia species, and Pseudomonas aeruginosa also can
cause endogenous endophthalmitis.
Nocardia asteroides, Actinomyces species, and Mycobacterium tuberculosis are
acid-fast bacteria that may cause endogenous endophthalmitis.

Exogenous endophthalmitis

Organisms that reside at the conjunctiva, eyelid, or eyelashes and are introduced at
the time of surgery usually cause postoperative endophthalmitis.
Most cases of exogenous endophthalmitis develop postoperatively or after trauma to
the eye. In fact, postoperative endophthalmitis is the most common cause of the
disease. Of these cases, gram-positive organisms account for almost 90% of cases,
of which the majority are coagulase-negative Staphylococcus from the natural
conjunctival flora.[8]
The single most common cause of exogenous endophthalmitis is S
epidermidis,which is a normal flora of the skin and conjunctiva. Other common grampositive bacteria are S aureus and streptococcal species.
The most common gram-negative organisms associated with postoperative
endophthalmitis are P aeruginosa and Proteus and Haemophilus species.
Although very rare, many different fungi have caused postoperative endophthalmitis,
including Candida, Aspergillus, and Penicillium species.
The rates of endophthalmitis postoperatively after cataract surgery appear to be
declining in the last decade.[9, 10]
The use of intracameral antibiotics is associated with a decreased occurrence of
postoperative endophthalmitis.[11]

Traumatic endophthalmitis
Bacteria or fungi are introduced at the time of injury. Endophthalmitis can occur in up
to 13% of cases of penetrating injury to the globe. Since penetrating trauma usually
occurs in a nonsterile environment, most objects that strike the eye are contaminated
with multiple infectious agents.
The risk of developing traumatic endophthalmitis by foreign objects carrying soil or
vegetable matter is highest in rural settings. Staphylococcal, streptococcal,
andBacillus species usually cause traumatic endophthalmitis. [12] B cereus causes
much more infections in the traumatic population than in either of the other two
groups, and can cause serious infection. [13] A history of penetrating trauma with
intraocular foreign body contaminated with organic matter
implicates Bacillus species.[14]
Patients with open globe injuries are at risk of developing endophthalmitis.
Specifically, those with pure corneal injuries, intraocular foreign bodies, lens rupture,
or needle-related injuries have a higher incidence. [15]

Patients with larger lacerations, delay in time to repair of open globe, and those with
more virulent organisms tend to do worse than patients with traumatic etiology.[16]

Penunjang
The most important laboratory study for endophthalmitis is Gram stain and culture of
the aqueous and vitreous obtained by the ophthalmologist.
Real-time polymerase chain reaction (RT-PCR) has improved diagnostic results over
traditional culture.[17]
For endogenous endophthalmitis, other laboratory studies that may be performed
include the following:

Complete blood count with differential - Evaluating for signs of infection,

elevated white count, left shift
Erythrocyte sedimentation rate - Evaluating for rheumatic causes, chronic
infections, or malignancy. The ESR is often normal in cases of endophthalmitis.
Blood urea nitrogen - Evaluating for renal failure or patients at increased risk
Creatinine - Evaluating for renal failure or patients at increased risk