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Endophthalmitis, Bacterial

Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Updated: Feb 12, 2009

Introduction

Background

Bacterial endophthalmitis is an inflammatory reaction of the intraocular fluids or tissues caused by microbial organisms.

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.

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.

Clinical

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
  • 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.
  • 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.
  • Filtering bleb associated: Clinical features are similar to acute postoperative infection with purulent bleb involvement.
  • Posttraumatic: History of trauma is present, and infection usually progresses rapidly.
• Endogenous source
  • No recent history of ocular surgery is present.
  • Confusion with delayed onset or chronic postoperative is possible if suspicion for endogenous route is not ruled out.
  • The symptoms are rarely bilateral.

Physical

• General findings
  • Visual acuity decreased below the level expected
  • Lid edema
  • Conjunctival hyperemia
  • Corneal edema
  • Anterior chamber cells and flare
  • Keratic precipitates
  • Hypopyon
  • Fibrin membrane formation
  • Vitritis
  • Loss of red reflex
  • Retinal periphlebitis if view of fundus possible
• Specific findings
  • Delayed onset or chronic: Occasionally, findings display a white plaque within the equator of the remaining lens capsule.
  • Filtering bleb associated: A purulent bleb is seen occasionally with areas of necrosis in the sclera from the use of antimetabolites.
  • Posttraumatic: Evidence of penetrating trauma is seen with the possibility of an intraocular foreign body.
  • Endogenous: Patient may appear systemically ill.

Causes

Causes are related to classification of exogenous and endogenous.

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

Differential Diagnoses

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.

Treatment

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 non–cataract-related endophthalmitis.
• When the inflammation is severe, systemic and periocular therapy may be used in non–cataract-induced, delayed onset, filtering bleb–associated, 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
  • Acute pseudophakic postoperative - When the presenting vision is light perception or worse
  • Delayed onset or chronic postoperative - If marked inflammation or a subcapsular plaque is identified, surgical removal is required.
  • 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.
  • Posttraumatic - If marked inflammation or rapid onset occurs
• Technique
  • 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.
  • 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.
  • 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

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

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

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.

Dosing

Adult

Topical: 50 mg/mL q1h
Intravitreal: 1 mg/0.1 mL
Periocular: 25 mg
Systemic: 1 g IV q12h

Pediatric

Topical: Administer as in adults
Intravitreal: Administer as in adults
Systemic: 10 mg/kg/dose IV q6h

Interactions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Corneal toxicity; in systemic administration ototoxicity, nephrotoxicity reversible neutropenia may occur; adjust dose in renal insufficiency; caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction

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.

Dosing

Adult

Topical: 50 mg/mL q1h
Intravitreal: 2.25 mg/0.1 mL
Periocular: 100 mg
Systemic: 1 g IV q12h

Pediatric

Not established

Interactions

Can cause false-positive results in glucose-urine testing with copper reduction test (Benedict or Fehling solution); false-negative results in ferricyanide test; positive Coombs test; nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

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.

Dosing

Adult

Topical: 13.6 mg/mL
Intravitreal: 0.4 mg/0.1 mL
Systemic: 75 mg/kg IV q12h

Pediatric

Administer as in adults

Interactions

Coadministration with other aminoglycosides, penicillins, cephalosporins, and amphotericin B increases nephrotoxicity; enhances effects of neuromuscular blocking agents; causes respiratory depression; irreversible hearing loss may occur with coadministration of loop diuretics

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not intended for long-term therapy; caution in patients with renal failure (not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission

Ciprofloxacin (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.

Dosing

Adult

Topical: 1 gtt qid to q1h
Systemic: 750 mg PO q12h

Pediatric

Not established

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Corticosteroids

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

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.

Dosing

Adult

1 gtt qid to q1h

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, fungal, or tubercular infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)

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.

Dosing

Adult

Intravitreal: 0.4 mg/0.1 mL

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; active bacterial, viral, or fungal infection

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use may increase hazard of secondary ocular infection; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)

Triamcinolone (Aristocort)

Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Dosing

Adult

Periocular: 40 mg

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use in decreased skin circulation; prolonged use, applications over large areas, and use of potent steroids and occlusive dressings may result in systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria

Cycloplegics

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.

Atropine (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.

Dosing

Adult

Topical: 1 gtt bid

Pediatric

Not established

Interactions

Coadministration with other anticholinergics have additive effects; pharmacologic effects of atenolol and digoxin may increase with atropine; antipsychotic effects of phenothiazines may decrease with this medication; tricyclic antidepressants with anticholinergic activity may increase effects of atropine

Contraindications

Documented hypersensitivity, thyrotoxicosis, narrow-angle glaucoma, and tachycardia

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with Down syndrome and/or children with brain damage to prevent hyperreactive response; caution also in coronary heart disease, tachycardia, congestive heart failure, cardiac arrhythmias, hypertension, peritonitis, ulcerative colitis, hepatic disease, and hiatal hernia with reflux esophagitis; in prostatic hypertrophy, prostatism can have dysuria and may require catheterization

Follow-up

Further Inpatient Care

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

Further Outpatient Care

• Patients should receive follow-up care on a daily basis. Clinical features indicating improvement include the following:
  • Reduced pain
  • Decreased inflammation and hypopyon
  • Increased red reflex
  • Retraction of any fibrin
  • Improved visual acuity
• If no improvement occurs in 48-72 hours, consider the following:
  • Repeat tap/biopsy and antibiotic injections
  • 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
  • Vancomycin 50 mg/mL 1 gtt qid to q1h
  • Ceftazidime 50 mg/mL 1 gtt qid to q1h
  • Prednisolone 1 gtt qid to q1h
  • Atropine 1 gtt bid

Deterrence/Prevention

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

Complications

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

Prognosis

• The prognosis depends on the following:
  • Duration of endophthalmitis
  • Time to treatment
  • Virulence of bacteria
  • Etiology of entry
  • Existing ocular diseases
• From the EVS, the percentage of patients achieving a final visual acuity of 20/100 or better were as follows:
  • Gram-positive, coagulase-negative micrococci - 84%
  • S aureus - 50%
  • Streptococci - 30%
  • Enterococci - 14%
  • 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.

Patient Education

• Direct patients to maintain hygienic practice after surgery.

Miscellaneous

Medicolegal Pitfalls

• Medicolegal problems usually occur when the expectations of the patient are not met. If the potential for infection and the risk of loss of vision are explained clearly to the patient, the risk for legal action may be avoided. The problem most often occurs in elective surgery (eg, cataract extraction) when patients expect improved vision but end with significant loss of vision and morbidity. Document the discussions in all cases.

Multimedia

Media file 1: Bacterial endophthalmitis. Hypopyon, 3 days after phacoemulsification.

Media file 2: Bacterial endophthalmitis. Retinopathy induced by Enterococcus faecalis endotoxin.

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Keywords

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

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.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors, David T Wong, MD, FRCS(C), and Hesham Lakosha, MBChB, MS, FRCS, to the development and writing of this article.

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