Post-Traumatic Endophthalmitis

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Disease Entity

Disease

Intraocular infection involving the anterior and posterior segment of the eye after a traumatic open globe injury.

Etiology

Introduction of infectious agent into the eye during trauma can result in post-traumatic endophthalmitis. The incidence of endophthalmitis is reported in up to 12% of eyes with history of penetrating injury without IOFBs. Higher infection rates are noted in eyes with open globe injury contaminated with organic matter.

Most of the cases of post-traumatic endophthalmitis are bacterial, usually gram-positive organisms - Staphylococcus, Streptococcus, Enterococcus and Bacillus species. 10% –15% are due to gram-negative organisms mainly Pseudomonas aeruginosa and some species of Enterobacteriaceae. Polymicrobial post-traumatic endophthalmitis account for 10-30% of cases, caused by Gram-positive bacteria, Gram-negative bacteria or mixed organisms. Candida species, Aspergillus and Fusarium are fungal entities that have been identified in chronic indolent cases.

Risk Factors

  • Delayed primary repair of open globe injury by greater than 24 hours
  • Intraocular Foreign Body (IOFB)
  • Contaminated injury with soil, rural or organic matter
  • Lens rupture
  • Large wound size
  • Vitreous prolapse through the open globe wound


General Pathology

Infection of the vitreous, retina, and the anterior segment of the eye.

Pathophysiology

Infectious agents are introduced at the time of primary open globe injury. The trauma usually occurs in a non-sterile environment which increases the risk of infection. Prophylactic antibiotics are used during the repair of the primary injury but the best route and duration of the antibiotics to decrease the risk of endophthalmitis in non-IOFB penetrating injuries is not clear.

Primary prevention

  • Expedited closure of the open globe wound
  • Expedited removal of IOFB
  • Use of intravitreal antibiotics in cases of IOFB

Diagnosis

History

A recent history of penetrating ocular trauma is present.

Physical examination

Includes a detailed anterior segment and posterior segment examination. A B-scan of the posterior segment may be performed in traumatic eyes suspicious for IOFBs.

Signs

  • Conjunctival injection +/-Chemosis
  • Purulent discharge
  • Mild to moderate anterior chamber reaction
  • Hypopyon +/- fibrin membranes
  • Vitritis
  • Lid edema
  • Possible periorbital erythema and proptosis


Symptoms

  • Depend on the virulence of the organism.
  • Range from mild photophobia and pain to excruciating pain, tearing and decreased vision.
  • Pain may be out of proportion to the injury.


Clinical diagnosis

Diagnosis can be difficult in early infection in traumatized eyes. However, pain with hypopyon and vitritis suggests an infection until proven otherwise. It is important to distinguish bacterial from fungal infection since the treatment is different. The patient with a fungal infection may just have mild discomfort.

Diagnostic procedures

  • B-scan to evaluate for vitreous opacities, IOFB and status of retina and choroid
  • CT scan to evaluate a retained IOFB if the history is suspicious for one.


Laboratory test

  • Cultures from the wound, vitreous and possibly anterior chamber for identification of aerobic, anaerobic bacteria and fungus. Gram stain and KOH preparation of vitreous should also be ordered. Only 70% of vitreous cultures usually yield positive results. PCR assays of vitreous for identification of bacterial and fungal strains should be considered.
  • Blood cultures if septicemia suspected

Differential diagnosis

  • Post-traumatic non-infectious inflammation
  • Phacoanaphylactic endophthalmitis

Management

General treatment

Emergent admission to the hospital for emergent localized ocular treatment and systemic antibiotic treatment.

Medical therapy

  • Start systemic antibiotics immediately; vancomycin 1 g q12h and ceftazidime 1g q8h is initiated. Addition of clindamycin (300 mg every 8 hours), amikacin (240 mg q8hr) or gentamycin 80 mg q8hr should be considered in severe cases suspicious for Bacillus (history of IOFB) or anaerobic bacteria. Systemic fluconazole (200 mg BID) or more recently, voriconazole (200mg BID) is recommended intravenously for fungal infections.
  • Perform expeditedexpedited vitreous biopsy with empiric intravitreal vancomycin 1mg/0.1ml and ceftazidime 2.25 mg/0.1ml injections in cases where emergent pars plana vitrectomy cannot be performed.
  • Initiate fortified topical vancomycin (50 mg/ml) with ceftazidime (100 mg/ml) every hour


Medical follow up

  • Inhospital stay of 3-5 days for intravenous antibiotic treatment with daily follow-up for clinical examination and B-scan of the vitreous cavity is recommended.
  • Once hypopyon resolves and vitritis improves, the antibiotics are switched to the oral route and the patient is discharged from the hospital. Oral fluoroquinolones (e.g. Ciprofloxacin 750 mg q 12 hr) are widely used for bacterial infections and oral voriconazole (200 mg BID) for fungal infections.
  • Semiweekly to weekly follow-ups with B-scans are performed until the infection fully resolves.


Surgery

  • Immediate pars plana vitrectomy (PPV) with intravitreal antibiotics is the mainstay of treatment for post-traumatic endophthalmitis. Bacterial and fungal cultures of undiluted vitreous are ordered. For mild suspicious cases of traumatic endophthalmitis, intravitreal antibiotics (without vitrectomy) with vitreous cultures can be considered
  • Emergent removal of intraocular foreign bodies, if present
  • Empiric intravitreal vancomycin 1mg/0.1ml and ceftazidime 2.25 mg/0.1ml injections are given during PPV. Avoid aminoglycosides for gram negative coverage due to high risk of retinal toxicity. If history of IOFB is elicited, suspect Bacillus. B. Cereus is resistant to cephalosporins and has a rapid deterioration of infection. In severe cases where Bacillus is suspected, a meticulously prepared low dose gentamycin 40ug intravitreal injection may be considered in eyes with average volume vitreous cavity with no choroidal detachment. Intravitreal corticosteroid (dexamethasone, 0.4 mg / 0.1 ml) may be *Consider amphotericin (5 ug/0.1 ml) or voriconazole (40-50 µg in 0.1 ml) intravitreal injection if vegetable matter contamination is suspected. Use of intravitreal corticosteroids is not recommended if fungal infection is suspected.


Surgical follow up

  • Daily follow-up until marked improvement of infection noted
  • Repeat intravitreal antibiotics in 48-72 hours if no improvement noted.
  • Possible repeat vitrectomy for further debridement of the infectious material in the vitreous especially if a limited vitrectomy was performed initially due to media opacity

Complications

  • Vitreous hemorrhage
  • Recurrent endophthalmitis
  • Retinal tears
  • Retinal detachment
  • Choroidal Detachment
  • Drug induced retinal toxicity
  • Cataract
  • Secondary glaucoma


Prognosis

Visual prognosis is poor and depends on the virulence of the infecting organism, presence of retinal detachment, timing of treatment, and the extent of initial injury.

Additional Resources

References

  1. Bhagat N, Nagori S, Zarbin MA. Traumatic endophthalmitis. Survey of Ophthalmology. Forthcoming.
  2. Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic endophthalmitis. Ophthalmology. 2004 Nov;111(11):2015-22.Meredith TA. Posttraumatic endophthalmitis. Archives of ophthalmology. 1999 Apr;117(4):520-1.
  3. Peyman GA, Lee PJ, Seal DV. Endophthalmitis: Diagnosis and Management. London, England: Taylor & Francis; 2004: pp 90-91.
  4. Soheilian M, Rafati N, Mohebbi MR, Yazdani S, Habibabadi HF, Feghhi M, et al. Prophylaxis of acute posttraumatic bacterial endophthalmitis: a multicenter, randomized clinical trial of intraocular antibiotic injection, report 2. Archives of ophthalmology. 2007 Apr;125(4):460-5.