Postoperative Endophthalmitis Clinical Presentation

Updated: Jan 15, 2019
  • Author: Hemang K Pandya, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Presentation

History

Patients with acute postoperative endophthalmitis typically present within 6 weeks of intraocular surgery with moderate to severe eye pain and decreased vision.

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Physical

The hallmark findings on ophthalmic examination are posterior and anterior chamber inflammation. [12, 13, 14]

Hypopyon is present in most cases. [12, 13, 14]

Other important findings include conjunctival hyperemia and chemosis, corneal edema, wound abnormalities, and associated eyelid or orbital inflammation.

In rare circumstances, patients may develop chronic, infectious endophthalmitis months to years after intraocular surgery. These patients exhibit indolent inflammation, which is initially responsive to corticosteroids, but over time, become refractory to therapy. Although conjunctival hyperemia, corneal edema, and anterior and posterior chamber inflammation are often present, rapid deterioration of vision and hypopyon are not seen frequently. [15, 16]

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Causes

Risk factors for development of postoperative endophthalmitis may include the following:

  • Increased operative time, low volume (experienced) surgeon [17]

  • Posterior capsule rupture/vitreous loss [13, 14]

  • Retained lens fragments

  • Inadequate sterilization of the operative field

  • Contamination of surgical instruments

  • Inadequate wounds (eg, leaky), as in some cases of sutureless clear corneal cataract incisions and sutureless sclerotomies [5, 6, 18, 19]

In the EVS, a prospective randomized clinical trial that evaluated the management of acute postoperative (cataract extraction or secondary IOL implantation) endophthalmitis, the most common organisms isolated were coagulase-negative staphylococci (70%), Staphylococcus aureus (9.9%), and streptococci species (9.0%). Infections caused by gram-negative organisms were seen in 6% of cases. [1, 20]

Endophthalmitis following other types of intraocular surgery has a similar microbiological profile with the following exceptions:

  • In filtering bleb-associated cases, the most common offending species is Streptococcus, followed by Haemophilus influenzae and coagulase-negative staphylococci. [13, 21]

  • In chronic postoperative endophthalmitis, an important causative organism is Propionibacterium acnes, a slow-growing, gram-positive bacillus that is associated with a characteristic white, intracapsular plaque that develops weeks to months and years after cataract surgery. [15, 16, 22]

  • Coagulase-negative staphylococci, fungal species, and unusual gram-negative organisms also have been reported to cause chronic postoperative endophthalmitis. [13]

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Complications

The main complication associated with postoperative endophthalmitis is severe visual loss. This occurs most commonly in patients who develop infections from virulent organisms (non–coagulase-negative staphylococci, streptococci, and gram-negative organisms), receive delayed treatment, or have vision worse than hand motion at presentation. [1, 13, 20]

An important late complication of treatment of postoperative endophthalmitis remains retinal detachment. [27]  In a report from the EVS, retinal detachment can occur in 10% of patients after treatment. Possible factors involved include iatrogenic retinal tears at the time of vitreous tap, injection of antibiotics, vitrectomy, late tears associated with subtotal posterior vitrectomy, or just a consequence of the infection/inflammation and the secondary retinal necrosis. Prompt treatment of retinal detachment may result in good visual outcomes in select cases. [13]

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