Metastatic Endophthalmitis
Presenter-Dr Shubhangini JModerator-Dr Sachin Fegde
DefinitionClassificationPredisposing factorsHisto-pathological descriptionOrganism causing metastatic endophthalmitisInvestigationManagement
Definition-Inflammation within the anterior segment or
posterior segment or both, concurrent with partial thickness involvement of an adjacent ocular wall
Associated with-Decreased visionPainConjunctival hyperemiaLid oedemaAnterior chamber & vitreous cellular reactionHypopyon
Classification of Endophthalmitis
Infectious
Exogenous
Post surgical 1. Acute Onset
2. Delayed Onset3. Bleb associated
Non surgical1. Post-traumatic
Endogenous
Hematogenous Spread
Sterile
Lens Induced
Toxic
S Michael Kresloff, Endophthalmitis survey of ophthalmology vol 43:no.3:nov-dec 1998
CaseMrs K P 45 yrs old female housewife from
panvel presented to us on 3-9-2013
Chief complaint –RE Diminution of vision since 1 month
RE Pain since 1 month
History Diminution of vision:
gradualNo h/o flashes of light
Pain Dull aching
History Past Ocular history:
H/o spectacle use since 7yrsNo h/o ocular surgeryNo h/o ocular traumaNo h/o similar complaints in the past
h/o of hospitalisation 3 months back for fever& generalised bodyache
Personal history insignificantFamily history insignificant
Examination- Head posture normalOrthophoriaExtraocular movements: Full & freeVisual acuity
RE LE
Visual Acuity CF FC, <N36 6/9, N6
Refraction Plano +1.00 DS
Intra ocular Pressure
10 18
Ocular Examination-On anterior segment examination
RE LE
Lids N N
Conjunctiva N N
Cornea Clear Clear
AC Cells ++++ ND Quiet
Pupil TAPD NSRL
Lens Clear Clear
Fundus RE LE
Impression-Endogenous Endophthalmitis
Differential Diagnosis-TuberculosisToxoplasmaToxocara SarcoidosisHarada’s diseaseSyphilitic uveitis
Investigation-Hb/CBC/ESR LFT/RFTHIV/VDRL Vitreous tapMantoux testRBS,Blood culture
Treatment-Predforte eye drop 6t/dayAtropine eye drop 3t/dayVitrectomy+BB + EL+silicon oil implantation
NVP
DiscussionIntraocular infection caused by
haematogenous spread of microorganism from distant foci to the eye from site of infection elsewhere in the body or from contaminated catheters & needles
Epidemiology-Accounts for 2-8% Affects any age & sexRE more commonly involvedMost common is bacterial metastatic
endophthalmitis
fungal metastatic endophthalmitis
Okada AA et al Endogenous bacterial endophthalmitis 10 yr retrospective study 101:832-
838,1994
Discussion-Most common site- uveal tract,choroid which
are most vascular tissues
Study on ocular oncology service of wills eye hospital, philadelphia(1996) , in a sample size of 420 patients had observed breast cancer(47%) most common tumor forming ocular metastatis followed by lung(21%)
Predisposing factors-Immunocompromised patientsIntravenous drug abuseDiabetes milletusChronic renal failureMalignancyDental surgery Contaminated intravenous fluid
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct 1999
Metastatic endophthalmitis classified based on Metastatic
Endophthalmitis
Extent
Focal Diffuse
Location
Anterior sement
Posterior segment
Surv Ophthalmol 31:81-101,2000 greenwald et al
Focal endophthalmitis-Mild external evidence of inflammation1 or more discrete foci of whitish nodule or
plaqueMeasures 1-3mm in iris Cell reaction , hypopyon, photophobia,
irritationRetina –Whitish emboli seen in multiple retinal
arteriolesPerivascular haemmorrhagesRoth Spot (inflammatory infiltration)
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct 1999
Diffuse endophthalmitis-
Anterior diffuse inflammationGeneralised sign of inflammationConjunctival injectionHypopyonCorneal oedemaFibrinous clot in AC
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct 1999
Diffuse endophthalmitis- Posterior diffuse inflammation
Intense inflammatory reaction Vitritis Bscan shows vitreous echoesWhitish emboli in multiple retinal arteriesPerivascular haemorrhageDiffuse narrowing & sclerosed vesselspanophthalmitis
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct 1999
Histopathological features-Focal inflammation
Inflammatory cells occluding the lumen of vessels surrounding tissue
Diffuse inflammation Inflammatory cells NecrosisHaemmorhage of
involved tissue
Infitration of all the intraocular structure by inflammatory cells
Pathogenesis- Metastatic
Embolization Ocular blood vessel
Blood ocular barrier
Ocular Tissue
Inflammatory response
Ocular fluidsJ Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct 1999
Summary-Ant Focal Post Focal Ant diffuse Post
DiffusePanophthalmitis
Orbit/EOM Normal Limited motility
Normal No proptosis
Proptosis
Lids Mild oedema
Mild oedema/ptosis
Mild-mod oedema
Mild –mod,oedema/Ptosis
Marked oedema/ptosis
Conjunctiva
Mild-modreaction
Normal-mildreaction
Marked reaction
Mild-modreaction
Marked reaction
Cornea Mild haze Clear /precipitates
Marked haze
Clear to mild haze /precipitates
Mod-marked haze
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct 1999
Ant Focal Post Focal Ant diffuse Post Diffuse
Panophthalmitis
AC Marked reaction/ Hypopyon
Mild-Marked reaction/ Hypopyon
Marked reaction/ Hypopyon
Marked reaction/ hypopyon
Marked reaction/ hypopyon
Iris/Pupil Abscess/ poor movement/ late synechiae
Normal ,mild movement no synechiae
Poorly seen no movements/ late synechaie
Mild-marked limited movements/ late synechiae
Poorly seen no movement
Vitreous Ant opacity/post echoes
Marked cells/mod haze
Ant opacity/post echoes
Marked cells,totally opaque/post echoes
Poorly seen,totally opaque/post echoes
Fundus Normal Discrete lesion ;normal ares
Normal White retina/emboli
Necrotic retina
Prognosis Excellent Good Good poor Very poor
Most common organism responsible for endophthalmitis
Gram positive bacteria 75%-85%
Gram negative bacteria 10%-15%
Staphylococcus 43% Pseudomonas 8%
Streptococcus spp 20% Proteus 5%
Staphylococcus aureus 15% Haemophilus influenzae 0-1%
Propionibacterium acnes 30 reports
Klebsiella 0-1%
Bacillus cereus 1% Coliform spp 0-1%
Fungi
Candida parapsilosis
Aspergillus
Cephalosporium spp.
Gram positive organism-
Streptococcus pneumoniae(m/c) & Staphylococcus epidermis- linked to non
inflammatory fundus lesion (R. Haemorrhage, cotton wool spot)secondary to meningitisEndocarditisMalignant neoplasm(breast cancer m/c)
Gram positive organism-Clostridium species-M/c seen in I.V. drug abuserSecondary to bowel carcinomaCharacteristic-
Conjunctival injectionDecreased visionChocolate brown exudateRing shaped white infiltrate in cornea
Gram positive bacilli-Listeria monocytogenes
Mild external inflammationAbsent systemic signs of infectionIndolent infectionBrown hypopyonWithout corneal involvement
Gram negative organism-Haemophilus influenzae
Present in a manner similar to meningococcus with bacteremia
MeningitisAnterior diffuse inflammation of eyePost subretinal abscess confusing it with
disciform scar or a choroidal tumor
AF Bacilli-Nocardia asteroides(AF bacilli)
Lead to BEE secondary to dissemination from pulmonary foci
Infecting choroidProliferating to produce chorioretinitis&
vitritisPosterior subretinal abscessSeen in immunocompromised patients
AF Bacilli-Mycobacterium Tuberculosis(AF bacilli)
Disseminates from pulmonary focusInfecting & proliferating chorioretinitisVitritisAcute endophthalmitis
AF Bacilli-Anterior uveitis,mutton fat KP,posterior
synechiaeThe main types of choroidal involvement in
tuberculosis include choroiditis, subretinal abscess, tubercles,
tuberculomas Yellowish subretinal abscesses can occur
from liquefaction necrosis within a tubercular granuloma
A tubercle may grow into a large tumor-like mass up to 14 mm, called a choroidal tuberculoma, which often has a surrounding exudative retinal detachment
Fungii-Candida albicans
75-80%It forms germ tube in serum that embolize and
lodges in choriocapillariesCreamy retinal infiltrate extends in vitreousIntraretinal haemmorhagePapillitis Focal choroiditisString of pearls(white opacities/snowball)
Fungii-Aspergillus
15%Immunocompromised patientsTransplants of stem cellEndocarditisLeukemia I.V. drug abuse,contaminated Dextrose infusion
fluidCOPD on corticosteriod therapy
Parasite-Taenia solium is the most common species
causing cysticercosis in humansCaused by consumption of the adult worm Symptoms may include periorbital pain,
diplopia, ptosis, blurring or loss of vision, distortion of images, and the sensation of light flashes
Parasite-On fundus examination living form of
cysticercosis has the features of an undulating, expanding and contracting “pearl” with intermittent evagination and invagination of the protoscolex
This may result in an inflammatory chorioretinitis Ocular ultrasonography- subretinal cyst
Assays for eosinophilia in anterior chamber fluid sample
Evaluation-Complete history Physical examination Specific evaluation
E.C.G. for endo carditis, CXR PA View,CT Scan, Sputum ,urine for culture sensitivityESR,BUN,CreatinineCT/MRI OrbitPCRCulture of CSF,throat swab, stool,indwelling
catheter
When to culture…..??Presence of systemic infectionSigns of acute or chronic intraocular
inflammation in absence of extraocular culture
In presence of culture positive-systemic infection with sign of inflammation, unresponsive to antibiotic therapy
To rule out suspected malignancy after a negative systemic work up
What to culture…??Culture of blood, urine, aqueous, vitreous,
CSF & wound culture & smear indicatedTo locate site of original infectionDocument systemic involvement
How to culture….???Aqueous material can be obtained by
30 gauge needle in tuberculin syringeLimbal stab incision required0.1-0.2ml of fluid to be aspirated
Vitreous biopsy performed via- Pars plana,1,2,3,port vitrectomy probe ORBy 25-27gauge needle in tuberculin syringe0.1-0.2ml aspirated.
Treatment-Managed similar to acute post operative
infectious endophthalmitisNon ocular culture sensitivity data to guide
initial therapySpecific therapy to begun after ocular culture
Treatment-Mild endogenous endophthalmitis- focal
metastatic abscess in anterior & posterior segment
Topical & systemic therapyVitrectomy done for removal of infecting
organism ,endotoxin, exotoxin & vitreous membrane , vitreous opacities , better distribution of intravitreal antibiotic
Treatment for gram positive organism-
Because most cases are caused by gram positive organisms, vancomycin- (broad-spectrum activity against most gram positive species) has become an agent of choice
Non toxic in recommended clinical dosage.
Thus vancomycin 1 mg in (0.1 ml) BD is given intra vitreally after blood culture & vitreous tap
Arch Ophth 1999; 117: 1023-1027
Treatment for gram negative organism-
Ceftazidine has emerged as on alternativeMore effective than aminoglycosidesRetinal toxicity studies in primates reveal
concentration of 2.25 mg/0.1 ml to be safe after vitreous tap
Excellent ocular penentrationAfter 2 weeks to shift on oral tab cefuroxime
500mg BD
Arch Ophthalmol 1994; 112: 48-53
Br. J. Ophth 97; 81: 1006-15
Treatment for fungal endophalmitis-If vitreous is minimally involved
culture/smear is positive for fungus- oral Fluconazole /vitrectomy to be considered
In metastatic aspergillus endophthalmitis IntraVitreal. amphotericin B (5-10µg) with
IntraVitreal. Dexamethasone(400µg)Repeated for persistance disease after5-7 days
in nonvitrectomised eye & after 2 days in vitrectomised eye
Systemically I.V. amphotericin(0.005mg/0.1ml)/ itraconazole is advocated
Forvitreous seeding- vitrectomy
Treatment for TB -For metastatic ocular TB approach to neuro
physician is mandatory to start empirical therapy of ATT
in cases in which ,uncertainty about TB remains, biopsy of the eye for culture, histologic examination, is useful to establish the diagnosis of ocular TB.
Treatment for parasitic endophthalmitis-Praziquantil ,Metrifonate Spontaneous extrusion of cystercerci from
the eye may occur Vitrectomy along with photocoagulation has
shown some success in removing cystercerci from the vitreous cavity
Conclusion-
Metastatic endophthalmitis is dreaded ocular condition ,high index of clinical suspicion is necessary along with a co-ordinated multidisciplinary approach to handle this difficult situation
Thank you
Fungii-Presentation-
PainSevere visual lossPresents with pneumonia Seeding of end organsVitritisChoroidal lesionsChorioretinal abscessSubhyaloid or sub retinal hypopyon
Indicated- Inflammatory focus in AS Aphakic eye,dehiscence of post. Cap Vitritis,no improvement in vision, non ocular culture
are negative