eMedicine Specialties > Ophthalmology > Globe

Endophthalmitis, Bacterial: Differential Diagnoses & Workup

Author: Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Contributor Information and Disclosures

Updated: Feb 12, 2009

Differential Diagnoses

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

Other Problems to Be Considered

Retained lens material following cataract surgery

Workup

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:
    • Blood culture
    • Sputum culture
    • Urine culture

Imaging Studies

  • B-scan ultrasound
    • Perform B-scan ultrasound of the posterior pole if view of fundus is poor.
    • Typically, choroidal thickening and ultrasound echoes in the anterior and posterior vitreous support the diagnosis.
    • Occasionally, another source of inflammation other than or in addition to bacteria, such as retained lens material, may be seen.
    • 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.
    • 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.
    • Two-dimensional echocardiogram
    • 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
    • A retrobulbar block or a sub-Tenon block with lidocaine with epinephrine is given.
    • 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.
    • 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.

More on Endophthalmitis, Bacterial

Overview: Endophthalmitis, Bacterial
Differential Diagnoses & Workup: Endophthalmitis, Bacterial
Treatment & Medication: Endophthalmitis, Bacterial
Follow-up: Endophthalmitis, Bacterial
Multimedia: Endophthalmitis, Bacterial
References
[ CLOSE WINDOW ]

References

  1. Aaberg TM Jr, Flynn HW Jr, Schiffman J, Newton J. Nosocomial acute-onset postoperative endophthalmitis survey. A 10-year review of incidence and outcomes. Ophthalmology. Jun 1998;105(6):1004-10. [Medline].

  2. Alfonso E, Crider J. Ophthalmic infections and their anti-infective challenges. Surv Ophthalmol. Nov 2005;50 Suppl 1:S1-6. [Medline].

  3. Ayata A, Uzun G, Unal M, Yildiz S, Bilge AH. Does hyperbaric oxygen therapy improve outcome in bacterial endophthalmitis?. Med Hypotheses. Sep 2008;71(3):470-1. [Medline].

  4. Barza M, Pavan PR, Doft BH, et al. Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. Arch Ophthalmol. Sep 1997;115(9):1142-50. [Medline].

  5. Bouza E, Grant S, Jordan C, Yook RH, Sulit HL. Bacillus cereus endogenous panophthalmitis. Arch Ophthalmol. Mar 1979;97(3):498-9. [Medline].

  6. Callegan MC, Gilmore MS, Gregory M, et al. Bacterial endophthalmitis: therapeutic challenges and host-pathogen interactions. Prog Retin Eye Res. Mar 2007;26(2):189-203. [Medline].

  7. Chan IM, Jalkh AE, Trempe CL, Tolentino FI. Ultrasonographic findings in endophthalmitis. Ann Ophthalmol. Aug 1984;16(8):778-84. [Medline].

  8. Chiquet C, Cornut PL, Benito Y, et al. Eubacterial PCR for bacterial detection and identification in 100 acute postcataract surgery endophthalmitis. Invest Ophthalmol Vis Sci. May 2008;49(5):1971-8. [Medline].

  9. Cohen SM, Flynn HW Jr, Murray TG, Smiddy WE. Endophthalmitis after pars plana vitrectomy. The Postvitrectomy Endophthalmitis Study Group. Ophthalmology. May 1995;102(5):705-12. [Medline].

  10. Costello P, Bakri SJ, Beer PM, et al. Vitreous penetration of topical moxifloxacin and gatifloxacin in humans. Retina. Feb 2006;26(2):191-5. [Medline].

  11. Deramo VA, Lai JC, Winokur J, Luchs J, Udell IJ. Visual outcome and bacterial sensitivity after methicillin-resistant Staphylococcus aureus-associated acute endophthalmitis. Am J Ophthalmol. Mar 2008;145(3):413-417. [Medline].

  12. Donahue SP, Kowalski RP, Jewart BH, Friberg TR. Vitreous cultures in suspected endophthalmitis. Biopsy or vitrectomy?. Ophthalmology. Apr 1993;100(4):452-5. [Medline].

  13. Endophthalmitis Vitrectomy Study Group. 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. Dec 1995;113(12):1479-96. [Medline].

  14. Flynn HW Jr, Pulido JS, Pflugfelder SC, et al. Endophthalmitis therapy: changing antibiotic sensitivity patterns and current therapeutic recommendations. Arch Ophthalmol. Feb 1991;109(2):175-6. [Medline].

  15. Forster RK. Etiology and diagnosis of bacterial postoperative endophthalmitis. Ophthalmology. Apr 1978;85(4):320-6. [Medline].

  16. Gan IM, Ugahary LC, van Dissel JT, et al. Intravitreal dexamethasone as adjuvant in the treatment of postoperative endophthalmitis: a prospective randomized trial. Graefes Arch Clin Exp Ophthalmol. Dec 2005;243(12):1200-5. [Medline].

  17. Garat M, Moser CL, Alonso-Tarres C, Martin-Baranera M, Alberdi A. Intracameral cefazolin to prevent endophthalmitis in cataract surgery: 3-year retrospective study. J Cataract Refract Surg. Nov 2005;31(11):2230-4. [Medline].

  18. Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF, Flynn HW Jr. Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol. Aug 1996;114(8):943-9. [Medline].

  19. Gregory M, Callegan MC, Gilmore MS. Role of bacterial and host factors in infectious endophthalmitis. Chem Immunol Allergy. 2007;92:266-75. [Medline].

  20. Han DP, Wisniewski SR, Wilson LA, et al. Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol. Jul 1996;122(1):1-17. [Medline].

  21. Hariprasad SM, Shah GK, Chi J, Prince RA. Determination of aqueous and vitreous concentration of moxifloxacin 0.5% after delivery via a dissolvable corneal collagen shield device. J Cataract Refract Surg. Nov 2005;31(11):2142-6. [Medline].

  22. Hariprasad SM, Shah GK, Mieler WF, et al. Vitreous and aqueous penetration of orally administered moxifloxacin in humans. Arch Ophthalmol. Feb 2006;124(2):178-82. [Medline].

  23. Irvine WD, Flynn HW Jr, Murray TG, Rubsamen PE. Retained lens fragments after phacoemulsification manifesting as marked intraocular inflammation with hypopyon. Am J Ophthalmol. Nov 15 1992;114(5):610-4. [Medline].

  24. Iyer MN, He F, Wensel TG, Mieler WF, Benz MS, Holz ER. Clearance of intravitreal moxifloxacin. Invest Ophthalmol Vis Sci. Jan 2006;47(1):317-9. [Medline].

  25. Katz HR, Masket S, Lane SS, et al. Absorption of topical moxifloxacin ophthalmic solution into human aqueous humor. Cornea. Nov 2005;24(8):955-8. [Medline].

  26. Kowalski RP, Romanowski EG, Mah FS, Yates KA, Gordon YJ. Intracameral Vigamox (moxifloxacin 0.5%) is non-toxic and effective in preventing endophthalmitis in a rabbit model. Am J Ophthalmol. Sep 2005;140(3):497-504. [Medline].

  27. Kunimoto DY, Das T, Sharma S, et al. Microbiologic spectrum and susceptibility of isolates: part I. Postoperative endophthalmitis. Endophthalmitis Research Group. Am J Ophthalmol. Aug 1999;128(2):240-2. [Medline].

  28. Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg. Feb 2006;32(2):324-33. [Medline].

  29. Mandelbaum S, Forster RK, Gelender H, Culbertson W. Late onset endophthalmitis associated with filtering blebs. Ophthalmology. Jul 1985;92(7):964-72. [Medline].

  30. Mieler WF, Ellis MK, Williams DF, Han DP. Retained intraocular foreign bodies and endophthalmitis. Ophthalmology. Nov 1990;97(11):1532-8. [Medline].

  31. Miller JJ, Scott IU, Flynn HW Jr, Smiddy WE, Newton J, Miller D. Acute-onset endophthalmitis after cataract surgery (2000-2004): incidence, clinical settings, and visual acuity outcomes after treatment. Am J Ophthalmol. Jun 2005;139(6):983-7. [Medline].

  32. Ng JQ, Morlet N, Pearman JW, et al. Management and outcomes of postoperative endophthalmitis since the endophthalmitis vitrectomy study: the Endophthalmitis Population Study of Western Australia (EPSWA)'s fifth report. Ophthalmology. Jul 2005;112(7):1199-206. [Medline].

  33. Okada AA, Johnson RP, Liles WC, D'Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective study. Ophthalmology. May 1994;101(5):832-8. [Medline].

  34. Packer AJ, Weingeist TA, Abrams GW. Retinal periphlebitis as an early sign of bacterial endophthalmitis. Am J Ophthalmol. Jul 1983;96(1):66-71. [Medline].

  35. Prydal JI, Jenkins DR, Lovering A, Watts A. The pharmacokinetics of linezolid in the non-inflamed human eye. Br J Ophthalmol. Nov 2005;89(11):1418-9. [Medline].

  36. Rathinam SR, Rao NA. Sympathetic ophthalmia following postoperative bacterial endophthalmitis: a clinicopathologic study. Am J Ophthalmol. Mar 2006;141(3):498-507. [Medline].

  37. Smiddy WE, Smiddy RJ, Ba'Arath B, et al. Subconjunctival antibiotics in the treatment of endophthalmitis managed without vitrectomy. Retina. Sep 2005;25(6):751-8. [Medline].

  38. Soheilian M, Rafati N, Mohebbi MR, et al. Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2. Arch Ophthalmol. Apr 2007;125(4):460-5. [Medline].

  39. Somani S, Grinbaum A, Slomovic AR. Postoperative endophthalmitis: incidence, predisposing surgery, clinical course and outcome. Can J Ophthalmol. Aug 1997;32(5):303-10. [Medline].

  40. Suzuki T, Uno T, Kawamura Y, Joko T, Ohashi Y. Postoperative low-grade endophthalmitis caused by biofilm-producing coccus bacteria attached to posterior surface of intraocular lens. J Cataract Refract Surg. Oct 2005;31(10):2019-20. [Medline].

  41. Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE. Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System. Ophthalmology. Oct 1993;100(10):1468-74. [Medline].

  42. van Kooij B, Rothova A, de Vries P. The pros and cons of intravitreal triamcinolone injections for uveitis and inflammatory cystoid macular edema. Ocul Immunol Inflamm. Apr 2006;14(2):73-85. [Medline].

  43. Winward KE, Pflugfelder SC, Flynn HW Jr, Roussel TJ, Davis JL. Postoperative Propionibacterium endophthalmitis. Treatment strategies and long-term results. Ophthalmology. Apr 1993;100(4):447-51. [Medline].

  44. Wolner B, Liebmann JM, Sassani JW, Ritch R, Speaker M, Marmor M. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5-fluorouracil. Ophthalmology. Jul 1991;98(7):1053-60. [Medline].

  45. Zhang YQ, Wang WJ. Treatment outcomes after pars plana vitrectomy for endogenous endophthalmitis. Retina. Sep 2005;25(6):746-50. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

bacterial endophthalmitis, bacterial infection in the eye, bacteria in the eye, bacterial eye infection, eye infection, ocular infection

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society
Disclosure: WebMD/eMedicine Salary Employment

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

R Christopher Walton, MD, Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital
R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.