Endophthalmitis

Endophthalmitis is an abscessing inflammation of the internal structures of the eye, leading to the accumulation of purulent exudate in the vitreous body. With endophthalmitis, there are pains in the eyeball, swelling and redness of the eyelids and conjunctiva, a significant decrease in visual acuity, hypopion. In the diagnosis of endophthalmitis, visometry, field of vision examination, biomicroscopy of the eye, diaphanoscopy, ophthalmoscopy, electroretinography, ultrasound of the eye are used. Complex treatment includes antibiotic therapy, detoxification, anti-inflammatory, resorption therapy; intravitreal, parabulbar or subconjunctival injections, paracentesis and anterior chamber lavage; in severe endophthalmitis – vitrectomy.

ICD 10

H45.1 Endophthalmitis in diseases classified elsewhere

General information

Purulent inflammation of the tissues of the eyeball are among the formidable conditions in ophthalmology that require specialized emergency care. The purulent process in endophthalmitis progresses rapidly, sometimes within a few hours leading to the development of panophthalmitis – total inflammation and melting of all the membranes of the eyeball and orbital tissues. According to various data, the frequency of blindness, functional and anatomical death of the eye, leading to enucleation, in patients with intraocular infection reaches 28-89%. These circumstances pose to ophthalmologists the task of timely prevention, early detection and adequate treatment of infections of the eyeball.

Causes

Exogenous causes

Exogenous cases of intraocular tissue infection are mainly associated with the following factors:

• penetrating eye wounds (95-97%),
• operations on the eyeball (2-4%),
• punctured purulent ulcers of the cornea,
• infected burns of the eyes.

The structure of mechanical eye injuries accompanied by the development of endophthalmitis is dominated by childhood injuries (40%), industrial (30%) and agricultural (25-50%) injuries. Penetration of a foreign body into the eye significantly increases the risk of endophthalmitis. Postoperative endophthalmitis develops more often due to cataract extraction with implantation of a posterior chamber IOL.

With exogenous infection of the eye, primary and secondary microbial invasion is isolated. In the first case, microbes get into the deep structures of the eye at the time of penetrating injury or invasive intervention, and the inflammatory reaction develops already in the first 2-3 days. With secondary microbial invasion, infection develops at a late date due to inadequate primary treatment of the wound, its gaping, crushing of the edges, etc.

Endogenous causes

The endogenous mechanism of endophthalmitis development occurs in 1-2% of cases and is associated with hematogenous introduction of microbial pathogens into the capillaries of the iris and ciliary body from distant inflammatory foci in the body when:

• boils, abscesses, phlegmon,
• sinusitis, tonsillitis,
• pneumonia,
• osteomyelitis,
• sepsis,
• meningitis,
• septic endocarditis, etc.

The pathogens of exogenous and endogenous endophthalmitis are diverse. The most common bacteriological examination reveals staphylococci, Streptococci, Corynebacteria, proteus, Hemophilus bacillus, Pseudomonas aeruginosa, Neisseria, Enterobacteria, Klebsiella, pneumococci and various polymicrobial associations. A dangerous variety is fungal endophthalmitis, which can be caused by more than twenty varieties of fungi (the genus acremonium, candida, aspergillus, cephalosporium, neurospora, etc.).

Pathogenesis

The pathogenesis of endophthalmitis in exogenous infection is multifaceted. In case of violation of the integrity of the cornea or sclera, microorganisms penetrate into the vitreous body, where they multiply freely. An intraocular focus of infection is formed, which quickly spreads to all the membranes of the eye. In turn, the violation of the immunological isolation of the eye is accompanied by an autoimmune inflammatory reaction, which contributes to the weakening of the resistance to infection, and the aggressive course of endophthalmitis and panophthalmitis.

The resulting purulent exudate leads to uveitis, melting of the vascular and mesh membranes, encapsulation with the formation of mooring. Mooring subsequently causes traction and retinal detachment with the outcome of hypotension and atrophy of the eyeball.

Symptoms

Endophthalmitis can occur by the type of a delimited focus in the eye (vitreous abscess) or a diffuse process; sometimes a mixed form occurs. According to the severity of symptoms, there are mild, moderate and severe degrees of endophthalmitis.

Exogenous endophthalmitis develops 2-3 days after mechanical damage to the eye. The progressive course of the disease is accompanied by pain in the eyeball, an increasing decrease in visual acuity, sometimes to light perception, floating opacities in the field of vision. External changes of the eye are characterized by moderate swelling of the eyelids and conjunctiva, a sharp mixed injection of the eyeball. Signs of iridocyclitis may develop. A characteristic feature of endophthalmitis is the formation of an abscess in the vitreous body, which shines through the pupil with a yellowish glow.

Complications

With severe endophthalmitis, pronounced chemosis, hypopion and suppuration develop. Endogenous endophthalmitis occurring against the background of immunodeficiency or intoxication may be bilateral in nature. The progression of endophthalmitis leads to the transition to panophthalmitis, which threatens the anatomical and functional death of the eye, the risk of meningitis.

Diagnostics

A comprehensive ophthalmological examination for endophthalmitis allows you to assess the severity of the process and develop therapeutic tactics. If endophthalmitis is suspected , it is carried out:

• Visometry. A typical ophthalmological picture with endoophthalmitis is characterized by a decrease in visual acuity: with a mild degree – partial, with an average degree – pronounced, with severe – a significant decrease or absence of vision.
• The study of visual fields. The field of view is narrowed or absent.
• Biomicroscopy. Biomicroscopy reveals a mixed injection of the eyeball, the presence of precipitates on the surface of the cornea, hypopion, hyperemia and infiltration of the iris, the formation of posterior synechiae
• Diaphanoscopy of the eye. Diaphanoscopy of the eye in transmitted light allows you to detect a yellowish-gray pupillary reflex, indicating the formation of an abscess in the vitreous body. With the reverse development of endophthalmitis, due to the formation of connective tissue in place of the abscess, the reflex acquires a milky white hue.
• Ophthalmoscopy. Direct and reverse ophthalmoscopy in endophthalmitis is difficult and partially possible only with mild severity of the disease.
• Measurement of IOP. Intraocular pressure in endophthalmitis is usually reduced.
• Ultrasound of the eyes. Reveals limited or total opacities in the vitreous body. To verify the pathogen, a culture of vitreous and watery moisture is seeded.
• Electrophysiological studies. Electroretinography indicators may correspond to or be close to normal (with focal endophthalmitis), significantly decrease until disappearance (with diffuse or mixed endophthalmitis).

The consequences of endophthalmitis in children need to be differentiated from a malignant retinal tumor – retinoblastoma.

Treatment

Treatment of endophthalmitis is carried out in the conditions of the department of surgical ophthalmology. Immediately after the diagnosis is made , it is prescribed:

1. Systemic therapy: shock doses of broad-spectrum antibiotics, sulfonamides, antimycotics, anti-inflammatory drugs (NSAIDs, corticosteroids), powerful detoxification therapy, restorative therapy (vitamin therapy, autohemotherapy), resorption therapy (enzymes).
2. Intraocular injections. To achieve the maximum concentration of antibacterial drugs inside the eye, their intravenous, intramuscular, subconjunctival, retrobulbar, parabulbar, suprachoroidal, intravitreal administration is carried out. At the same time, instillations of antimicrobial eye drops and applications of ointments are prescribed.
3. Puncture of the vitreous body. With vitreitis or hypopion, a therapeutic and diagnostic puncture of the vitreous body is performed with the collection of exudate for bacterial seeding and the introduction of an antibiotic into the vitreous body. With endophthalmitis, intraarterial ophthalmoperfusion of drugs through the supraorbital artery is possible. For the treatment of endophthalmitis, cephalosporins, glycopeptides, penicillins, aminoglycosides, fluoroquinolones, macrolides, etc. are used.

If intensive conservative therapy of endophthalmitis is ineffective, there is a need for surgical removal of a part of the vitreous body – vitrectomy. In the postoperative period, antibiotic therapy should be continued.

Prognosis and prevention

Timely comprehensive treatment of endophthalmitis, started in a mild stage, allows you to preserve visual functions. In later stages, it is often possible to preserve the eye as an anatomical organ, but it is almost impossible to save vision. The outcome of endophthalmitis is most often subatrophy and atrophy of the eyeball. With the progression of endophthalmitis into panophthalmitis, it is necessary to resort to enucleation of the eyeball.

Prevention of exogenous infectious endophthalmitis requires the prevention of eye injuries, adequate PST wounds in penetrating wounds, timely removal of foreign bodies of the conjunctiva and cornea, competent operations on the structures of the eye. To exclude the development of endogenous endophthalmitis, it is necessary to sanitize focal purulent foci and treat general septic conditions.