Infective endophthalmitis

1. Infective endophthalmitis

2. Endophthalmitis
• An inflammation of the inner structures of the
eyeball
• Uveal tissue
• Retina
• associated with pouring of exudates in the
vitreous cavity, anterior chamber and
posterior chamber.

5. Classification
Infectivity
Infective
Non-infective
Mode of
entry
Exogenous
Endogenous
Etiological
agent
Bacterial
Fungal

6. Infective endophthalmitis

7. Modes of infection
Exogenous
• Perforating
injuries
• Perforation of
infected corneal
ulcers
• Postoperative
infections
Endogenous
• Bloodstream
• Caries teeth
• Generalised
septicaemia
• Puerperal sepsis
Secondary
infections
• Extension of
infection
• Orbital cellulitis
• Thrombophlebitis
• Infected corneal
ulcers

8. Causative organisms
Bacterial
Stahpylococcus
Pseudomonas
Pneumococcus
Streptococcus
E. coli
Fungal
- Aspegillus
fumigatus
- Candida
albicans
- Nocardia
asteroides
- Fusarium

9. • Acute postoperative endophthalmitis -
complication of intraocular surgery with an
incidence of about 0.1%.
• Source of infection - periocular bacterial flora
of the eyelids, conjunctiva, and lacrimal sac.
• Other potential sources of infection -
contaminated solutions and instruments, and
environmental flora

10. Risk factors
• Eye trauma
• Eye surgery
– Previous presence of infection
– Poor surgical technique.
– Contaminated intraocular lens.
• Intraocular injection
• Bloodstream infection

11. • Ophthalmic risk factors:
– Contact lens wear (poor hygiene).
– Chronic corneal ulceration.
• Non-ophthalmic risk factors:
– Immunosuppression.
– Intravenous drug use.
– AIDS.

12. Post operative endophthalmitis

13. Clinical features
• Sudden onset
• Severe pain
• Redness of eye
• Marked visual loss
• Swollen eyelid
• Lacrimation
• Photophobia

14. Signs
• Visual acuity may be reduced.
• Lids → red and swollen.
• Conjunctiva → chemosis and marked
circumcorneal congestion.
• Cornea → oedematous, cloudy and ring
infiltration may be formed.
• Anterior chamber → hypopyon
• Iris → oedematous and muddy

17. • Pupil → yellow reflex , absent red reflex
• Vitreous exudation - yellowish white mass is
seen through fixed dilated pupil (amaurotic
cat’s-eye reflex)
• Intraocular pressure → raised in early stages
• but in severe cases – hypotony
• Edges of wound → yellow and necrotic and
wound may gape

21. Diagnosis
• Culture and sensitivity studies on aqueous and
vitreous samples
– Anterior chamber tap
– Vitreous tap
– Vitreous biopsy
• Full infection screen
– FBC, blood cultures and culture of all indwelling lines
and catheters
• B-scan ultrasound
– the degree of vitritis and integrity of retina

22. Management
• Medical and ophthalmological emergency
• Suspected acute endophthalmitis requires
emergency admission.
• Suspected delayed postoperative
endophthalmitis needs urgent referral within
24 hours.
• Most patients will be admitted for a diagnostic
work-up and antimicrobial treatment

23. Goals of treatment
• Retention of useful vision
• Minimize the infection with antimicrobial
agents
• Limit the inflammation
• Symptomatic relief

24. Treatment
Medical
• Antibiotics - Intravitreal , periocular , topical ,
systemic
• Anti-inflammatory - topical , periocular ,
systemic (not for chronic Endophthalmitis)
• Supportive
Surgical
• Vitrectomy

25. Medical treatment
Broad spectrum antibiotics
• Intravitreal – aminoglycoside & vancomycin
First choice Vancomycin 1 mg in 0.1 ml
Ceftazidime 2.25 mg in 0.1 m
Second choice Vancomycin 1 mg in 0.1 ml
Amikacin 0.4 mg in 0.1 ml
Third choice Vancomycin 1 mg in 0.1 ml
Gentamycin 0.2 mg in 0.1 ml

26. • Perioricular / subconjunctival injection
– vancomycin 25 mg & ceftazidine 100mg daily
– Gentamycin 20mg & cefuroxime 125mg daily
• Topical therapy every 30-60 min
• Systemic
– IV ceftazidine , cefotaxime
– Oral ciprofloxacin

27. Corticosteroids
• Indication
– recent onset after rule out fungal infection.
• Contraindication
– Late onset endophthalmitis
– Fungal endophthalmitis
• Reduce inflammation → limit ocular damage
• Eg : dexamethasone

28. • Intravitreal → dexamethasone 0.4 mg in 0.1ml.
• Subconjunctival → dexamethasone 4 mg (1ml)
OD for 5-7 days.
• Topical dexamethasone (0.1%) or predacetate
(1%) used frequently.
• Systemic → Oral corticosteroids should
preferably be started after 24 hours of intensive
antibiotic therapy. A daily therapy – 60 mg
prednisolone to be followed by 50, 40, 30, 20 and
10 mg for 2 days each

29. • Atropine and analgesic
– relieve pain
• Vitrectomy
– Severe and resistant cases
– Fungal endophthalmitis

30. Antifungal
• Amphotericin B
– Intravitreal
– Systemic

31. Complications
• Panophthalmitis
• Papillitis
• Phthisis bulbi

32. • Retinal necrosis
• Retinal detachment
• Increased intraocular pressure
• Retinal vascular occlusion
• Optic neuropathy
• Hypotony

33. Expected outcomes
• Bacterial endophthalmitis → most treatable
type, but the prognosis of vision is often poor.
• Mycotic endophthalmitis → chorioretinal
scarring and optic nerve atrophy from
glaucoma may result in blindness.
• Endophthalmitis caused by fungus / neoplasia
/ foreign bodies → not responsive to medical
therapy

34. Failure of treatment
• Inflammation is too severe to overcome.
• The underlying infectious agent is resistant to
therapy.
• The medical therapy does not penetrate the
eye well.
• Therapy is not administered for an adequate
duration.
• The diagnosis is incorrect.

35. PANOPHTHALMITIS
• intense purulent inflammation of the whole
eyeball including the Tenon’s capsule

36. Clinical features
– Severe ocular pain and headache
– Complete loss of vision
– Profuse watering
– Purulent discharge
– Marked redness and swelling of the eyes
– Associated w. malaise and fever