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Endophthalmitis

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Endophthalmitis
Author: Daniel J Egan, MD; Chief Editor: Robert E O'Connor, MD, MPH more... Updated: May 6, 2013

Background
Endophthalmitis is an inflammatory condition of the intraocular cavities (ie, the aqueous and/or vitreous humor) usually caused by infection. Noninfectious (sterile) endophthalmitis may result from various causes such as retained native lens material after an operation or from toxic agents. Panophthalmitis is inflammation of all coats of the eye including intraocular structures.

Severe endophthalmitis. Image courtesy of Joan W. Miller, MD, and Mehran Afshari, MD, Massachusetts Eye and Ear Infirmary, Boston, Mass.

The 2 types of endophthalmitis are endogenous (ie, metastatic) and exogenous. Endogenous endophthalmitis results from the hematogenous spread of organisms from a distant source of infection (eg, endocarditis). Exogenous endophthalmitis results from direct inoculation of an organism from the outside as a complication of ocular surgery, foreign bodies, and/or blunt or penetrating ocular trauma.

Pathophysiology
Under normal circumstances, the blood-ocular barrier provides a natural resistance against invading organisms. In endogenous endophthalmitis, blood-borne organisms (seen in patients who are bacteremic in situations such as endocarditis) permeate the blood-ocular barrier either by direct invasion (eg, septic emboli) or by changes in vascular endothelium caused by substrates released during infection. Destruction of intraocular tissues may be due to direct invasion by the organism and/or from inflammatory mediators of the immune response.
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Endophthalmitis may be as subtle as white nodules on the lens capsule, iris, retina, or choroid. It can also be as ubiquitous as inflammation of all the ocular tissues, leading to a globe full of purulent exudate. In addition, inflammation can spread to involve the orbital soft tissue. Any surgical procedure that disrupts the integrity of the globe can lead to exogenous endophthalmitis (eg, cataract, glaucoma, retinal, radial keratotomy, intravitreal injections).

Epidemiology
Frequency
United States Endogenous endophthalmitis is rare, occurring in only 2-15% of all cases of endophthalmitis. Average annual incidence is about 5 per 10,000 hospitalized patients. In unilateral cases, the right eye is twice as likely to become infected as the left eye, probably because of its more proximal location to direct arterial blood flow from the right innominate artery to the right carotid artery. Since 1980, candidal infections reported in IV drug users have increased. The number of people at risk may be increasing because of the spread of AIDS, more frequent use of immunosuppressive agents, and more invasive procedures (eg, bone marrow transplantation). Most cases of exogenous endophthalmitis (about 60%) occur after intraocular surgery. When surgery is implicated in the cause, endophthalmitis usually begins within 1 week after surgery. In the United States, postcataract endophthalmitis is the most common form, with approximately 0.1-0.3% of operations having this complication, which has increased over the last 3 years.[1] Although this is a small percentage, large numbers of cataract operations are performed each year making the chances that physicians may encounter this infection higher. Endophthalmitis may also occur after intravitreal injections, although this risk in an analysis of over 10,000 injections is estimated at 0.029% per injection.[2] Posttraumatic endophthalmitis occurs in 4-13% of all penetrating ocular injuries. Incidence of endophthalmitis with perforating injuries in rural settings is higher when compared with nonrural settings.[3] Delay in the repair of a penetrating globe injury is correlated with increased risk of developing endophthalmitis.[4] Incidence of endophthalmitis with retained intraocular foreign bodies is 7-31%.

Mortality/Morbidity
Decreased vision and permanent loss of vision are common complications of endophthalmitis. Patients may require enucleation to eradicate a blind and painful eye. Mortality is related to the patient's comorbidities and the underlying medical problem, especially when considering the etiology of hematogenous spread in endogenous infections.

Age
An association appears to exist between the development of endophthalmitis in cataract surgery and age greater than or equal to 85 years.[5]

Contributor Information and Disclosures

Author Daniel J Egan, MD Associate Attending Physician, Associate Residency Director, Department of Emergency Medicine, St Luke's Roosevelt Hospital Center; Assistant Professor of Clinical Medicine, Columbia University College of Physicians and Surgeons Daniel J Egan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose.
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Coauthor(s) Jessica Radin Peters MD, Attending Physician, Urgent Care Center, Newton-Wellesley Hospital Jessica Radin Peters is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. David A Peak, MD Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society Disclosure: Pfizer Salary Employment Specialty Editor Board Richard Lavely, MD, JD, MS, MPH Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Douglas Lavenburg, MD Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery Disclosure: Nothing to disclose. John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Chief Editor Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
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Disclosure: Nothing to disclose.

References
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