Endophthalmitis

doi:10.1016/S0039-6257(98)00036-8

Survey of Ophthalmology

Volume 43, Issue 3, November–December 1998, Pages 193-224

https://doi.org/10.1016/S0039-6257(98)00036-8 Get rights and content

Abstract

Endophthalmitis is an inflammatory reaction of intraocular fluids or tissues. Infectious endophthalmitis is one of the most serious complications of ophthalmic surgery. Occasionally, infectious endophthalmitis is the presenting feature of an underlying systemic infection. Successful management of infectious endophthalmitis depends on timely diagnosis and institution of appropriate therapy. Recognition of the different clinical settings in which endophthalmitis occurs and awareness of the highly variable presentation it may have facilitate timely diagnosis. Biopsy of intraocular fluid/tissue is the only method that permits reliable diagnosis and treatment. The different presenting clinical settings, a rational approach to diagnosis (i.e., when, what, and how to biopsy), and the treatment of infectious endophthalmitis are reviewed.

Section snippets

Postoperative endophthalmitis

Postoperative infectious endophthalmitis can be encountered after any intraocular procedure. The incidence of infectious endophthalmitis after cataract surgery, for example, has been estimated to be 0.07% to 0.13%.2, 152, 165, 245 The incidence of endophthalmitis after pars plana vitrectomy is 0.046% to 0.07%.2, 69 In a meta-analysis of published literature, the pooled percentage of eyes experiencing endophthalmitis after cataract surgery (weighted by the sample size and, when pertinent, by

Clinical Findings

Postoperative infectious endophthalmitis that occurs within 6 weeks of surgery is classified as acute. Initial intraocular signs and symptoms may include decreased visual acuity, afferent pupillary defect, pain, hypopyon, corneal edema, corneal infiltrate, fibrinoid anterior chamber response, vitreous inflammation, retinitis, and/or retinal periphlebitis. External signs of inflammation, such as ciliary injection, chemosis, and lid edema, may be present. If infection has spread to the orbit,

Clinical Findings

The postoperative course of patients undergoing trabeculectomy may be complicated by the development of endophthalmitis weeks to years after surgery and has been associated with the concomitant presence of a functioning conjunctival filtering bleb. The incidence of endophthalmitis after glaucoma filtering surgery is estimated to be between 0.061% and 1.80%.2, 165 There are two types of infection that occur after glaucoma filtration surgery: blebitis, which describes a presumed bleb infection

Clinical Findings

Endogenous infectious endophthalmitis is less common than exogenous endophthalmitis and is usually seen in debilitated or immunocompromised patients or in patients with a history of intravenous drug abuse.107, 128 Endogenous endophthalmitis is the result of hematogenous spread of organisms to the eye from a site of infection elsewhere in the body or from contaminated catheters or needles. Endophthalmitis occurs at an average annual incidence of only about 5 in 10,000 hospitalized patients, and

Diagnosis

Once the possibility of infectious endophthalmitis is considered, it is of foremost importance to begin diagnostic and therapeutic management promptly. Appropriate workup varies with the intensity of inflammation and the category of infection.

Intraocular Antibiotics

Table 7 lists the drugs and doses used in the EVS; Table 8 summarizes our recommendations. Administration of intravitreal antibiotics is the mainstay of treatment of acute postoperative endophthalmitis. The intraocular concentration of antibiotics after intravitreal injection is greater than that achieved by any other modality.29, 101 The infection is almost always seated in the vitreous cavity, and other routes of drug administration, in particular topical and subconjunctival, generally do not

Conclusion

Effective treatment of infectious endophthalmitis depends on early recognition of the various clinical presentations (postoperative, endogenous, posttraumatic), as timing of therapy is an important factor in visual outcome.5, 16, 45, 164 It is helpful to distinguish “acute” from “chronic” presentations in determining a management plan. Ultimately, biopsy is the only reliable way to diagnose and treat postoperative uveitis. When, what, and how to biopsy and treat postoperative uveitis depends on

Acknowledgements

The authors acknowledge the expert secretarial assistance of Mary Felder and the photographic assistance of Maxine Wanner, Ilene Sugino, and Evan Wolf, MS IV, PhD.

References (319)

T.M. Aaberg et al.
Nosocomial acute-onset postoperative endophthalmitis survey
Ophthalmology
(1998)
J.C. Affeldt et al.
Microbial endophthalmitis resulting from ocular trauma
Ophthalmology
(1987)
H.E. Aguilar et al.
Comparative treatment of experimental Staphylococcus aureus endophthalmitis
Am J Ophthalmol
(1996)
D.M. Albert et al.
A historical review of sympathetic ophthalmia and its epidemiology
Surv Ophthalmol
(1989)
D.V. Alfaro et al.
The effect of trauma on the ocular penetration of intravenous ciprofloxacin
Am J Ophthalmol
(1996)
S.D. Allen et al.
Current issues and problems in dealing with anaerobes in the clinical laboratory
Clin Lab Med
(1995)
M. Amon et al.
Long-terms results and biocompatibility of heparin-surface-modified intraocular lenses
J Cataract Refract Surg
(1993)
A. Antonello et al.
Successful treatment of Bacillus alvei endophthalmitis
Am J Ophthalmol
(1989)
R.G. Ariyasu et al.
Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair
Am J Ophthalmol
(1995)
C.D. Armeniades et al.
Effect of incision length, location, and shape on local corneoscleral deformation during cataract surgery
J Cataract Refract Surg
(1990)

A.K. Arsan et al.

Acute endophthalmitis outbreak after cataract surgery

J Cataract Refract Surg

(1996)

R.F. Beatty et al.

Anaerobic endophthalmitis caused by Propionibacterium acnes

Am J Ophthalmol

(1986)

P.M. Beer et al.

Complete visual recovery after Bacillus cereus endophthalmitis in a child

Am J Ophthalmol

(1990)

B.B. Berger

Endophthalmitis complicating neonatal group B streptococcal septicemia

Am J Ophthalmol

(1981)

D.A. Boes et al.

Effects of povidone-iodine chemical preparation and saline irrigation on the perilimba flora

Ophthalmology

(1992)

G.M. Bohigian et al.

Factors associated with a poor visual result in endophthalmitis

Am J Ophthalmol

(1986)

H.C. Boldt et al.

Rural endophthalmitis

Ophthalmology

(1989)

A.N. Carlson et al.

Intraocular lens complications requiring removal or exchange

Surv Ophthalmol

(1998)

S.J. Chen et al.

Endogenous Candida endophthalmitis after induced abortion

Am J Ophthalmol

(1998)

S. Chen et al.

Xanthomonas maltophilia endophthalmitis after implantation of sustained-release ganciclovir (letter)

Am J Ophthalmol

(1992)

A.M. Chien et al.

Propionibacterium acnes endophthalmitis after intracapsular cataract extraction

Ophthalmology

(1992)

M. Chishti et al.

Spontaneous rupture of anterior lens capsule (phacoanaphylactic endophthalmitis)

Am J Ophthalmol

(1970)

T.A. Ciulla et al.

Blebitis, early endophthalmitis and late endophthalmitis after glaucoma filtering surgery

Ophthalmology

(1997)

S.M. Cohen et al.

Intraocular fluid cultures after primary pars plana vitrectomy

Am J Ophthalmol

(1992)

S.M. Cohen et al.

Endophthalmitis after pars plana vitrectomy

Ophthalmology

(1995)

A. Cusumano et al.

Mycotic infection of the capsular bag in postoperative endophthalmitis

J Cataract Refract Surg

(1991)

D.J. D’Amico et al.

Comparative toxicity of intravitreal aminoglycoside antibiotics

Am J Ophthalmol

(1985)

J.L. Davis

Intravenous antibiotics for endophthalmitis

Am J Ophthalmol

(1996)

J.B. Dickey et al.

Anterior chamber aspirate cultures after uncomplicated cataract surgery

Am J Ophthalmol

(1991)

B.H. Doft et al.

Additional procedures after the initial vitrectomy or tap-biopsy in the Endophthalmitis Vitrectomy Study

Ophthalmology

(1998)

S.P. Donahue et al.

Vitreous cultures in suspected endophthalmitis

Ophthalmology

(1993)

E.D. Donnenfeld et al.

Penetration of topically applied ciprofloxacin, norfloxacin, and ofloxacin into the aqueous humor

Ophthalmology

(1994)

W.T. Driebe et al.

Pseudophakic endophthalmitisDiagnosis and management

Ophthalmology

(1986)

A. El-Massry et al.

Aminoglycoside levels in the rabbit vitreous cavity after intravenous administration

Am J Ophthalmol

(1996)

R.A. Elston et al.

Postoperative endophthalmitis

J Hosp Infect

(1991)

T.M. Aaberg et al.

Intraocular ceftazidime as an alternative to the aminoglycosides in the treatment of endophthalmitis

Arch Ophthalmol

(1994)

Abramowicz M (ed): Med Lett Drugs Ther 34:49–56,...

H.E. Aguilar et al.

Vitreous cavity penetration of ceftazidime after intravenous administration

Retina

(1995)

D.V. Alfaro et al.

Intravenous cefazolin in penetrating eye injuries. I. Effects of trauma and multiple doses on intraocular delivery

Graefes Arch Clin Exp Ophthalmol

(1994)

D.V. Alfaro et al.

Intravenous cefazolin in penetrating eye injuriestreatment of experimental posttraumatic endophthalmitis

Retina

(1993)

E.C. Alfonso et al.

Controversies in endophthalmitis preventionthe risk of emerging resistance to vancomycin

Arch Ophthalmol

(1995)

B.D.S. Allan et al.

Strategies for management of microbial keratitis

Br J Ophthalmol

(1995)

M.V. Antworth et al.

Bacillus cereus posttraumatic endophthalmitiscase report indicating need for prompt, aggressive treatment

Vitreoretinal Surg Tech

(1992)

L. Apt et al.

Chemical preparation of the eye in ophthalmic surgery. III. Effect of povidine-iodine on the conjunctiva

Arch Ophthalmol

(1984)

R.G. Ariyasu et al.

Intraoperative bacterial contamination of the aqueous humor

Ophthalmic Surg

(1993)

I. Ashkenazi et al.

Risk factors associated with late infection of filtering blebs and endophthalmitis

Ophthalmic Surg

(1991)

J.J. Augsburger et al.

Fine needle aspiration biopsy of solid intraocular tumorsindications, instrumentation, and techniques

Ophthalmic Surg

(1984)

R.S. Ayyala et al.

Recurrent endophthalmitis after cataract surgery with a scleral-tunnel incision

Cornea

(1998)

Kapusnik-Uner JE, Sande MA, Chambers HF. Atimicrobial agents: tetracyclines, chloramphenicol, erythromycin, and...

T.L. Bannerman et al.

The source of coagulase-negative staphylococci in the Endophthalmitis Vitrectomy Study

Arch Ophthalmol

(1997)

Cited by (286)

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives
2023, Progress in Retinal and Eye Research
Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment.
Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.
Proteomic landscape of extracellular vesicles in human retinal cells infected with Staphylococcus aureus and Pseudomonas aeruginosa: Role in endophthalmitis
2023, Experimental Cell Research
Extracellular Vesicles (EVs) have evolved as a promising entity for developing diagnostic and therapeutic biomarkers. We profiled global EV proteome of EVs from Human retinal cells (ARPE-19) infected with S. aureus and P. aeruginosa. EVs were isolated by ultracentrifugation and subjected to LC-MS/MS for proteome analysis. In S. aureus infection, sequest identified 864 proteins, of which 81 were differentially expressed in comparison to control. Similarly, in P. aeruginosa infection, of 516 proteins identified, 86 were differentially expressed. Additionally, 38 proteins were exclusive to infected sets. KEGG and Gene Ontology revealed crucial dysregulated pathways involving proteins such as complement cascades, annexins and calpain-2, all playing major role in the pathogenesis of the disease. This study provides insight into the global EV proteome of S. aureus and P. aeruginosa endophthalmitis with their functional correlation and distinctive pattern of expression. Calpain-2 and C8a are attractive biomarkers for bacterial endophthalmitis.
Cataracts
2023, The Lancet
94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.
Traumatic Injuries of the Eye, Ear, Nose, and Throat
2023, Physician Assistant Clinics
Characterization and proteome profiling of extracellular vesicles in a murine model of Staphylococcus aureus endophthalmitis
2022, Microbes and Infection
Endophthalmitis is a vision-threatening complication of intraocular surgery or penetrating injury of which Staphylococcus aureus is an important etiological agent. Extracellular vesicles (EVs) hold a tremendous possibility for developing diagnostic and therapeutic biomarkers due to their role in the pathogenesis of various infections. The aim of this study was to characterise the protein cargo of EVs, isolated from a murine (C57BL/6) model of S. aureus endophthalmitis by LC–MS/MS. Contralateral eye injected with sterile media served as control and both eyes were enucleated after 24 h, followed by extraction of EVs by ultracentrifugation. EVs were characterized by DLS and western blotting with tetraspanin markers, CD9 and CD81 and quantified by ExoCet quantification kit. Proteomic analysis identified 1964 proteins (FDR ≤ 0.01) in EVs from infected mice eyes, of which 40 proteins varied significantly in their amounts in comparison to EVs obtained from control eyeballs (P-value ≤ 0.05). The results of this study provide insight into the global EV proteome of S. aureus endophthalmitis with their functional correlation and differential protein amounts between infected and control set. Annexin A5, cathepsin D and C5a play a pivotal role in disease pathogenesis and could possibly play a role as a prognostic marker in endophthalmitis.
Proteome profiling of Extracellular Vesicles in Pseudomonas aeruginosa endophthalmitis: Prognostic and therapeutic significance in a mouse model
2022, Experimental Cell Research
Endophthalmitis is a sight-threatening infection and a serious consequence of complications during intraocular surgery or penetrating injury of which Pseudomonas aeruginosa is an important etiology. Extracellular vesicles (EVs) have evolved as a promising entity for developing diagnostic and therapeutic biomarkers due to their involvement in intracellular communication and pathogenesis of diseases. We aimed to characterise the protein cargo of extracellular vesicles, isolated from a murine (C57BL/6) model of P. aeruginosa endophthalmitis by LC-MS/MS at 24 h post infection (p.i). EVs were extracted by ultracentrifugation, characterized by Dynamic Light Scattering (DLS) and western blotting with tetraspannin markers, CD9 and CD81 and quantified by the ExoCet quantification kit. Multiplex ELISA was performed to estimate the levels of TNF-α, IL-6, IFN-γ and IL-1β. Proteomic analysis identified 2010 proteins (FDR ≤0.01) in EVs from infected mice eyes, of which 137 were differentially expressed (P-value ≤ 0.05). A total of 101 proteins were upregulated and 36 were downregulated. Additionally, 43 proteins were exclusive to infection set. KEGG and Gene Ontology revealed, Focal adhesion, Phagosome pathway, Complement cascade and IL-17 signalling pathway are crucial upregulated pathways involving proteins such as Tenascin, caveolin 1, caveolin 2, glutamine synthetase, microtubule-associated protein, C1, C8 and IL-17. Tenascin and caveolins are known to suppress anti-inflammatory cytokines further exacerbating the disease. The result of this study provides insight into the global extracellular vesicle proteome of P. aeruginosa endophthalmitis with their functional correlation and distinctive pattern of expression and tenascin, caveolin 1 and caveolin 2 are attractive biomarkers for P. aeruginosa endophthalmitis.

View all citing articles on Scopus

View full text

ReviewEndophthalmitis

Abstract

Section snippets

Postoperative endophthalmitis

Clinical Findings

Clinical Findings

Clinical Findings

Diagnosis

Intraocular Antibiotics

Conclusion

Acknowledgements

Ophthalmology

Ophthalmology

Am J Ophthalmol

Surv Ophthalmol

Am J Ophthalmol

Clin Lab Med

J Cataract Refract Surg

Am J Ophthalmol

Am J Ophthalmol

J Cataract Refract Surg

J Cataract Refract Surg

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Surv Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

J Cataract Refract Surg

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

J Hosp Infect

Intraocular ceftazidime as an alternative to the aminoglycosides in the treatment of endophthalmitis

Arch Ophthalmol

Vitreous cavity penetration of ceftazidime after intravenous administration

Retina

Intravenous cefazolin in penetrating eye injuries. I. Effects of trauma and multiple doses on intraocular delivery

Graefes Arch Clin Exp Ophthalmol

Intravenous cefazolin in penetrating eye injuriestreatment of experimental posttraumatic endophthalmitis

Retina

Controversies in endophthalmitis preventionthe risk of emerging resistance to vancomycin

Arch Ophthalmol

Strategies for management of microbial keratitis

Br J Ophthalmol

Bacillus cereus posttraumatic endophthalmitiscase report indicating need for prompt, aggressive treatment

Vitreoretinal Surg Tech

Chemical preparation of the eye in ophthalmic surgery. III. Effect of povidine-iodine on the conjunctiva

Arch Ophthalmol

Intraoperative bacterial contamination of the aqueous humor

Ophthalmic Surg

Risk factors associated with late infection of filtering blebs and endophthalmitis

Ophthalmic Surg

Fine needle aspiration biopsy of solid intraocular tumorsindications, instrumentation, and techniques

Ophthalmic Surg

Recurrent endophthalmitis after cataract surgery with a scleral-tunnel incision

Cornea

The source of coagulase-negative staphylococci in the Endophthalmitis Vitrectomy Study

Arch Ophthalmol

Review
Endophthalmitis