OcuLearning › Uveitis

Endophthalmitis

CRITICAL — Uveitis

Symptoms

sudden onset of decreased vision

increasing eye pain after surgical procedure or trauma

insidious vision loss, redness, and pain (subacute form)

Clinical Findings

Anterior segment

  • hypopyon and fibrin with severe anterior chamber reaction
  • eyelid and corneal edema
  • intense conjunctival injection and chemosis

Posterior segment

  • vitreous cells, haze, and vitreous abscesses
  • decreased red reflex

Subacute presentation

  • white plaque or opacities on the lens capsule (c. acnes)
  • clumps of fibrinous exudate in the ac, on the iris, or pupillary border
  • transient response to steroids followed by recurrence

Etiology

Postoperative

  • acute (<6 weeks): s. epidermidis (most common), s. aureus, or streptococcus
  • acute gram-negative: pseudomonas, proteus, klebsiella, e. coli
  • chronic (>6 weeks): cutibacterium acnes or fungi (aspergillus, candida)

Other causes

  • post-injection: streptococcus (oral flora) or s. epidermidis
  • post-traumatic: bacillus cereus (fulminant; associated with organic/soil matter)
  • bleb-associated: streptococcus or gram-negative species from leaking blebs
  • endogenous: hematogenous spread from endocarditis, ivdu, or catheters

Red Flags

pain and vision loss post-surgery (endophthalmitis until proven otherwise)

hypopyon and severe vitritis within days of surgery

endogenous presentation signaling systemic sepsis

bleb-associated or bacillus cereus cases (highly fulminant)

Investigations

Examination

  • evaluate for wound/bleb leaks, exposed sutures, or vitreous to the wound
  • b-scan ultrasound to assess vitritis and membranes if fundus view is limited

Sampling (vision-based)

  • vision lp or worse: diagnostic and therapeutic pars plana vitrectomy (ppv)
  • vision hm or better: vitreous tap (aspiration) or ac paracentesis

Laboratory

  • smears: gram, giemsa, and methenamine-silver
  • cultures: blood, chocolate, sabouraud, and thioglycolate media

Treatment

Intravitreal therapy

  • vancomycin (1mg/0.1ml) and ceftazidime (2.25mg/0.1ml) cornerstone
  • amikacin (0.4mg/0.1ml) if penicillin allergic
  • consider dexamethasone (0.4mg/0.1ml) for severe vitritis

Medical therapy

  • prednisolone acetate 1% q1h for ac inflammation
  • fortified antibiotics (vancomycin/tobramycin) if bleb/wound leak present
  • atropine 1% bid–tid

Prevention

  • 5% povidone-iodine prep of conjunctiva/eyelids (proven risk reduction)
  • intraoperative intracameral antibiotics

Differential Diagnosis

  • toxic anterior segment syndrome (tass)
  • acute noninfectious uveitis flare
  • iol-induced uveitis (iris chafing/ugh syndrome)

Related Uveitis Conditions