Post-traumatic endophthalmitis

Jump to: navigation, search

WikiDoc Resources for Post-traumatic endophthalmitis

Articles

Most recent articles on Post-traumatic endophthalmitis

Most cited articles on Post-traumatic endophthalmitis

Review articles on Post-traumatic endophthalmitis

Articles on Post-traumatic endophthalmitis in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Post-traumatic endophthalmitis

Images of Post-traumatic endophthalmitis

Photos of Post-traumatic endophthalmitis

Podcasts & MP3s on Post-traumatic endophthalmitis

Videos on Post-traumatic endophthalmitis

Evidence Based Medicine

Cochrane Collaboration on Post-traumatic endophthalmitis

Bandolier on Post-traumatic endophthalmitis

TRIP on Post-traumatic endophthalmitis

Clinical Trials

Ongoing Trials on Post-traumatic endophthalmitis at Clinical Trials.gov

Trial results on Post-traumatic endophthalmitis

Clinical Trials on Post-traumatic endophthalmitis at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Post-traumatic endophthalmitis

NICE Guidance on Post-traumatic endophthalmitis

NHS PRODIGY Guidance

FDA on Post-traumatic endophthalmitis

CDC on Post-traumatic endophthalmitis

Books

Books on Post-traumatic endophthalmitis

News

Post-traumatic endophthalmitis in the news

Be alerted to news on Post-traumatic endophthalmitis

News trends on Post-traumatic endophthalmitis

Commentary

Blogs on Post-traumatic endophthalmitis

Definitions

Definitions of Post-traumatic endophthalmitis

Patient Resources / Community

Patient resources on Post-traumatic endophthalmitis

Discussion groups on Post-traumatic endophthalmitis

Patient Handouts on Post-traumatic endophthalmitis

Directions to Hospitals Treating Post-traumatic endophthalmitis

Risk calculators and risk factors for Post-traumatic endophthalmitis

Healthcare Provider Resources

Symptoms of Post-traumatic endophthalmitis

Causes & Risk Factors for Post-traumatic endophthalmitis

Diagnostic studies for Post-traumatic endophthalmitis

Treatment of Post-traumatic endophthalmitis

Continuing Medical Education (CME)

CME Programs on Post-traumatic endophthalmitis

International

Post-traumatic endophthalmitis en Espanol

Post-traumatic endophthalmitis en Francais

Business

Post-traumatic endophthalmitis in the Marketplace

Patents on Post-traumatic endophthalmitis

Experimental / Informatics

List of terms related to Post-traumatic endophthalmitis

For the main page on endophthalmitis, please click here
For more information on bacterial endophthalmitis, please click here
For more information on post-operative endophthalmitis, please click here
For more information on bleb-related endophthalmitis, please click here
For more information on endogenous endophthalmitis, please click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Synonyms and Keywords: Post-traumatic bacterial endophthalmitis; Post-traumatic fungal endophthalmitis


Overview

Post-traumatic bacterial endophthalmitis occurs following penetrating ocular injuries. Post-traumatic endophthalmitis is associated with a large variety of organisms. The most commonly isolated organisms include gram-positive Staphylococcus epidermidis and Streptococcus (as a part of the normal skin flora and regularly contaminate open wounds). Bacillus cereus is second most common. In some cases post-traumatic endophthalmitis is polymicrobial. The risk for developing endophthalmitis after open globe injuries is estimated at about 7% of injured eyes.[1][2][3][4]

Historical Perspective

  • In 1903, post-traumatic fungal endophthalmitis was first reported by Romer.[5]
  • In 1933, exogenous fungal endophthalmitis was first described by Rychener.[6]

Classification

Post-traumatic endophthalmitis may be classified according to the causative organisms into 2 subtypes: bacterial or fungal.[4]

Pathophysiology

Pathogenesis

Post-traumatic endophthalmitis occurs following penetrating ocular injuries. Following penetrating injury, the eye globe integrity disturbed. The microorganisms are often implanted via direct inoculation by the penetrating object, by a retained foreign body, or by infection of the open wound. Penetrating ocular injuries are accompanied by infection at a much higher rate compared to ocular surgery.

Post-traumatic endophthalmitis is associated with a large variety of organisms. The most commonly isolated organisms include gram-positive Staphylococcus epidermidis and Streptococcus (as a part of the normal skin flora and regularly contaminate open wounds). Bacillus cereus is the second most common cause. In some cases post-traumatic endophthalmitis is polymicrobial.[1][2][3][4]

Gross Pathology

On gross pathology, eyelid swelling, eyelid erythema, injected conjunctiva and sclera, hypopyon, chemosis, and mucopurulunt discharge are characteristic findings of endophthalmitis.[3][7]

Microscopic histopathological analysis

On microscopic histopathological analysis, infiltration of polymorphonuclear leukocytes or chronic inflammatory cells (depending on the duration of the inflammation) and destruction of ocular structures are characteristic findings of post-traumatic bacterial endophthalmitis.

Causes

Post-traumatic bacterial endophthalmitis

Common causes of post-traumatic bacterial endophthalmitis include:[1][2][8][9]

Post-traumatic fungal endophthalmitis

Common causes of post-traumatic fungal endophthalmitis include:[8][10][9]

Differentiating Post-traumatic Endophthalmitis from Other Diseases

Post-traumatic endophthalmitis must be differentiated from:[11]

  • Post-traumatic non-infectious inflammation
  • Phacoanaphylactic endophthalmitis
  • Sympathetic ophthalmia with bilateral anterior uveitis

Epidemiology and Demographics

The incidence of traumatic endophthalmitis may be decreasing due to earlier wound closure and prompt initiation of antibiotics. Post-traumatic endophthalmitis accounts for 25,000 to 31,000 cases per 100,000 individuals with endophthalmitis. The incidence of post-traumatic endophthalmitis varies according to the following factors:

  • Presence of an intraocular foreign body
  • Delay primary globe repair
  • Location and extent of laceration of the globe

Prevalence and Incidence

  • The incidence of post-traumatic endophthalmitis was estimated to range from 3.300 to 30,000 per 100,000 individuals with penetrating ocular trauma.[1][2]
  • The incidence of post-traumatic endophthalmitis was estimated to range from 1,300 to 61,000 per 100,000 individuals with intraocular foreign body.[1][2]

Risk Factors

Common risk factors in the development of post-traumatic bacterial endophthalmitis include:[1][2][7][3]

  • Retained intraocular foreign bodies
    • Non-metallic intraocular foreign body (IOFB)
  • Injury in a rural setting
  • Delay in repair more than 24 hours
  • Disruption of the lens
  • Ocular tissue prolapse
  • Large wound size

Screening

Screening for post-traumatic endophthalmitis is not recommended after open globe injuries.[12] There is insufficient evidence to recommend routine aqueous culture in all cases of open globe injury.[1][13]

Natural History, Complications, and Prognosis

Natural History

Post-traumatic endophthalmitis may occur within hours after the trauma or up to several weeks after injury. Post-traumatic endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal ring ulceration and infiltration, corneal opacification, corneal perforation, and permanent vision loss. [8][14]

Complications

Common complications of post-traumatic endophthalmitis include:

Prognosis

Post-traumatic bacterial endophthalmitis is associated with a particularly poor visual outcome. Only 22% to 42% patients with post-traumatic bacterial endophthalmitis obtain a final visual acuity of 20/400 or better.[1][15]

Diagnosis

History & Symptoms

History

  • A recent history of penetrating ocular trauma

Symptoms

Symptoms of post-traumatic bacterial endophthalmitis may include the following:[16][17]

  • Decreased vision
  • Disproportionate pain
  • Lid swelling
  • Photophobia
  • Tearing

Physical Examination

Ophthalmologic examination of patients with post-traumatic endophthalmitis is usually remarkable for:[18][19]

Laboratory Findings

Laboratory studies consistent with the diagnosis of post-traumatic endophthalmitis include:[8][14][20]

Imaging Findings

X Ray

Plain film x ray is helpful for the detection of intraocular foreign bodies (IOFBs). However, it may detect only about 40% of intraocular foreign bodies (IOFBs).[21]

CT

Orbital CT scan is helpful for localization of metallic intra ocular foreign bodies (IOFBs) in the setting of trauma. [1][15]

MRI

Orbital MRI scan is helpful for localization of intra ocular foreign bodies (IOFBs) that may be radiolucent on CT in the setting of trauma. However, metallic IOFB must be excluded first.[1][15]

Ultrasound

On ocular ultrasonography, endophthalmitis may be characterized by anterior vitreous haze echoes and retinochoroidal thickening.[1][8][21]

Other Imaging Findings

Orbital echography is helpful for assessment of vitreous opacification, presence of (IOFBs), status of the posterior hyaloid face, and retinal detachment in a patient with post-traumatic endophthalmitis.[1][15]

Other Diagnostic Studies

Slit lamp examination

On slit lamp examination, post-traumatic endophthalmitis is characterized by:[8][14]

Treatment

  • The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retinal specialist who will determine the need for intravitreal injection of potent antibiotics or pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.[22]
  • Closure of the wound is the first step in management of open globe injury
  • Removal of intraocular foreign bodies (IOFB) and debridement of necrotic tissue is necessary
  • Bacterial and fungal cultures from vitreous samples are required
  • Vitrectomy is often indicated
  • Immunization against tetanus based on history is necessary

Medical Therapy

  • Systemic broad spectrum antibiotics are recommended
  • Systemic antifungal agents are recommended in patients with suspected fungal endophthalmitis

Antimicrobial Regimens

  • Infectious endophthalmitis[8]
  • 1. Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
  • Note (1): Removal of foreign bodies and debridement of necrotic tissue is necessary
  • Note (2): In addition to antimicrobial therapy, vitrectomy is necessary
  • Note (3): Systemic broad spectrum antibiotics are recommended in post-traumatic endophthalmitis
  • 2. Pathogen-directed antimicrobial therapy
  • 2.1 Bacillus spp.
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 2.2 Non-Bacillus gram-positive bacteria
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 2.3 Gram-negative bacteria
  • Preferred regimen: Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 2.4 Candida spp.
  • Preferred regimen: (Fluconazole 400-800 mg IV/PO qd for 6-12 weeks OR Voriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks OR Amphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 2.5 Aspergillus spp.
  • Preferred regimen: Amphotericin B 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose AND Dexamethasone 400 microgram intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy

Surgery

Vitrectomy

Vitrectomy surgically debrides the vitreous humor, similarly to draining an abscess. It is the fastest way of clearing infection in eyes with fulminant endophthalmitis.[8][14][23][24][25]

  • Vitrectomy is recommended for all patients who develop exogenous bacterial endophthalmitis.
  • Vitrectomy is recommended in severe cases of endogenous bacterial endophthalmitis.

The benefits of vitrectomy include:

  • Better vitreous sample
  • Rapid and complete sterilization of the vitreous
  • Removal of toxic bacterial products
  • Enhancement of systemic antimicrobial penetration in to the eye

Prevention

Primary prevention

Effective measures for the primary prevention of post-traumatic endophthalmitis include:[26]

  • Primary globe repair within 24 h
  • Removal of foreign bodies and debridement of necrotic tissue
  • Intracameral or intravitreal antibiotic injection after penetrating eye injury
  • Systemic antimicrobial prophylaxis is recommended
  • Systemic antifungal prophylaxis is recommended with the suspicion of fungal infection.

Secondary prevention

There are no secondary preventive measures available for post-traumatic endophthalmitis.

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Essex RW, Yi Q, Charles PG, Allen PJ (2004). "Post-traumatic endophthalmitis". Ophthalmology. 111 (11): 2015–22. doi:10.1016/j.ophtha.2003.09.041. PMID 15522366.
  3. 3.0 3.1 3.2 3.3 Bhagat N, Nagori S, Zarbin M (2011). "Post-traumatic Infectious Endophthalmitis". Surv Ophthalmol. 56 (3): 214–51. doi:10.1016/j.survophthal.2010.09.002. PMID 21397289.
  4. 4.0 4.1 4.2 Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U; et al. (1999). "Microbiologic spectrum and susceptibility of isolates: part II. Posttraumatic endophthalmitis. Endophthalmitis Research Group". Am J Ophthalmol. 128 (2): 242–4. PMID 10458188.
  5. Romer, P. "Eine intraoculare Schimmelpilz-infection." Klin Monatsbl Augenheilkd 40 (1902): 331-333.
  6. Wu, Lihteh, and Guillermo Tapia-Herrera. "Fungal endophthalmitis." Current Fungal Infection Reports 3.1 (2009): 55-61.
  7. 7.0 7.1 Thompson JT, Parver LM, Enger CL, Mieler WF, Liggett PE (1993). "Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System". Ophthalmology. 100 (10): 1468–74. PMID 8414406.
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  9. 9.0 9.1 Abu el-Asrar AM, al-Amro SA, al-Mosallam AA, al-Obeidan S (1999). "Post-traumatic endophthalmitis: causative organisms and visual outcome". Eur J Ophthalmol. 9 (1): 21–31. PMID 10230588.
  10. Wykoff CC, Flynn HW, Miller D, Scott IU, Alfonso EC (2008). "Exogenous fungal endophthalmitis: microbiology and clinical outcomes". Ophthalmology. 115 (9): 1501–7, 1507.e1–2. doi:10.1016/j.ophtha.2008.02.027. PMID 18486220.
  11. Thach AB, Marak GE, McLean IW, Green WR (1991). "Phacoanaphylactic endophthalmitis: a clinicopathologic review". Int Ophthalmol. 15 (4): 271–9. PMID 1917323.
  12. US Preventivre Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=endophthalmitis Accessed on August 5, 2016
  13. Ariyasu RG, Kumar S, LaBree LD, Wagner DG, Smith RE (1995). "Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair". Am J Ophthalmol. 119 (2): 181–8. PMID 7832224.
  14. 14.0 14.1 14.2 14.3 Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP; et al. (1997). "Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study". Arch Ophthalmol. 115 (9): 1142–50. PMID 9298055.
  15. 15.0 15.1 15.2 15.3 Affeldt JC, Flynn HW, Forster RK, Mandelbaum S, Clarkson JG, Jarus GD (1987). "Microbial endophthalmitis resulting from ocular trauma". Ophthalmology. 94 (4): 407–13. PMID 3495766.
  16. Packer, Andrew J., Thomas A. Weingeist, and Gary W. Abrams. "Retinal periphlebitis as an early sign of bacterial endophthalmitis." American journal of ophthalmology 96.1 (1983): 66-71.
  17. 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." Archives of Ophthalmology 113.12 (1995): 1479.
  18. Packer, Andrew J., Thomas A. Weingeist, and Gary W. Abrams. "Retinal periphlebitis as an early sign of bacterial endophthalmitis." American journal of ophthalmology 96.1 (1983): 66-71.
  19. 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." Archives of Ophthalmology 113.12 (1995): 1479.
  20. Seal D, Reischl U, Behr A, Ferrer C, Alió J, Koerner RJ; et al. (2008). "Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract & Refractive Surgeons multicenter study and susceptibility testing". J Cataract Refract Surg. 34 (9): 1439–50. doi:10.1016/j.jcrs.2008.05.043. PMID 18721702.
  21. 21.0 21.1 Bryden FM, Pyott AA, Bailey M, McGhee CN (1990). "Real time ultrasound in the assessment of intraocular foreign bodies". Eye (Lond). 4 ( Pt 5): 727–31. doi:10.1038/eye.1990.103. PMID 2282949.
  22. 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." Archives of Ophthalmology 113.12 (1995): 1479.
  23. "Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group". Arch Ophthalmol. 113 (12): 1479–96. 1995. PMID 7487614.
  24. Endophthalmitis Vitrectomy Study Group. "Microbiologic factors and visual outcome in the Endophthalmitis Vitrectomy Study." American journal of ophthalmology 122.6 (1996): 830-846.
  25. 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." Archives of Ophthalmology 113.12 (1995): 1479.
  26. Soheilian M, Rafati N, Mohebbi MR, Yazdani S, Habibabadi HF, Feghhi M; et al. (2007). "Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2". Arch Ophthalmol. 125 (4): 460–5. doi:10.1001/archopht.125.4.460. PMID 17420365.

Linked-in.jpg