A 14-Year Retrospective Analysis of Endogenous Endophthalmitis in a Tertiary Referral Center of Southern Thailand

A Retrospective Review of Endogenous Endophthalmitis: Three Years of Experience at Sultan Ahmad Shah Medical Centre at International Islamic University Malaysia

Introduction Endogenous endophthalmitis is characterized by severe intraocular inflammation caused by the invasion of microorganisms into the anterior and posterior chambers of the eye. It results from hematogenous spread from distant foci of infection. This, in turn, leads to potential vision loss and blindness due to reduced anatomical and functional outcomes. The latest reported prevalence of endogenous endophthalmitis accounts for at least 2-8% of cases of general endophthalmitis which is fairly significant. Purpose This study aimed to analyze the clinical profile of endogenous endophthalmitis presented in the Ophthalmology Clinic, Sultan Ahmad Shah Medical Centre at International Islamic University Malaysia (SASMEC@IIUM). This study includes the patients' demographics, clinical manifestations, causative organism, treatment, and final visual outcome. Methods This is a retrospective case series of endogenous endophthalmitis patients from January 2020 to June 2023. The data were obtained from the patients' medical records in SASMEC@IIUM. Results A total of six patients (six eyes) were diagnosed with endogenous endophthalmitis from January 2020 to June 2023. Four patients (66.6%) were female, with a mean age of 51.6 ± 17.5 years. Presenting visual acuity ranged between 6/21 to hand movement (HM). Five patients (83.3%) presented with reduced vision, while one presented with eye redness (16.6%). Ocular signs included vitritis and retinitis (five eyes, 83.3%), hypopyon (five eyes, 83.3%), injected conjunctiva (five eyes, 83.3%), and eyelid swelling (one eye, 16.6%). The most common primary infection seen was intraabdominal sepsis (three patients, 50%), septic arthritis, hospital-acquired pneumonia (HAP), and urinary tract infection (UTI). Vitreous biopsy was only positive in two patients (33.3%) However, five out of the six patients (83.3%) had positive blood cultures (two Staphylococcus aureus, two Klebsiella pneumoniae and one Pseudomonas aeruginosa). All patients received intravitreal injections and intravenous antibiotics. Only one patient underwent subsequent trans pars plana vitrectomy (TPPV). Final visual acuity ranged from 6/6 to no light perception (NPL). Conclusion In this case series of six patients, we observed a variety of outcomes with similar presentations despite standardized treatment in all patients. Five out of six patients showed poorer visual outcomes and only one patient showed a final visual acuity of 6/6. Therefore, further study with a larger sample size is needed to evaluate the factors associated with the final visual outcome in endogenous endophthalmitis.

Evaluation of the Clinical Course of Endogenous Endophthalmitis

Purpose: To evaluate the presentations, clinical course, treatments, and outcomes of endogenous endophthalmitis cases. Methods: Consecutive medical records from 2016 to 2021 of a county hospital and an academic, private hospital in Dallas, Texas were retrospectively reviewed. This study comprised 37 eyes of 31 patients with endogenous endophthalmitis. Collected data included demographic factors, identifiable risk factors, medical history, presenting symptoms, infectious data, complications, and best-corrected visual acuity (VA) throughout the clinical course. Results: Twenty-two eyes had bacterial endophthalmitis, 7 had fungal endophthalmitis, and 8 had infections that could not be classified. Of the bacterial cases, 5 eyes had panophthalmitis with associated cellulitis. The most common organisms were Staphylococcus aureus, Candida albicans, and Pseudomonas aeruginosa. The most common presenting symptoms were decreased vision (70%), eye redness (41%), and eye pain (38%). Among all cases, there was no significant difference in the presenting logMAR VA (1.86) before treatment and the most recent logMAR VA (1.75; P = .70) after treatment. However, fungal infections demonstrated better logMAR VA than bacterial infections 6 months after diagnosis (mean logMAR VA, 0.93 vs 2.54, respectively; P = .016) and at most recent follow-up (mean logMAR VA, 0.76 vs 2.3, respectively; P = .004). There was also a strong correlation between presenting VA and most recent VA (r2 = 0.81; P < .01). Conclusions: Visual outcomes of endogenous endophthalmitis cases were poor. Our study found 2 components to be predictive of final VA: (1) whether the infecting organism was bacterial or fungal and (2) a patient's presenting VA.

Endogenous Endophthalmitis - A Major Review

Endogenous endophthalmitis (EE) is an uncommon but potentially devastating ocular infection involving the inner layers of the eye. The global incidence of EE is on the rise. Common ocular signs and symptoms associated with EE include conjunctival injection, ocular pain, and reduced visual acuity. On clinical examination, a history of prior or coexisting systemic infections, symptoms (e.g., fever, malaise), and localizing features may be noted. Clinical diagnosis is often challenging, resulting in critical delays that contribute to a poor prognosis. Blood cultures and ocular fluid samples can aid in conforming causative pathogen(s), after which empirical antibiotic therapy, both systemic and intravitreal, should be instated. The use of steroids to suppress inflammation remains controversial. Surgical options include pars plana vitrectomy. Overall prognosis varies depending on host and pathogen factors, and early diagnosis and initiation of appropriate treatment are crucial.

Metastatic endophthalmitis presenting as subretinal abscess following a forearm furuncle

Metastatic endophthalmitis (ME) is rare form of secondary uveitis commonly prevalent in immunocompromised patients. A 55-year-old immunocompetent woman presented with painful decrease in left eye vision (referred to us as cytomegalovirus retinochoroiditis). Ocular examination revealed diffuse yellowish-white retinitis lesion (diagnosed as subretinal abscess on macular optical coherence tomography). Vitreous tap was unremarkable, but vitreous biopsy from the posterior vitreous overlying the subretinal abscess confirmed the growth of methicillin-sensitive Staphylococcus aureus (MSSA). Detailed systemic examination revealed a forearm furuncle, which yielded MSSA on culture. The infection followed relentless course despite aggressive treatment with pars plana vitrectomy and antibiotics (topical, systemic and intravitreal). This case is presented due to rarity of presentation of ME as subretinal abscess following skin infection, which became a management challenge. Due to its rapid progression and irreversible damage to ocular tissue, high index of suspicion and aggressive management is needed in such cases. The disease course, management and prognosis of such cases are dismal in majority of the patients.