Background

Bacterial endophthalmitis is an inflammatory reaction of the intraocular fluids or tissues

caused by microbial organisms.

Bacterial endophthalmitis. Retinopathy induced by Enterococcus faecalis endotoxin.

Bacterial endophthalmitis. Hypopyon, 3 days after phacoemulsification.

Pathophysiology
The entry of bacteria into the eye occurs from a breakdown of the ocular barriers.
Penetration through the cornea or sclera results in an exogenous insult to the eye. If the
entry is through the vascular system, then an endogenous route occurs. After the bacteria
gain entry into the eye, rapid proliferation occurs.

The vitreous acts as a superb medium for bacteria growth, and, in the past, animal
vitreous was used as a culture medium. Bacteria, as foreign objects, incite an
inflammatory response. The cascade of inflammatory products occurs resulting in an
increase in the blood-ocular barrier breakdown and an increase in inflammatory cell
recruitment. The damage to the eye occurs from the breakdown of the inflammatory cells
releasing the digestive enzymes as well as the possible toxins produced by the bacteria.
Destruction occurs at all tissue levels that are in contact with the inflammatory cells and
toxins.
Epidemiology
Frequency

United States

Incidence after intraocular surgery is less than 0.1%. Incidence of culture-proven

endophthalmitis is similar to that of extracapsular cataract extraction and
phacoemulsification.

Mortality/Morbidity

If not properly treated, a risk of complete vision loss and the possibility of persistent
ocular pain exist. Infection very rarely spreads beyond the confines of the sclera and
tracks into surrounding tissue structures.

History
The clinical presentation is dependent on the route of entry, the infecting organism, and
the duration of the disease. In general, patients complain of a decrease in vision, often
with a red eye. Most patients also may complain of a deep ocular pain. Classification is
based on routes of entry.

Exogenous source
o Acute postoperative (< 6 wk postoperative)
Infection usually occurs 2-10 days after surgery.
Patients present with visual loss greater than expected in the usual
postoperative course.
Ocular pain is seen in 75% of patients.
The use of postoperative antibiotic and anti-inflammatory drugs
may blunt the severity of the disease and possibly delay medical
attention.
o Delayed onset or chronic pseudophakic postoperative (>6 wk
postoperative)
Patients typically present with mild-to-moderate inflammatory red
eye, reduced vision, and photophobia.
Chronic indolent course is present.
Patients may be diagnosed with idiopathic uveitis and treated with
topical steroids with temporary improvement.
Fungal species must be ruled out.
o Filtering bleb associated: Clinical features are similar to acute
postoperative infection with purulent bleb involvement.
o Posttraumatic: History of trauma is present, and infection usually
progresses rapidly.
o
 Endogenous source
o No recent history of ocular surgery is present.
o Confusion with delayed onset or chronic postoperative is possible if
suspicion for endogenous route is not ruled out.
o The symptoms are rarely bilateral.

Physical
General findings
o Visual acuity decreased below the level expected
o Lid edema
o Conjunctival hyperemia
o Corneal edema
o Anterior chamber cells and flare
o Keratic precipitates
o Hypopyon
o Fibrin membrane formation
o Vitritis
o Loss of red reflex
o Retinal periphlebitis if view of fundus possible

Specific findings
o Delayed onset or chronic: Occasionally, findings display a white plaque
within the equator of the remaining lens capsule.
o Filtering bleb associated: A purulent bleb is seen occasionally with areas
of necrosis in the sclera from the use of antimetabolites.
o Posttraumatic: Evidence of penetrating trauma is seen with the possibility
of an intraocular foreign body.
o Endogenous: Patient may appear systemically ill.

Causes
Causes are related to classification of exogenous and endogenous.

Exogenous
o Ocular surgical procedure - Increased risk when complications arise
o Trauma
o Ocular surface infection (eg, corneal ulcer)
o Filtering bleb associated - Use of antimetabolites or contaminated contact
lenses
Endogenous
o Septicemia
o Patients who are debilitated
 o Indwelling catheters
o Intravenous drug use
Bacteria involved include the following:
o Acute pseudophakic postoperative - Coagulase-negative staphylococci,
Staphylococcus aureus, and Streptococcus, Enterococcus, and gram-
negative species
o Delayed onset or chronic pseudophakic postoperative -Propionibacterium
acnes, and coagulase-negative and Corynebacterium species
o Filtering bleb associated -Streptococcus and Staphylococcus species and
Haemophilus influenzae
o Posttraumatic Bacillus and Staphylococcus species
o Endogenous -S aureus, Escherichia coli, and Streptococcus species

Differentials
Acute Retinal Necrosis
Ankylosing Spondylitis
Cataract, Traumatic
Endophthalmitis, Fungal
Foreign Body, Intraocular
Hemorrhage, Vitreous
HLA-B27 Syndromes
Hyphema
Ocular Manifestations of Syphilis
Sarcoidosis
Uveitis, Anterior, Granulomatous
Uveitis, Anterior, Nongranulomatous
Uveitis, Intermediate
Vitreous Wick Syndrome

Laboratory Studies
Perform culture and sensitivity studies on aqueous and vitreous samples to
determine the type of organism and antibiotic sensitivity.
If endogenous bacterial endophthalmitis is suspected, a systemic workup for the
source is required. This workup includes the following
o Blood culture
o Sputum culture
o Urine culture

Imaging Studies
B-scan ultrasound
o Perform B-scan ultrasound of the posterior pole if view of fundus is poor.
 o Typically, choroidal thickening and ultrasound echoes in the anterior and
posterior vitreous support the diagnosis.
o Occasionally, another source of inflammation other than or in addition to
bacteria, such as retained lens material, may be seen.
o The ultrasound is also important to provide a baseline prior to intraocular
intervention and to assess the posterior vitreous face and areas of possible
traction.
o Rarely, a retinal detachment is seen concurrently with endophthalmitis.
A CT scan rarely is performed unless trauma is involved. Thickening of the sclera
and uveal tissues associated with various degree of increased density in the
vitreous and periocular soft tissue structures may be seen.
If an endogenous route is considered, perform other imaging modalities to rule
out potential sources.
o Two-dimensional echocardiogram
o Chest x-ray

Procedures
Anterior chamber tap: A 30-gauge needle on a tuberculin syringe is used to obtain
a 0.1 cc sample under topical anesthesia through the limbus.
Vitreous tap
o A retrobulbar block or a sub-Tenon block with lidocaine with epinephrine
is given.
o A sub-Tenon block has the advantage over a retrobulbar block because it
does not create increased intraocular pressure that may cause recent
surgical wounds to open.
o A 21-gauge needle on a tuberculin syringe is used to obtain an adequate
vitreous sample of 0.1-0.2 cc. Smaller gauge needles may be used but with
increasing difficulty to create the aspiration vacuum necessary to obtain a
sample.
Vitreous biopsy: A 23-gauge vitrectomy cutter may be used if available.

Medical Care
Bacterial endophthalmitis is an ocular emergency, and urgent treatment is required to
reduce the potential of significant visual loss.

All patients should have therapy consisting of intravitreal and topical antibiotics,
topical steroids, and cycloplegics.
The Endophthalmitis Vitrectomy Study (EVS) identified that the use of periocular
and intravenous antibiotics are not required in endophthalmitis following cataract
surgery. Medical therapy was found to be statistically as effective as surgical
intervention when the presenting vision was hand motion or better. Use caution in
interpreting the data from the EVS; apply it cautiously to noncataract-related
endophthalmitis.
 When the inflammation is severe, systemic and periocular therapy may be used in
noncataract-induced, delayed onset, filtering blebassociated, and posttraumatic
endophthalmitis.
In endogenous endophthalmitis, systemic, topical, and possibly periocular therapy
is usually required.

Surgical Care
Surgical intervention is usually performed urgently except in the delayed onset category
where elective surgery may suffice.

Indications for surgical therapy

o Acute pseudophakic postoperative - When the presenting vision is light
perception or worse
o Delayed onset or chronic postoperative - If marked inflammation or a
subcapsular plaque is identified, surgical removal is required.
o Filtering bleb associated - If marked inflammation is present. Take care
not to disturb the bleb if some function still exists. To allow the possibility
of a shunt valve to be placed at a later time, make an attempt to minimize
the disturbance to the superior conjunctiva. If the patient is aphakic,
performing the pars plana vitrectomy from the temporal side using a
limbal approach may be required.
o Posttraumatic - If marked inflammation or rapid onset occurs
Technique
o A 3-port core pars plana vitrectomy with intravitreal antibiotic injections is
performed.If visualization is poor from anterior segment pathology, then a
2-port limited pars plana vitrectomy or endoscopic guided 3-port pars
plana vitrectomy may be performed.
o An increased risk for retinal tears and detachments occur when the
vitreous close to the retina is removed aggressively due to the higher
probability of retinal necrosis.
o Intravitreal antibiotics usually are given after the completion of the
vitrectomy; however, if an air-fluid exchange is to be performed, the
antibiotics may be mixed into the vitrectomy solution. Dilute the
antibiotics in the vitrectomy solution carefully to prevent possible toxic
retinopathy from incorrect dosages.

Consultations
In most exogenous cases of endophthalmitis, the ophthalmologist may manage the
case sufficiently; however, in cases of less common or extremely virulent
bacteria, consulting an infectious disease specialist may aid in the selection of
antibiotics.
When endogenous cases of endophthalmitis are suspected, an internist should be
consulted to look for a source.
Medication Summary
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to
prevent complications. Various routes for drug administration are available. Intravitreous
is the most effective.

Antibiotics
Class Summary

Therapy must be comprehensive and cover all likely pathogens in the context of this
clinical setting.

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Vancomycin (Vancocin, Vancoled, Lyphocin)

Potent antibiotic directed against gram-positive organisms and active against

Enterococcus species. Indicated for patients who cannot receive or have failed to respond
to penicillins and cephalosporins or have infections with resistant staphylococci.

To avoid toxicity, current recommendation is to assay vancomycin trough levels after

third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in
patients diagnosed with renal impairment. DOC for gram-positive organisms.

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Ceftazidime (Ceptaz, Fortaz, Tazicef, Tazidime)

First-line choice for intravitreal gram-negative coverage. Third-generation cephalosporin

with broad-spectrum, gram-negative activity; lower efficacy against gram-positive
organisms; higher efficacy against resistant organisms. Arrests bacterial growth by
binding to one or more penicillin-binding proteins.

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Amikacin (Amikin)
Second-line choice for intravitreal injection for gram-negative coverage. For gram-
negative bacterial coverage of infections resistant to gentamicin and tobramycin.
Effective against Pseudomonas aeruginosa.

Irreversibly binds to 30S subunit of bacterial ribosomes; blocks recognition step in

protein synthesis; causes growth inhibition. Use the patient's IBW for dosage calculation.

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Ciprofloxacin ophthalmic (Cipro, Ciloxan)

Fluoroquinolone with activity against pseudomonas, streptococci, MRSA, S epidermidis,

and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial
DNA synthesis, and consequently growth. Provides gram-positive coverage. Uncertain
benefit in noncataract causes.

Corticosteroids
Class Summary

Have anti-inflammatory properties and cause profound and varied metabolic effects.
Corticosteroids modify the body's immune response to diverse stimuli.

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Prednisolone acetate (Pred Forte)

Treats acute inflammations following eye surgery or other types of insults to eye.

Decreases inflammation and corneal neovascularization. Suppresses migration of

polymorphonuclear leukocytes and reverses increased capillary permeability.

In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if

signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be
reduced, but advise patients not to discontinue therapy prematurely. Dosage dependent on
severity of inflammation.

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Dexamethasone (Ocu-Dex)
For various allergic and inflammatory diseases. Decreases inflammation by suppressing
migration of polymorphonuclear leukocytes and reducing capillary permeability.
Optional; clinical data are controversial on benefit.

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Triamcinolone (Aristocort)

Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by

suppressing migration of polymorphonuclear leukocytes and reversing capillary
permeability.

Cycloplegics
Class Summary

Reduces ciliary spasm that may cause pain. Cycloplegic agents are also mydriatics, and
the practitioner should make sure that the patient does not have glaucoma. This
medication could provoke an acute angle-closure attack.

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Atropine ophthalmic (Isopto, Atropair, Atropisol)

DOC; acts at parasympathetic sites in smooth muscle to block response of sphincter

muscle of iris and muscle of ciliary body to acetylcholine, causing mydriasis and
cycloplegia.

Further Inpatient Care

Patients may be admitted or may be treated as outpatients depending on the
following:
o Severity of endophthalmitis and treatment modalities
o Underlying systemic diseases
o Patient reliability and compliance

Further Outpatient Care

 Patients should receive follow-up care on a daily basis. Clinical features
indicating improvement include the following:
o Reduced pain
o Decreased inflammation and hypopyon
o Increased red reflex
o Retraction of any fibrin
o Improved visual acuity
If no improvement occurs in 48-72 hours, consider the following:
o Repeat tap/biopsy and antibiotic injections
o Vitrectomy and injection of antibiotics, if no previous vitrectomy exists
If view is poor, B-scan ultrasound is useful to rule out retinal detachment.

Inpatient & Outpatient Medications

Topical antibiotic coverage with dosage dependent on severity
o Vancomycin 50 mg/mL 1 gtt qid to q1h
o Ceftazidime 50 mg/mL 1 gtt qid to q1h
o Prednisolone 1 gtt qid to q1h
o Atropine 1 gtt bid

Deterrence/Prevention
Identify high-risk patients before elective surgery
o Blepharitis
o Abnormal lacrimal drainage
o Active infection elsewhere
Preparation of operative field
o Prep with 5-10% povidone-iodine solution in preoperative area
o Prep with 5-10% povidone-iodine immediately before draping and allow
solution to dry
o Drape to cover lashes and lid margins
Prophylactic topical and/or periocular antibiotics[22, 36]
Prophylactic intravitreal antibiotics in trauma cases

Complications
Retinal necrosis
Retinal detachment
o Retinal necrosis
o Vitreous tap
o Vitrectomy
Increased intraocular pressure
Retinal vascular occlusion
Optic neuropathy
 Panophthalmitis
Hypotony
o Ciliary body shutdown
o Wound leakage
o Retinal detachment
o Cyclodialysis cleft
o Medication

Prognosis
The prognosis depends on the following:
o Duration of endophthalmitis
o Time to treatment
o Virulence of bacteria
o Etiology of entry
o Existing ocular diseases
From the EVS, the percentage of patients achieving a final visual acuity of 20/100
or better were as follows:
o Gram-positive, coagulase-negative micrococci - 84%
o S aureus - 50%[37]
o Streptococci - 30%
o Enterococci - 14%
o Gram-negative organisms - 56%
A statistically significant number (P < 0.001) of poorer visual outcomes occurred
with a positive Gram stain or when bacteria other than gram-positive, coagulase-
negative cocci were found.[21]

Patient Education
Direct patients to maintain hygienic practice after surgery.