Postoperative Endophthalmitis: Diagnosis and Symptoms

Sympathetic Ophthalmia

• A rare, bilateral diffuse granulomatous panuveitis occurs after trauma (more common) or surgery (less common)
• Typically develops two weeks to many years after a penetrating or perforating ocular injury or rarely intraocular surgery
• Uveitis may appear as early as 9 days or as late as 50-66 years
• 90% of cases present within three weeks to three months post-injury
• Removing an injured eye before sympathetic uveitis protects against inflammation in the non-injured eye if done within 2 weeks of the injury.
• Sympathetic uveitis rarely develops in the sympathizing eye after the injured eye is enucleated.

Etiology

• Etiology is unknown
• It is understood to be a delayed hypersensitivity response due to trauma or surgery on the other eye.
• Elschnig postulated that injury to the exciting eye leads to absorption and dissemination of uveal pigment, causing a hypersensitivity reaction.
• Continued absorption results in an allergic reaction in the sensitized tissue of the sympathizing eye.
• Predominantly, a T-cell lymphocyte reaction is seen in the injured and sympathizing eyes.
• Antiretinal antibodies, specifically targeting the rod outer segment and Muller cells, have been found.

Risk Factors and Symptoms

• Risk factors include prior ocular trauma with delayed wound closure and prior ocular surgery.
• Symptoms include external eyes not inflamed, severe bilateral issues, blurred vision and photophobia in the non-injured eye as a first symptom.
• Granulomatous lymphocytic infiltration to the uveal tracts is another symptom

Histopathology & Signs

• There is granulomatous inflammation throughout the uveal tissue, excluding the choriocapillaris and retinal vessels
• Yellowish-white choroidal lesions (Dalen-Fuchs nodules) clinically relate to collections of lymphocytes, histiocytes, and depigmented RPE cells beneath Bruch's membrane.
• Retinal infiltrates are present in 18% of sympathetic ophthalmia cases
• Signs include bilateral severe anterior chamber reaction, large mutton-fat keratic precipitates (KPs), and depigmented nodules (disseminated yellow-white spots in the funds).

Diagnosis & Factors that contribute to development of sympathetic ophthalmia

• Diagnosis is based history of injury or ocular surgery with clinical findings
• Use fluorescein angiography to indicate disease severity and for therapeutic guidance.
• In the acute phase, multiple hyperfluorescent leakage sites at the RPE are seen during the venous phase, persisting into late study frames
• Factors contributing to the development of sympathetic ophthalmia include penetrating type of trauma, surgical repair more than 48 hours after initial injury, and use of local and systemic corticosteroids for more than one week after initial injury.
• Also, site of injury is the ciliary body, larger than 5 mm wound size, and is more common in the first decade of life

Preventative Treatment & Prognosis

• Preventative treatment includes enucleation of the blind traumatized eye before sympathetic reaction develops however, this treatment is controversial.
• Enuclation is proposed 9 days after trauma, but best within the first 2 weeks
• Enucleation typically needs consideration within 1 to 2 months of trauma
• Prognosis: is a serious vision-threatening disease, 50% of patients will have 20/40 vision or worse, and 1/3 will end up legally blind

Anti-inflammatory Treatment Strategies

• Use atropine 1% qid for pain and to avoid synechia
• Prednisolone acetate 1% q 2h also helps
• Prednisone dosage is 1.0 to 2.0 mg/kg/day, tapered slowly over 3 to 4 months
• In severe cases, use IV Methylprednisolone 1.0 g/day for 3 days
• Immunosuppressive therapy is prescribed for steroid-resistant patients showing secondary effects
• Cyclosporine 5mg/kg/day is increased until controlled, then tapered slowly after at least 3 months by 0.5 mg/kg/day over 1-2 months

Noninfectious Postoperative Uveitis

• It involves normal inflammation where surgical manipulation breaks down the blood-aqueous barrier, causing protein leakage and cellular reaction.
• Underlying iridocyclitis due to intraocular surgery or cataract extraction
• Can be intraocular lens-related inflammation (less common with modern IOL polishing and sterilization techniques).

Endophthalmitis

• Inflammation of the intraocular tissues results from infection, trauma, immune reaction, or chemical changes
• The most common manifestation is acute postoperative endophthalmitis which is generally infectious
• Bacterial infections are the most common especially on the eyelids after surgery
• Fungal infections occur after 2 weeks

Post-surgical Bacterial Endophthalmitis

• It is uveitis secondary to bacteria where patient's own flora is the most common source
• 75% of cultures taken from normal eyes are positive for Staphylococcus epidermidis, Staph aureus and various streptococci Strep. Pyogenes or are gram negative species.
• Pseudomona, Proteus, and Escherichia coli are all gram negative

Bacterial & Streptococci

• Staph Epidermis is responsible for most cases
• Streptococci is diagnosed in 20% of infections after intraocular surgery, but account for 57% in late onset endophthalmitis after trabeculectomy
• Symptoms show a sudden onset (1-7 days postoperatively), rapid progression, pain, red eye, blurred vision (HM vs LP), floaters, photophobia, and headache along with fever and rigors

Signs in Bacterial & Streptococci

• Anterior segment signs: proptosis, hyperemia, chemosis, and swollen lids, discrete iris nodules, plagues
• Posterior segment signs: white or yellow retinal infiltrates, retinal necrosis in severe cases, spread to the orbit.

Procedures

Include:

• hospitalization, cultures and smears, anterior chamber paracentesis (0.2 ml) for aqueous samples and diagnostic vitrectomy for vitreous sample
• Significant media opacifications are seen and findings demonstrate: Dispersed vitreous opacities with vitritis and chorioretinal thickening
• Rule out RD or choroidal, dislocated lens material, and retained foreign bodies since retinal or choroidal detachments suggest poor prognosis

Treatment and Therapies

Include:

• Broad-spectrum therapy should be maintained until definitive culture reports are available
• Triple therapy is the most beneficial: intravitreal. subtenon/subconjunctival/systemic or topical antibiotics/ topical, intravitreal or oral corticoesteroids / Cycloplegic-mydriatics
• Vitrectomy is an option if there is no improvement in 36-48 hours or positive for Pseudomonas

Pharmacutical Treatments 1

• Amikacin 0.4 mg or 2.25 mg Ceftazidime + 1.0 mg of Vancomycin treats endophthalmitisto, plus glaucoma
• 1.0 mg vancomycin + 2.25 g ceftazidime or 2.0 mg of ceftriaxone helps postglaucoma filter, but may cause corneal opacification
• 0.4 mg/0.1 mL Amikacin replaces Ceftazidime for beta lactam allergy
• Periocular injection may use Gentamicin or tobramycin 40 mg (covers most organisms) and Cefazolin 100 mg (Covers pneumococcus and streptoccoci

Pharmacutical Treatments 2

• Amikacin systemically at 15 mg/kg IV or IM q 8 hrs + Cefazolin 1g IV q 6 hrs
• Fortified tobramycin or gentamicin topically at 14 mg/ml and cefazolin 133 mg/ml 2 at q 1 hr
• Steroids if not intravitreal
• Topical usage starts 24 hours after using antibiotic therapy
• Use 4-12 mg Dexamethasone phosphate/ Prednisolone succinate 25 mg subconjunctival every other day
• 40mg Oral Prednisolone qd is used for 10 days after initial therapies

Post-surgical Fungal Endophthalmitis

• Over 20 species have been isolated commonly like, Candida, Aspergiullius, Cephalosproium
• Usually appears later, 2-4 weeks from surgery
• The full clinical presentation is chronic endophthalmitis due to indolent inflammation
• Signs include some pain and redness, Transient hypopyon, Anterior/ gray-white patch, + light perception

Pharmacutical Treatments 3

• Signs and symptoms can also be masked with steroid usage which increase inflammation/ discomfort
• Treatment consists of Par plana and first choice anti-fungals such as, intravenous ampho-B along with the intra-vitreal injection after for an additive result
• Flucytosine at 50-150 mg/kg has a synergic effect while Ketoconazole should NOT be use
• Consider Natamycin q1h

Phacoanaphylactic Endophthalmitis

• Is also referred to as phacoanaphylactic uveitis
• Granulomatous inflammatory process associated with disrupted lens material
• Usually starts 14 days after the lens material has been injuries
• Rare auto-immune response to the broken-down lens protein
• Treat by removing all lens material after diagnosis is made

Test your knowledge of postoperative endophthalmitis, including causative agents, symptoms, and diagnostic signs. Questions cover anterior and posterior segment findings, as well as specific bacterial associations. Review typical presentations and complications.