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