Endophthalmitis 

  • Author: Daniel J Egan, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Sep 19, 2011
 

Background

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.

Severe endophthalmitis. Image courtesy of Joan W. Severe endophthalmitis. Image courtesy of Joan W. Miller, MD, and Mehran Afshari, MD, Massachusetts Eye and Ear Infirmary, Boston, Mass.

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.

Next

Pathophysiology

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.

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).

Previous
Next

Epidemiology

Frequency

United States

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.

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.[2] Delay in the repair of a penetrating globe injury is correlated with increased risk of developing endophthalmitis.[3] 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.[4]

Previous
Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Daniel J Egan, MD  Associate Attending Physician, Department of Emergency Medicine, St Luke's Roosevelt Hospital Center

Daniel J Egan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jessica Radin Peters  MD, Attending Physician, Urgent Care Center, Newton-Wellesley Hospital

Jessica Radin Peters is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David A Peak, MD  Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard Lavely, MD, JD, MS, MPH  Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine

Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Douglas Lavenburg, MD  Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

  1. Taban M, Behrens A, Newcomb RL. Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. May 2005;123(5):613-20. [Medline].

  2. Boldt HC, Pulido JS, Blodi CF, et al. Rural endophthalmitis. Ophthalmology. Dec 1989;96(12):1722-6. [Medline].

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

  4. Lundstrom M, Wejde G, Stenevi U, Thorburn W, Montan P. Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology. May 2007;114(5):866-70. [Medline].

  5. Ness T, Pelz K, Hansen LL. Endogenous endophthalmitis: microorganisms, disposition and prognosis. Acta Ophthalmol Scand. Dec 2007;85(8):852-6. [Medline].

  6. Connell PP, O'Neill EC, Fabinyi D, et al. Endogenous endophthalmitis: 10-year experience at a tertiary referral centre. Eye (Lond). Jan 2011;25(1):66-72. [Medline].

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

  8. Stein JD, Grossman DS, Mundy KM, Sugar A, Sloan FA. Severe adverse events after cataract surgery among medicare beneficiaries. Ophthalmology. Sep 2011;118(9):1716-23. [Medline].

  9. Melo GB, Bispo PJ, Regatieri CV, Yu MC, Pignatari AC, Hofling-Lima AL. Incidence of endophthalmitis after cataract surgery (2002-2008) at a Brazilian university-hospital. Arq Bras Oftalmol. Dec 2010;73(6):505-7. [Medline].

  10. Alfaro DV, Roth D, Liggett PE. Posttraumatic endophthalmitis. Causative organisms, treatment, and prevention. Retina. 1994;14(3):206-11. [Medline].

  11. Miller JJ, Scott IU, Flynn HW Jr, et al. Endophthalmitis caused by Bacillus species. Am J Ophthalmol. 2008;145:883-8. [Medline].

  12. Verbraeken H, Rysselaere M. Post-traumatic endophthalmitis. Eur J Ophthalmol. Jan-Mar 1994;4(1):1-5. [Medline].

  13. Faghihi H, Hajizadeh F, Esfahani MR, et al. Posttraumatic Endophthalmitis: Report No. 2. Retina. Jul 19 2011;[Medline].

  14. Gupta A, Srinivasan R, Gulnar D, Sankar K, Mahalakshmi T. Risk factors for post-traumatic endophthalmitis in patients with positive intraocular cultures. Eur J Ophthalmol. Jul-Aug 2007;17:642-7. [Medline].

  15. Ng JQ, Morlet N, Pearman JW, Constable IJ, McAllister IL, Kennedy CJ. 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].

  16. 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. Arch Ophthalmol. Dec 1995;113(12):1479-96. [Medline].

  17. Albert DM, ed; Jakobiec FA. Endogenous endophthalmitis. In: Principles and Practice of Ophthalmology. Vol 5. W B Saunders Co; 1994:3120-3125.

  18. Albert DM, Jakobiec FA. Postoperative endophthalmitis. In: Principles and Practice of Ophthalmology. W B Saunders Co; 2000:2441-2462.

  19. Mandelbaum S, Forster RK. Postoperative endophthalmitis. Int Ophthalmol Clin. Summer 1987;27(2):95-106. [Medline].

  20. Michelson JB, Friedlaender MH. Endophthalmitis of drug abuse. Int Ophthalmol Clin. Summer 1987;27(2):120-6. [Medline].

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

  22. Parrish CM, O'Day DM. Traumatic endophthalmitis. Int Ophthalmol Clin. 1987;27(2):112-9. [Medline].

  23. Rowsey JJ, Jensen H, Sexton DJ. Clinical diagnosis of endophthalmitis. Int Ophthalmol Clin. Summer 1987;27(2):82-8. [Medline].

  24. Uka J, Minamoto A, Shimizu R. A five-year review of patients admitted with the diagnosis of bacterial endophthalmitis. Hiroshima J Med Sci. Jun 2005;54(2):47-51. [Medline].

  25. Wilhelmus KR. The pathogenesis of endophthalmitis. Int Ophthalmol Clin. Summer 1987;27(2):74-81. [Medline].

  26. Wilson FM 2d. Causes and prevention of endophthalmitis. Int Ophthalmol Clin. Summer 1987;27(2):67-73. [Medline].

  27. Wong JS, Chan TK, Lee HM, Chee SP. Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction. Ophthalmology. Aug 2000;107(8):1483-91. [Medline].

 
Previous
Next
 
Severe endophthalmitis. Image courtesy of Joan W. Miller, MD, and Mehran Afshari, MD, Massachusetts Eye and Ear Infirmary, Boston, Mass.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
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.