The greatest threat is fungemia, and the most common organism causing EE is Candida [65]. Treatment of life-threatening primary inflammation is always a priority. Currently, no clear guidelines exist regarding the use of corticosteroids in endophthalmitis. Cultures of vitreous obtained by needle aspiration or vitrectomy are indicated as soon as infectious endophthalmitis is suspected. identifies the area of New England as being particularly hit by the crisis, where the number of deaths related to heroin use has increased significantly since 2014. EE is an ophthalmological emergency that requires prompt diagnosis and management. According to a study assessing differences between the risk factors for mold and yeast infections, patients with mold infections were more likely to be associated with the use of chemotherapy as well as organ transplantation especially cardiac and liver transplants [16]. Excision of the infected vitreous significantly reduces the population of microorganisms and the number of inflammatory cells in the eye. However, in the case of treating skin abscess or cellulitis, primary care physicians should alert patients to the risk of this complication. official website and that any information you provide is encrypted Microorganisms associated with this condition vary along a broad spectrum. Eur J Ophthalmol 19(5):812817. Sugita et al. Clin Infect Dis 48(5):503535. CAS EE can be a first symptom of bacterial meningitis and bilateral cases are reported quite frequently [32,34]. Intensive Care Med 26(9):13861389, Hu CC, Ho JD, Lou HY, Keller JJ, Lin HC (2012) A one-year follow-up study on the incidence and risk of endophthalmitis after pyogenic liver abscess. Timing of administration of the intravitreal antibiotics has not been officially established; however, Yonekawa et al. doi:10.1097/IAE.0000000000000135, Cho M, Khanifar AA, Chan RV (2011) Spectral-domain optical coherence tomography of endogenous fungal endophthalmitis. reported seven cases of EE caused by vancomycin-resistant bacteria [62]. 1, 11, 15, 16 If vagal maneuvers are . To optimize visual outcome, early diagnosis and treatment are essential. Hussain I., Ishrat S., Ho D.C., Khan S.R., Veeraraghavan M.A., Palraj B.R., Molton J.S., Abid M.B. Successful treatment of endogenous endophthalmitis with extensive subretinal abscess: A case report. Liver abscess is a rare disease, but it is associated with high mortality, up to 15% [19]. A recent report suggested decreasing incidence of neonatal EE in the developed world [32]. Visible massive fibrous proliferation on the optic nerve disc and subretinal proliferations, lifting the retina. Endophthalmitis can be classified as exogenous - following either trauma or an intraocular procedure, or endogenous and hence hematogenous in origin. Rodrigues IA, Jackson TL (2014) A high-definition view of endogenous fungal endophthalmitis. Neonatal endogenous endophthalmitis deserves a special mention. Other findings include corneal edema, presence of iris nodules, and pupillary distortion secondary to synechiae formation [44, 45]. Retina 34(3):592602. Endogenous Endophthalmitis From Methicillin-Resistant Staphylococcus aureus Bacteremia Treated With Ceftaroline - PMC Back to Top Skip to main content An official website of the United States government Here's how you know The .gov means it's official. Complications of EE, including retinal detachment may be difficult to assess clinically. Age, sex, and race are irrelevant to the risk of developing EE. Kashani A.H., Eliott D. The emergence of Klebsiella pneumoniae endogenous endophthalmitis in the USA: Basic and clinical advances. Endogenous endophthalmitis is an ophthalmic emergency that can have severe sight-threatening complications. Interestingly, inflammation occurs more often in the right eye. Nepal J Ophthalmol 4(1):179183. Retina 34(9):19141915. MKS participated in drafting the manuscript. Prevention of evisceration or enucleation in endogenous bacterial panophthalmitis with no light perception and scleral abscess. However a clinical diagnosis of EE is always difficult as it has a high false negative rate for EE [5, 49]. government site. Decision of early vitrectomy has also been associated with a decrease in incidence of retinal detachment and evisceration or enucleation [15, 81]. These can be detected as dome-shaped lesions arising from the choroid on B-scan. Group A and B streptococcus, Streptococcus pneumoniae, Kingella, Pseudomonas, Serratia, and Escherichia coli are less common. However, patients included in these statistics often received antibiotics before collecting the material for culture [18]. the contents by NLM or the National Institutes of Health. A natural history study of experimental stuphylococcus epidermidis endophthalmitis. Clinical findings in EE can be subdivided into three categories to aid the ophthalmologist to rule in the diagnosis. Results: A 56-year-old man presented with acute bilateral blurred vision and floaters with fever and hemodynamic instability. J Ophthalmol 2012:265078. doi:10.1155/2012/265078, de Lima LM, Cecchetti SA, Cecchetti DF, Arroyo D, Romao EA, Dantas M, Neto MM (2012) Endophthalmitis: a rare but devastating metastatic bacterial complication of hemodialysis catheter-related sepsis. In such situations, ultrasound B-scan can help in identification of retinal detachment (Fig. Lu X., Chen W., Xia H., Zheng K., Jin C., Ng D.S., Chen H. Atrophy of retinal inner layers is associated with poor vision after endophthalmitis: A spectral domain optical coherence tomography study. Microorganisms associated with this condition vary along a broad spectrum. Transthoracic echocardiogram is not recommended to rule out endocarditis [28]. Google Scholar, Grixti A, Sadri M, Datta AV (2012) Uncommon ophthalmologic disorders in intensive care unit patients. When symptoms take longer to emerge, it is chronic endophthalmitis. The prognosis for EE in the course of osteomyelitis is as poor as for other cases. Ocul Immunol Inflamm 8(3):189200, Sowmya P, Madhavan HN (2009) Diagnostic utility of polymerase chain reaction on intraocular specimens to establish the etiology of infectious endophthalmitis. doi:10.1093/cid/cir355, Article Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK, et al. An intravitreal injection of drugs may also be given while performing the surgery. The Lancet Infect Dis 14(4):358. doi:10.1016/S1473-3099(13)70216-0, Adam CR, Sigler EJ (2014) Multimodal imaging findings in endogenous Aspergillus endophthalmitis. It serves as a diagnostic as well as therapeutic purpose. Delayed diagnosis may exacerbate the poor visual prognosis. Visible aggregates of inflammatory cells accumulated on the endothelium. Median time from onset of symptoms or signs to first treatment was seven days (range one-40 days). Endogenous endophthalmitis: diagnosis, management, and prognosis. According to the available literature, errors in diagnosis may concern up to 2533% of cases [3,4]. Diagnosis and Management of Osteomyelitisof Osteomyelitis. In Europe, endocarditis is the third most common infectious source in patients with EE [29]. The study was conducted in accordance with the Declaration of Helsinki. volume5, Articlenumber:32 (2015) However, recently, there have been reports of gram-positive cases resistant to vancomycin [61]. reported that the eyes with bacterial EE had a worse outcome with more patients requiring enucleation or evisceration compared to patients with fungal EE [21]. Sallam et al. sharing sensitive information, make sure youre on a federal The disease can develop bilaterally, but most cases (over 70%) affect one eye [11]. Bloom C., Thomson E.C., Main J. Physician Assist. They participate in destroying pathogens without damaging ocular tissue and also inhibit immune cell infiltration [7]. Patients with comorbid conditions, especially with diabetes, malnutrition, and immunosuppression, are at greater risk [20]. In some reports, up to 50% of candidemia patients had EE [70]. The organisms most frequently isolated during infection are Streptococcus species, Klebsiella pneumoniae and Escherichia coli. The inflammatory process can affect the heart valves, resulting in their destruction and formation of abscesses. This underscores the importance of detecting and promptly treating the disease at early stages to preserve visual acuity [80]. Medicine 82(2):97105, Palexas GN, Green WR, Goldberg MF, Ding Y (1995) Diagnostic pars plana vitrectomy report of a 21-year retrospective study. The usual dose of voriconazole is 100200mcg in 0.1ml sterile water. The other classic features include eyelid edema, conjunctival injection, circumcorneal congestion, pain, photophobia, and the presence of floaters [5]. Tuon F.F., de Almeida G.M.D., Costa S.F. doi:10.1097/01.iae.0000250011.68532.a2, Marangon FB, Miller D, Giaconi JA, Alfonso EC (2004) In vitro investigation of voriconazole susceptibility for keratitis and endophthalmitis fungal pathogens. EE is frequently associated with many underlying systemic risk factors [3, 5, 10, 1623]. Bethesda, MD 20894, Web Policies Ullman A.J., Marsh N., Mihala G., Cooke M., Rickard C.M. On the other hand, in severely ill patients, ocular signs and symptoms are often disregarded [2]. In a study conducted to determine factors resulting in poor visual outcome, worse initial visual acuity and centrally located lesions were found to be associated with poor visual outcomes [81]. Depending on the pathway by which microbes enter the eye, we distinguish between two basic forms of inflammation. 1). Endogenous endophthalmitis (EE) is a sight-threatening emergency and the aetiology is often multifactorial. Google Scholar, Lingappan A, Wykoff CC, Albini TA, Miller D, Pathengay A, Davis JL, Flynn HW Jr (2012) Endogenous fungal endophthalmitis: causative organisms, management strategies, and visual acuity outcomes. Google Scholar, Lim HW, Shin JW, Cho HY, Kim HK, Kang SW, Song SJ, Yu HG, Oh JR, Kim JS, Moon SW, Chae JB, Park TK, Song Y (2014) Endogenous endophthalmitis in the Korean population: a six-year retrospective study. doi:10.1097/IAE.0b013e3182a2e705, Sridhar J, Flynn HW Jr, Kuriyan AE, Miller D, Albini T (2013) Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections. Ghoraba H.H., Ellakwa A.F., Elgemai E.M., Mansour H.O., Heikal M.A. Medical databases contain numerous case reports of EE in injecting drug users caused by less common pathogens such as Serratia [72,73]. A rarer but equally serious complication of EE is chronic hypotony. Diagnostic dilemmas in retinitis and endophthalmitis. The authors declare no conflict of interest. Table2 lists the most commonly used intravitreal antibiotics. Moreover, the pathogens causing EE has specific characteristics that make them more dangerous to the eye tissue. This method of treatment is widely used and effective. Surv Ophthalmol 31(2):81101, Samiy N, DAmico DJ (1996) Endogenous fungal endophthalmitis. Methicillin-resistant Staphylococcus aureus, Khan FA, Slain D, Khakoo RA (2007) Candida endophthalmitis: focus on current and future antifungal treatment options. Identifying the primary source of infection is important as most of these conditions require intensive and rapid treatment as life-threatening conditions. Open Access. J. In a retrospective review of EE presented in 20092016 at a reference center in southern India, urinary tract infection was the most common coexisting infection, occurring in 32.5% of cases [12]. Treatment depends on the underlying cause of endophthalmitis. Federal government websites often end in .gov or .mil. doi:10.3109/09273940903494717, Major JC Jr, Engelbert M, Flynn HW Jr, Miller D, Smiddy WE, Davis JL (2010) Staphylococcus aureus endophthalmitis: antibiotic susceptibilities, methicillin resistance, and clinical outcomes. Clinical Features of Endogenous Endophthalmitis Secondary to Minimally Invasive Upper Urinary Tract Calculus Removal. Liver abscess due to Klebsiella was described in Taiwan in the 1990s. Wang W.J., Tao Z., Wu H.L. doi:10.1016/j.ajo.2003.11.078, Jorgensen JS, Prause JU, Kiilgaard JF (2014) Bilateral endogenous Fusarium solani endophthalmitis in a liver-transplanted patient: a case report. In the case of EE, an additional risk for the patient is the presence of a primary source of infection, which can be directly life-threatening. In most cases, the primary source of the infection is easy to diagnose as inflammation causes symptoms such as pain, fever, or malaise. Visual acuity, systemic debility, etiology of infection, and ocular examination must guide the decision to intervene in such cases. However, it is an expensive method and still not widely used. However, there have been no major reviews encompassing all the infective etiologies, including both bacterial and fungal, in literature. Somya et al. It achieves an excellent intravitreal concentration after oral or intravenous administration [36]. However, they still suggested the use of surgical intervention, especially in patients with anterior chamber inflammation that did not respond well to intravitreal antibiotics. In connection with attempts to repair the breakdown of the bloodretinal barrier, some researchers suggest the use of corticosteroids in the course of EE. Other rare complications are peritonitis, endocarditis, osteomyelitis, and meningoencephalitis. Staphylococcal endogenous endophthalmitis in association with pyogenic vertebral osteomyelitis. Clin Experiment Ophthalmol 39(8):771778. In contrast, intraocular infections due to viruses or parasites (eg, cytomegalovirus [CMV] retinitis, toxoplasma chorioretinitis) are usually considered types of infectious uveitis rather than endophthalmitis. Early diagnosis and proper treatment are keys to saving the eye. Federal government websites often end in .gov or .mil. Subsequently, a major review including approximately 335 cases of bacterial EE was published in 2003 [11], and the authors have recently updated their initial data by accommodating further reports [13]. The source of pathogens in endogenous endophthalmitis is located inside the body, and infection spreads hematogenously. Clinical features include conjunctival hyperemia , corneal haziness, hypopyon , and decreased visual acuity . In fungal infections, general treatment is usually sufficient in cases of chorioretinitis that proceed without lesions threatening the macular area. In the case of endogenous endophthalmitis, reaction time is absolutely crucial for prognosis. OCT examination of the patient presented in Figure 15. In fungal infections, characteristic cotton-like foci on the retina and in the vitreous body often appear, often in the form of strings of pearls (Figure 11). Patients with EE were more likely to have comorbidities such as diabetes, heart valve disease, kidney damage, cirrhosis, or a history of cancer [67]. On the other hand, Sheu et al. In the published literature, most EE cases of Streptococcus pneumoniae etiology eventually lose light perception [33]. It is recommended for severe and sight-threatening Candida, Aspergillus, or bacterial endophthalmitis [5, 73, 79]. In most of these cases with Klebsiella, diabetes is the major underlying systemic risk factor [25, 26]. They include hemorrhage into the vitreous chamber, retinal tear, lens damage, temporary increase in intraocular pressure, and hemorrhagic occlusive retinal vasculitis [86,87]. doi:10.1097/IAE.0b013e31820d3f9e, Ang M, Jap A, Chee SP (2011) Prognostic factors and outcomes in endogenous Klebsiella pneumoniae endophthalmitis. Visual acuity, as explained above, can be variably affected at the time of presentation, but is generally used as an outcome measure along with a dilated funduscopic examination to follow up the patient after starting treatment. With properly selected antibiotic therapy, even large abscesses may be absorbed. A total of 370 patients were enrolled; among them, 60 (16.2%) patients were found to have ocular manifestations on fundoscopic examination. Pharmacotherapy 27(12):17111721. Osteomyelitis is an inflammatory process caused by an infecting microorganism. Eye (Lond) 25(1):6672. Performing a vitrectomy improved the prognosis of final visual acuity and decreased the risk of progression to the state requiring enucleation [88]. doi:10.1016/j.ejogrb.2008.12.007, Padberg S, Wacker E, Meister R, Panse M, Weber-Schoendorfer C, Oppermann M, Schaefer C (2014) Observational cohort study of pregnancy outcome after first-trimester exposure to fluoroquinolones. In approximately 18% of the patients, new lesions were seen after an initial negative funduscopic examination. Various causes of transient bacteremia such as routine colonoscopy can also lead to EE [29]. This finding is most prominently noted in the Asian population where bacterial endophthalmitis is more common [15]. The causative organisms are often bacteria from Streptococci species, especially S. agalactiae, gram-negative rods like Klebsiella or Pseudomonas and fungi including Candida species. Curr Opin Ophthalmol 12(6):464470, Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C, Schlamm HT, Oborska IT, Rex JH, Kullberg BJ (2011) Ocular manifestations of candidemia. Clinical review of endogenous endophthalmitis in Korea: A 14-year review of culture positive cases of two large hospitals. It is important to note that EE has also been reported in immunocompetent patients without underlying predisposing conditions. A large analysis of 342 cases of bacterial EE showed that osteomyelitis accounted for only 0.58% of cases [4]. Am J Ophthalmol 137(5):820825. Licensee MDPI, Basel, Switzerland. Endophthalmitis typically causes severe ocular ache and decreased vision. OCT examination of the patient presented in Figure 11. Usually, amphotericin or voriconazole is used. The authors declare that they have no competing interests. In cases of bacterial EE, vitrectomy is generally performed when there is no response to intravitreal antibiotics within 48h or when the eye condition continues to decline or with a worse grade of RAPD [26]. doi:10.3109/09273948.2013.870212, Itoh M, Ikewaki J, Kimoto K, Itoh Y, Shinoda K, Nakatsuka K (2010) Two cases of endogenous endophthalmitis caused by gram-positive bacteria with good visual outcome. Kim S.J., Seo S.W., Park J.M., Chung I.Y. . Early diagnosis and treatment has been associated with 64% of patients having visual acuity of counting fingers (CF) or better in one study for bacterial EE [28]. From a diagnostic point of view, it is extremely important that over 16% of Klebsiella patients with EE have negative blood culture results. This happens when specific types of bacteria or fungi enter the eye. Candidemia increases the risk of developing EE 15 times [67]. Similarly MRSA endophthalmitis has been reported to be associated with significant mortality [28]. PubMed The histopathological examination of the removed eyes also shows deep inflammatory changes, infiltration of tissues by inflammatory cells, and their disorganization [10]. c A wide-angled fundus photograph of the left eye with vitreous haze secondary to vitritis along with focal sheathing of superior vessels. In a retrospective study in one of the Danish centers carried out in the years 20002016, it was shown that complications after intestinal surgery were the source of EE in 6% of cases [14]. In order to avoid mistakes, a thorough medical history and physical examination should be carried out. Previous large series have shown higher rates of positivity following blood culture as compared to vitreous aspirate possibly due to larger volume sampled. For severe vitritis, the best approach appears to be vitrectomy accompanied by intravitreal injection of amphotericin or voriconazole and systemic antifungal therapy [70, 71]. A Am J Ophthalmol 151(6):11051106. Breazzano M.P., Jonna G., Nathan N.R., Nickols H.H., Agarwal A. Endogenous Serratia marcescens panophthalmitis: A case series. PubMed The blue arrow marks a detached retina. Direct spread from contagious sites can also occur in cases of central nervous system infection via the optic nerve [41]. doi:10.1016/S0140-6736(04)17228-0, Chhablani J (2011) Fungal endophthalmitis. As with infections associated with intravenous drug use, Rhodotorula infections are increasingly being observed in immunocompromised patients with CVADs. Confirmatory identification of extra ocular sources of infection are reported in 21100% of cases in the literature [5, 18, 21]. However, in different reports proportions ranged widely due to geographic, genetic or alimentary factors [2]. It is an uncommon but visual severe loss cause that may have devastating ocular and systemic complications [ 1 ]. Posterior adhesions causing pupil irregularities. OCT examination of the patient presented in Figure 15. and R.K.; writingoriginal draft preparation, M.G., K.F. What is more surprising, the prevalence of diabetes mellitus remains significantly higher in patients with Klebsiella liver abscess as compared to the patients with non-Klebsiella etiology [25]. AA participated in the analysis and revision of the manuscript. doi:10.1016/j.ajo.2010.07.008, e51, Noyola DE, Bohra L, Paysse EA, Fernandez M, Coats DK (2002) Association of candidemia and retinopathy of prematurity in very low birthweight infants. There have been many reports on the incidence of EE in patients with bacteremia and fungemia. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Candida and is more common in immunocompromised individuals. Livingston E.T., Mursalin M.H., Callegan M.C. The source of this relationship is seen in the differences in drug use between men and women. However, the study did report better final visual outcomes in patients with initial visual acuity better than counting fingers. The decision regarding vitrectomy is usually based on the clinicians judgment. Other non-specific findings can include flame-shaped hemorrhages, Roth spots and cotton wool spots [6, 45]. Common ocular signs and symptoms associated with EE include conjunctival injection, ocular pain, and reduced visual acuity. Jpn J Ophthalmol 45(2):181186, Tanaka M, Kobayashi Y, Takebayashi H, Kiyokawa M, Qiu H (2001) Analysis of predisposing clinical and laboratory findings for the development of endogenous fungal endophthalmitis. Ansari A.S., Lai K., Tejwani D. An unexpected case of iatrogenic Escherichia coli endogenous pan-endopthalmitis after ERCP-associated biliary sepsis: A case report. Google Scholar, Novosad BD, Callegan MC (2010) Severe bacterial endophthalmitis: towards improving clinical outcomes. doi:10.1128/AAC.02413-14, Barza M (1998) Treatment options for candidal endophthalmitis [editorial; comment]. Poowanawittayakom N., Dutta A., Stock S., Touray S., Ellison R.T., Levitz S.M. In the US and Western countries, it is currently estimated to be 4.1 per 100,000, in Canada, the United Kingdom and Denmark it is 1.12.3 per 100,000. Persistent edema of the macular area seen on OCT. A much more serious complication of intense inflammation is the development of proliferative vitreoretinopathy. In a neonate with white reflex, endophthalmitis (along with other considerations such as malignancy) must be kept as a possibility in the differential diagnosis. Infective endocarditis presenting as endogenous endophthalmitis secondary to Streptococcus agalactiae in a healthy adult: Case report and literature review. Endogenous endophthalmitis is an ophthalmic emergency that can have severe sight-threatening complications. In a meta-analysis of EE cases published between 2001 and 2012, 56% of patients received systemic antibiotics, 76% received intravitreal antibiotics, 12% received intravitreal corticosteroids, and 32% of eyes underwent vitrectomy. Endogenous endophthalmitis: diagnosis, management, and prognosis, https://doi.org/10.1186/s12348-015-0063-y, Journal of Ophthalmic Inflammation and Infection, http://creativecommons.org/licenses/by/4.0/. Although the first symptoms of infection occur thanks to non-resident cells, which allows for its diagnosis and treatment, it is the action of these cells that is responsible for the destruction of extremely delicate eye tissues [7]. Pillai G.S., Remadevi K.K., Anilkumar V., Radhakrishnan N., Rasheed R., Ravindran G.C. Retina 25(6):746750, Sugita S, Kamoi K, Ogawa M, Watanabe K, Shimizu N, Mochizuki M (2012) Detection of Candida and Aspergillus species DNA using broad-range real-time PCR for fungal endophthalmitis. Additionally, gastrointestinal procedures are associated with an increased risk of spreading microorganisms through the bloodstream, and thus the development of EE [47]. Lancet 364(9443):14391450. Villasmil R.J., Lattanzio N., Burns K., Alkayali T. More Than Meets the Eye: Infective Endocarditis Presenting as Endogenous Endophthalmitis. Zhang et al. Early diagnosis and treatment is essential for a better prognosis. https://doi.org/10.1186/s12348-015-0063-y, DOI: https://doi.org/10.1186/s12348-015-0063-y. Bacterial and Fungal Endophthalmitis. Endophthalmitis (pronounced en-dof-thal- my-tis) is the medical name for an infection that affects the inside of your eye. Large retrospective studies from 2000 to 2016 found that EEs associated with the presence of CVAD account for 4% of cases [14]. In general, endogenous fungal endophthalmitis does not have a favorable prognosis and results in complete vision loss, especially if diagnosis and treatment are delayed. Retina 29(6):831834. It is often a diagnostic challenge because it can manifest at any age and is associated with a number of underlying predisposing factors. All authors read and approved the final manuscript. doi:10.1038/eye.2010.95, Jackson TL, Paraskevopoulos T, Georgalas I (2014) Systematic review of 342 cases of endogenous bacterial endophthalmitis. The risk of a hospitalized patient developing EE from bacteriemia or fungemia is low, 0.050.4% [17]. The test material may be aqueous fluid, vitreous, blood, and urine [1]. Another emerging technique is the use of real-time polymerase chain reaction (RT-PCR) of aqueous and vitreous samples for detection of the etiology of EE. doi:10.1586/eop.10.52, Article The genitourinary system is the common way by which pathogens gain access to the bloodstream. found that all the patients in their study needing enucleation were infected by Klebsiella [10]. The prognosis of patients with endogenous endophthalmitis is disappointing; even with aggressive treatment, useful vision (i.e., ability to count fingers or better) is preserved in only about 40% of patients .
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