Professional Documents
Culture Documents
MAJOR REVIEW
Endogenous Bacterial Endophthalmitis: A 17-year
Prospective Series and Review of 267 Reported Cases
Timothy L. Jackson,1 FRCOphth, Susannah J. Eykyn,2 FRCP, FRCPath, Elizabeth M.
Graham,1 FRCP, FRCOphth, and Miles R. Stanford,1 FRCOphth
1
Medical Eye Unit, St Thomas Hospital, London, UK; and 2Department of Infection, St Thomas Hospital, London, UK
Abstract. Endogenous bacterial endophthalmitis is a rare but serious condition that occurs when
bacteria cross the bloodocular barrier and multiply within the eye. We provide an overview of
endogenous bacterial endophthalmitis by reviewing 267 reported cases and integrating this with
our experience of an additional 19 cases. The majority of patients with endogenous bacterial
endophthalmitis are initially misdiagnosed and many have an underlying disease known to predispose
to infection. This condition is often previously undiagnosed. Blood cultures are the most frequent
means of establishing the diagnosis. The most common Gram positive organisms are Staphylococcus
aureus, group B streptococci, Streptococcus pneumoniae, and Listeria monocytogenes. The most common
Gram negative organisms are Klebsiella spp., Escherichia coli, Pseudomonas aeruginosa, and Neisseria
meningitidis. Gram negative organisms are responsible for the majority of cases reported from East
Asian hospitals, but Gram positive organisms are more common in North America and Europe. The
visual outcome is poor with most cases leading to blindness in the affected eye. Many patients
have extraocular foci of infection, with an associated mortality rate of 5%. The outcome of
endogenous bacterial endophthalmitis has not improved in 55 years and clinicians need to have a high
level of awareness of this commonly misdiagnosed condition. (Surv Opthalmol 48:403423, 2003.
2003 by Elsevier Inc. All rights reserved.)
Key words. Bacterial
endogenous
endophthalmitis
metastatic
review
404
EBE is associated with underlying medical conditions such as diabetes, cardiac disease, and malignancy in up to 90% of patients.135 Although it can
occur in isolation, hematogenous spread means it
is usually associated with other foci of infection.
Patients may present with systemic infections such as
liver abscess, meningitis, and endocarditis and subsequently develop EBE. In either setting clinicians may
fail to appreciate the overlap of ocular and systemic
disease, particularly given the low incidence of EBE.
Prompt diagnosis and treatment is essential if useful
vision is to be preserved and therefore ophthalmologists, physicians, and microbiologists need to have a
high level of awareness of this disease.
Since the last major review in 1986,71 most reports
of EBE detail the clinical features of a single patient or
small case series. This review collates 267 cases of
EBE reported in the English literature since 1986
and includes 19 cases treated in our own center.
I. Methods
A. ST THOMAS CASE SERIES
405
II. Results
A. ST THOMAS CASE SERIES
both intravitreal and intravenous antibiotics, 4 received intravenous therapy alone, and 1 had intravitreal antibiotics alone. The visual outcome was poor,
with only light perception or worse in 17 of 21 (81%)
eyes. Six of these 17 eyes became phthisical and two
required evisceration. Patients who presented with a
VA of 6/36 or better were more likely to retain useful
(count fingers or better) vision than those with an
initial VA worse than 6/36 (Fishers exact test; p
0.032).
B. LITERATURE REVIEW
4 74M S. pneumoniae
(Type 1)
Type 2
diabetes
3 74M Streptococcus
pneumoniae
Heart
failure
and
acute
renal
failure
Type 2
diabetes
Staphylococcus
aureus
Organism
2 50M S. aureus
1 55F
Age/
No. Sex
Underlying
Medical
Condition
Pain
Redness
Blurred
vision
Floaters
Ocular
Symptoms
Confusion Pain
Shortness Redness
of breath Blurred
vision
Floaters
Productive Pain
cough
Redness
Blurred
vision
Fever
Weight
loss
Spiking
fever
Systemic
Features
LE:
PL
Chemosis
Hypopyon
IOP 26 mm Hg
No fundal view
RE:
PL
Corneal edema
Hypopyon
IOP 62 mm Hg
RAPD
No red reflex
LE: 6/18
Hypopyon
IOP 13 mm Hg
Poor fundal view
LE: 6/18
Anterior
chamber cells
Vitritis
IOP 14 mm Hg
Ocular
signs
Side:
Posterior
diffuse
Posterior
diffuse
Posterior
diffuse
Posterior
diffuse
Principal
Site of
Ocular
Inflammation
Pneumonia
Pneumonia
IV canula
Other
Foci
TABLE 1
Sputum
Sputum
IV canula
Other
Positive
Cultures
IV
clarithromycin
and
levofloxacin
Intravitreal
amikacin
and
vancomycin
IV
benzylpenicillin
Intravitreal
gentamicin
and
vancomycin
IV
flucloxacillin
Intravitreal
amikacin
and
vancomycin
IV
flucloxacillin
Intravitreal
ceftazidime
and
vancomycin
Definitive
Treatment
(continued)
PL (1)
Evisc
(12)
NPL (2)
6/12 (0.25)
Visual
Outcome
(Follow-up in
months)
406
Surv Ophthalmol 48 (4) JulyAugust 2003
8 65M Group B
streptococcus
(Type 1b)
Fever
Confusion
Falls
Arthralgia
Fever
Type 2
Arthralgia
diabetes
Fever
(previously
undiagnosed)
None
7 76F
Group B
streptococcus
(Type 1b/c)
Systemic
Features
Psoriasis
Rigors
(treated
Confusion
with oral
prednisolone)
Alocohol
abuse
Group A
streptococcus
Organism
6 72M Group A
streptococcus
5 67F
Age/
No. Sex
Underlying
Medical
Condition
Blurred
vision
Blurred
vision
Redness
Blurred
vision
Blurred
vision
Ocular
Symptoms
RE:
PL
Hypopyon
IOP 28 mm Hg
No fundal view
BEs:
PL
Hypopyon
Proptosis
Restricted
extraocular
movements
LE:
HMs
Hypopyon
IOP 8
mm Hg
Reduced red reflex
RE:
PL
Hypopyon
IOP 24 mm Hg
Corneal epithelial defect
Poor fundal view
Central retinal vein
occlusion fellow eye
Ocular
signs
Side:
Septic
arthritis
Cellulitis
Infected
skin
lesions
Other
Foci
Posterior
diffuse
Mitral
valve
endocarditis
Septic
arthritis
PanUrinary
ophthalmitis tract
infection
Orbital
cellulitis
Posterior
diffuse
Posterior
diffuse
Principal
Site of
Ocular
Inflammation
Continued
TABLE 1
ND
ND
Conjuntiva
Urine
Knee
aspirate
Definitive
Treatment
IV
benzylpenicillin
Intravitreal
ceftazidime
IV
erythromycin
ceftazidime
IV
benzylpenicillin
Intravitreal
ceftazidime
and
vancomycin
IV
benzylpenicillin
Conjunctiva Intravitreal
ceftazidime
and
vancomycin
Other
Positive
Cultures
(continued)
Phthisis (2)
RE: PL
LE: NPL (1)
Phthisis (5)
PL (05)
Visual
Outcome
(Follow-up in
months)
Organism
Ocular
Symptoms
Fever
Nausea
Vomiting
Leg pain
Type 2
diabetes
(previously
undiagnosed)
11 57M Streptococcus
milleri
Pain
Redness
Blurred
vision
Pain
Redness
Blurred
vision
Multiple
Fever
myeloma
Loin pain
(previously
Arthralgia
undiagnosed)
None
Systemic
Features
10 55M Group B
streptococcus
(Type 1b)
9 60M Group B
streptococcus
(Type 1a/c)
Age/
No. Sex
Underlying
Medical
Condition
LE:
6/60
Chemosis
Corneal edema
IOP 55 mm Hg
Poor fundal view
RE:
HMs
Hypopyon
IOP 40 mm Hg
No fundal view
LE:
6/36
Mild anterior
uveitis
IOP 18 mm Hg
Mild vitritis
RE:
PL
Fibrin in anterior
chamber
RAPD
No fundal view
Ocular
signs
Side:
Posterior
diffuse
Anterior and
posterior
diffuse
Posterior
diffuse
Posterior
diffuse
Principal
Site of
Ocular
Inflammation
Continued
TABLE 1
Cellulitis of
lower limb
Septic
arthritis
Other
Foci
Other
Positive
Cultures
IV
flucloxacillin
and gentamicin
Intravitreal
ceftazidime
IV amoxycullin
and gentamicin
Intravitreal
ceftazidime
(RE only)
(continued)
Phthisis
(32)
RE: PL
LE: 6/6 (24)
IV
Evisc (1)
benzylpenicillin
and
gentamicin
Definitive
Treatment
Visual
Outcome
(Follow-up in
months)
408
Surv Ophthalmol 48 (4) JulyAugust 2003
15 38M Escherichia
coli
(0101)
Lisieria
None
monocytogenes
(Serotype 1/2)
14 73F
HIV
None
Neisseria
meningitidis
13 7F
Systemic
Features
Pain
Blurred
vision
Ocular
Symptoms
Nausea
Diarrhea
Vomiting
None
Pain
Blurred
vision
Pain
Redness
Blurred
vision
Rash
Pain
Fever
Redness
Transient
headache
& neck
stiffness
Type 2
Loin pain
diabetes
Dysuria
Renal failure
Fever
(previously
undiagnosed)
Serratia
marcescens
Organism
12 55F
Age/
No. Sex
Underlying
Medical
Condition
RE:
PL
Hypopyon
IOP not
recorded
No red
reflex
LE:
6/24
IOP 40 mm Hg
Poor fundal view
Red reflex
present
RE:
Clear corneal
epithelial defect
Anterior
uveitis
LE:
PL
Chemosis
Hypopyon
IOP 46 mm Hg
No red reflex
Ocular
signs
Side:
Posterior
diffuse
Posterior
diffuse
Anterior
diffuse
Posterior
diffuse
Principal
Site of
Ocular
Inflammation
Continued
TABLE 1
Urinary
tract
infection
Obstructive
pyonephrosis
Other
Foci
Definitive
Treatment
Urine
IV
ceftazidime
and
co-amoxjclav
Intravitreal
ceftazidime
and
vancomycin
Intravitreal
vancomycin
IV
ceftazidime
Skin
Intravitreal
scrapings* amikacin
and
vancomycin
Urine
Other
Positive
Cultures
(continued)
PL (3)
6/60 (2)
PL (2)
NPL
(42)
Visual
Outcome
(Follow-up in
months)
Organism
E. coli
(06)
Weight
loss
Pain
Blurred
vision
Ocular
Symptoms
RE:
PL
Proptosis
Renal
Hypopyon
parenchymal
IOP 40 mm Hg
malakoplakia
RAPD
(previously
Iris bombe
undiagnosed)
Reduced
red reflex
Type 2
None
Blurred
LE:
diabetes
vision
PL
Eyelid
Proptosis
swelling Chemosis
Hypopyon
IOP 18 mm Hg
RAPD
No red reflex
Alcohol
Arthralgia Redness LE:
abuse
Blurred
PL
vision
Hypopyon
Posterior
synechiae
IOP 22 mm Hg
Poor fundal view
Type 2
Loss of
Pain
RE:
diabetes
appetite Redness
6/36
(previously
Weight loss Blurred
Swollen lids
undiagnosed) Fever
vision
IOP 10 mm Hg
Moderate Vitritis
Type 2
diabetes
Systemic
Features
Ocular
signs
Side:
Posterior
diffuse
Anterior
and
posterior
diffuse
Liver
abscess
Septic
arthritis
Urinary
tract
infection
PanUrinary
ophthalmitis tract
infection
Psoas
abscess
PanRenal
ophthalmitis abscess
Other
Foci
Urine
Urine
Psoas
abscess
aspirate
Other
Positive
Cultures
Phthisis (6)
Phthisis
(5)
IV
co-amoxyclav
and
cefuroxime
Intravitreal
amikacin
and
vancomycin
IV
vancomycin
Phthisis (21)
IV
cefuroxime
and gentamicin
Intravitreal
6/36 (12)
ceftazidime
Intravitreal
amikacin
and
vancomycin
IV
amoxycillin
Definitive
Treatment
Visual
Outcome
(Follow-up in
months)
*N. meningitidis serogroup C indentified with polymerase chain reaction of skin scraping. Abbreviations: Left eye (LE), right eye (RE), intraocular pressure (IOP), hand Movements vision (HMs), perception
of light (PL), no perception of light (NPL), relative afferent pupillary defect (RAPD), not done (ND), intravenous (IV). Visual acuity given as best corrected, metric Snellen acuity.
19 57M Klebsiclla
pneumoniae
(K2)
18 74M E. coli
(075)
17 77F
16 47M E. coli
(018ac)
Age/
No. Sex
Underlying
Medical
Condition
Principal
Site of
Ocular
Inflammation
Continued
TABLE 1
410
Surv Ophthalmol 48 (4) JulyAugust 2003
411
Number of Cases of Bacteremia and Blood Culture Positive Endogenous Bacterial Endophthalmitis Treated
at St Thomas Hospital During Study Period
Community Acquired
Causative Pathogen
Staphylococcus aureus
Streptococcus pneumoniae
Group A streptococcus
Group B streptococcus
S. melleri
Escherichia coli
Klebsiella spp.
Serratia marcescens
Other
Total
Hospital Acquired
Bacteremia
EBE
Bacteremia
EBE
281
431
82
68
41
720
127
3
987
2740
1
1
2
4
1
2
1
12
725
61
19
29
24
466
257
62
1476
3119
or perforated ocular contents in 13, and from biopsy of a choroidal abscess in 5. Many small series
gave limited details of cultures but for those larger
series that included relevant negative investigations,36,102,135,191 blood cultures were positive in 94%
(61/65) of patients and vitreous cultures in 56%
(35/63).
An extraocular focus of infection was found in
180 (67%) patients. Twenty-two (12%) of these had
involvement of more than one site giving a total of
229 extraocular infections. The most common sites
were liver (60), lung (32), central nervous system
(25), endocardium (24), and renal and urinary tracts
(24) (Table 5).
In 56% of patients (150), EBE was caused by Gram
negative organisms, most commonly Klebsiella spp.
(80), E. coli (22), Pseudomonas aeruginosa (16), N. meningitidis (15), and Serratia marscescens (6). Eighty
percent (64) of all patients with klebsiella EBE were
from East Asian hospitals. Gram positive organisms
were responsible for 40% (105) of cases. The most
common Gram positive organisms were Staphylococcus
TABLE 3
n
93
14
31
48
15
11
8
5
5
5
7
149
n
24
6
6
5
4
3
2
1
1
1
1
1
1
1
1
6
64
412
n
60
27
24
21
17
18
12
10
6
6
28
229
Skin and wound infections (10), cellulitis (7), necrotizing fasciitis (3) myositis (1).
bPeritonitis (3), Prostate infection (3) lung abscess (2),
osteomyelitis (2), pancreatic abscess or pancreatitis (2),
mediastinal infection (2), splenic emboli (1), cholecystitis
(1), abdominal abscess (1), gastroenteritis (1), perinephric-psoas abscess (1), pericarditis (1), testicular abscess
(1), pneumonitis (1), empyema (1), pleural abscess (1),
epidural abscess (1), chorioamnionitis (1), infected hemodialysis fistula (1), sinusitis (1).
Twenty-one (8%) patients received systemic steroids. Pars plana vitrectomy was performed in 68
(23%) eyes, lensectomy in 15 (5%), and repair of
retinal detachment in 6 (2%). Other operations included cataract extraction (3), drainage of subretinal
abscess (2), trabeculectomy (1), implantation of
Molteno tube (1), and penetrating keratoplasty (1).
The final VA of the 271 eyes with known outcome
was poor (Fig. 1). Only 5% of eyes had a VA of 20/
20 or better and the majority (69%) had vision worse
than counting fingers. Twenty-five percent of eyes
required evisceration or enucleation and 5% of patients died as a direct result of extraocular infection.
The results of univariable and multivariable analysis of the effect of causative pathogen and treatment
strategy on visual outcome are shown in Table 7.
Compared to Gram positive infection, eyes with Gram
negative EBE were less likely to retain useful (count
fingers or better) vision, but had a similar rate of evisceration or enucleation. Eyes that received intravitreal antibiotics had a similar probability of retaining
useful vision to those that did not, but univariable
analysis suggested that they were less likely to
require evisceration or enucleation. This difference
was not significant with multivariable analysis. The
small number of eyes that received intravitreal
steroids were more likely to retain useful vision than
those that did not. They were also less likely to require
evisceration and enucleation, but this difference was
not significant. Eyes that underwent vitrectomy were
Klebsiella spp.28,36,91,102,104,113,135,186,193,29,30,34,37,41,44,55,68,77,81,89,99,103,132,154,173,191,192
Escherichia coli8,40,43,58,61,63,83,135,141,145,148,160,172,178,184,186,188,191
Pseudomonas aeruginosa16,51,67,87,120,126,131,135,147,159,172,177
Neisseria meningitidis1,11,15,33,67,68,90,108,109,112,135,163,164,190,191
Serratia sp.4,6,46,114,125,135
Gram negativee
1
4
2
56
11
14
9
1
6
1
(1)
(4)
(2)
(52)
(10)
(13)
(8)
(1)
(6)
(1)
Cases
1935197570,88,162
n 108 (%)
5
5
2
8
3
7
2
10
3
3
11
(7)
(7)
(3)
(11)
(4)
(10)
(3)
(14)
(4)
(4)
(15)
Cases
1976198571
n 72 (%)
80 (30)d
22 (8)
16 (6)
15 (6)
6 (2)
27 (10)a
13 (5)
29 (11)b
10 (4)
9 (3)
6 (2)
Cases
19862001
n 267 (%)
References shown in superscript in the second column are for present literature review, 19862001.
Note: In the present review series there was an additional six cases caused by acid fast bacilli7,73,101,152,191 and six by mixed infection.26,67,104,135,149,172
a
Includes three cases of methicillin resistant S. aureus.151,169
b
Other streptococci included (n), Group B streptococci (14),20,49,66,82,115,128,133,167,191 Group C streptococci (2),80,124 Group G streptococci (8),13,135,140,175,183
S. milleri (1),135 Viridans group streptococcus (2),75,91 S. sanguis (1),164 Streptococcus-species not stated (1).107
c
Other Gram positive organisms in present literature review included S. epidermidis (3),62,166 Bacilus-species not stated (1),181 Clostridium septicum (3),25,100,139C. perfringens
(2),10,130 Enterococcus faecalis (1),180 Propionibacterium acnes (1).48
d
Klebsiella species not stated in 1 case. Other 79 cases reported as K. pneumoniae; 80% of these occurred in East Asian hospitals.
e
Other Gram negative bacteria in the present review series included Enterobacter agglomerans (2)186,194 Kingella kingae (1),27 Aeromonas hydrophila (1),64 A. sobria (1),35
Ochrobactrum anthropi (1),14 Brucella melitensis (1),3 Haemophilus influenzae (1),172 Tropheryma whippelii (1),150 Actinobacillus actinomycete incomitans (1),84 Salmonella typhimurium (1).191
Staphylococcus aureus9,38,39,67,98,119,127,129,134,135,140,151,156,169,171,179,185,191
Streptococcus pneumoniae2,31,47,135,140,145,163,189
Other Streptococcus sp.
Listeria monocytogenes5,18,50,54,56,78,105,110,118,140
Nocardia asteroides45,59,72,85,111,144,146,174,191
Bacillus cereus42,79,125,135,181
Gram positivec
Organism
TABLE 6
414
V. Diagnosis
A. INCIDENCE OF DIAGNOSTIC ERRORS
1. Adults
The differential diagnosis of EBE depends largely
on the predominant clinical features, but review of
the literature indicated that there were several
common misdiagnoses. The most common in adults
was acute, non-infectious, anterior uveitis. Early in
the disease process EBE was sometimes misdiagnosed
as conjunctivitis while later presentation with severe
inflammation and high IOP led to several patients
being misdiagnosed with acute angle-closure glaucoma. Fungal endophthalmitis was another commonly reported diagnostic error, especially in
patients with intravenous drug use (IVDU). Unlike
the association of endogenous fungal endophthalmitis and IVDU, the association of EBE and IVDU may
be less well recognized. This may explain why there
were several reports of patients with EBE and IVDU
who were misdiagnosed as having fungal endophthalmitis. IVDU was the second most commonly reported
predisposing factor associated with EBE.
N. asteroides choroidal abscesses may also be mistaken for fungal endophthalmitis, or alternatively,
neoplastic choroidal metastases. All three conditions
may have a similar fundal appearance, abnormal
cells in the vitreous and extraocular manifestations
of disease. In this setting, transvitreal fine needle
aspiration of a choroidal abscess has been used to
establish the diagnosis.72,144
Eyelid swelling and chemosis may be a feature of
EBE and this may wrongly suggest mucormycosis,
cavernous sinus thrombosis, or orbital cellulitis.
Similarly, headache, systemic malaise, and localised
tenderness may lead to a misdiagnosis of temporal
arteritis. Although none of the patients in our case
series or literature review were originally thought to
have either ocular lymphoma, sympathetic ophthalmia, necrosis of an intraocular tumor, or granulomatous conditions such as sarcoidosis, these conditions
415
Univariable and Multivariable Analysis of Visual Outcome in Relation to Causative Pathogen and
Treatment Strategy (Patients in Literature Review with Known Visual Outcome)
Odd Ratio (95% confidence interval)a
Outcome
Univariable Analysis
Multivariable Analysis
0.94
3.92
2.35
0.40
(0.541.62)
(1.5310.1)
(1.314.24)
(0.230.71)
0.64
4.44
2.93
0.43
(0.341.20)
(1.4313.8)
(1.525.64)
(0.240.78)
0.54
0.31
0.27
1.12
(0.300.94)
(0.071.45)
(0.120.62)
(0.622.03)
0.68
0.45
0.30
1.10
(0.371.23)
(0.092.30)
(0.120.74)
(0.592.04)
a
Odds ratio given for each treatment strategy compares eyes that had undergone the intervention with those that had not.
For example, eyes that received intravitreal steroids were more likely to have a favourable visual outcome (count fingers or
better) than those that did not (Odds ratio 3.92 with univariable analysis, confidence interval 1.53 to 10.1). Outcome in eyes
with Gram negative infection compared to those with Gram positive infection. Mixed and Tuberculous infection excluded
from analysis.
VI. Investigations
A. MICROSCOPY AND CULTURE
1. Blood Culture
Blood culture is the most reliable way of establishing the diagnosis. In four large series of
EBE,36,102,135,191 blood cultures were more likely to
be positive than vitreous. Review of all 267 cases shows
that blood culture was the commonest means of confirming the diagnosis, and in our own case series
almost three-quarters of blood cultures were positive.
2. Intraocular Cultures
Although useful, blood cultures alone cannot be
relied upon to establish the diagnosis. In the absence of positive cultures from elsewhere, we advocate obtaining intraocular specimens in most
patients. In our own case series 56% of intraocular
specimens were positive. The two most common
methods of obtaining an intraocular specimen are
anterior chamber paracentesis (AC tap) and removal
416
3. Extraocular Cultures
Three-quarters of the patients in our case series,
and almost two-thirds of those in the literature review,
had at least one extraocular focus of infection. Although these involved a wide range of sites, lung,
liver, endocardium, and soft tissue were most commonly reported.
B. POLYMERASE CHAIN REACTION
PCR is becoming increasingly utilized in the diagnosis of endophthalmitis, and has a number of potential advantages.136,182 PCR greatly amplifies the
quantity of bacterial DNA available for analysis and
this may enable the detection of a single organism.138
The process of DNA replication can also be performed within a few hours. In one report, PCR of an
AC tap identified L. monocytogenes 3 days before the
definitive culture result.105 PCR is particularly helpful
in the detection of unusual organisms such as Tropheryma whippelii150 and Mycobacterium avium-intracellulare.152 It may also enable detection of organisms in
culture-negative samples, especially those that are obtained after antibiotic therapy has been commenced.182 PCR of extraocular specimens may also
help identify the causative organism, as demonstrated
in patient 13 of our own case series.
Although PCR is a rapid and highly sensitive test
it also has disadvantages. The high sensitivity may
lead to false-positive results, and specimens need to
be carefully collected and processed to avoid exogenous or cross-contamination.106 False-negative results
are also possible, particularly with unusual organisms.93 Careful control experiments are therefore
required if the results of PCR are to be meaningful.137,176 PCR may be used to rapidly establish the
presence of bacterial infection but may take 4872
hours for final species identification,93 and unlike
tradition culture techniques, it does not detect the
ability of an organism to replicate, or its antibiotic
sensitivity.106,138 In addition, PCR is not yet routinely
available182 and is of limited use in mixed infections.138 For these reasons PCR is likely to become a
useful adjunct to microscopy and culture, rather than
replacing it.
417
VIII. Treatment
A. INTRAVITREAL ANTIBIOTICS
be safe in primate studies23 of exogenous endophthalmitis and clinical studies of postoperative endophthalmitis found that it had a similar,74 or
better,83 spectrum of activity than amikacin. There
have been no equivalent studies of EBE, but in
the present case series all Gram negative organisms
were sensitive to ceftazidime.
B. INTRAVITREAL STEROIDS
2. Choice of Agent
Although 1 to 2 mg vancomycin is the intraocular
antibiotic most commonly chosen for treatment of
Gram positive infection, the choice of antibiotic for
Gram negative infection is contentious.52 Most ophthalmologists no longer use intravitreal gentamicin
because of the risk of macular infarction.22 Many now
use amikacin (0.4mg) instead, despite the known risk
of retinal toxicity22,24,86 and dilution errors19 from
this aminoglycoside. In view of these risks, several
authors recommend intravitreal ceftazidime (2 mg
in 0.1 ml).22,24,32,86 Ceftazidime has been shown to
418
of intravitreal antibiotics.57 The disadvantages of vitrectomy include the added cost and inconvenience,
and the risk of anesthetic and surgical complications,
such as cataract formation.
IX. Prognosis
The visual outcome of EBE has not improved in
55 years. Review of the literature from 19761985
showed that 41% of patients had count fingers vision
or better, 26% were blind, and 29% required evisceration or enucleation.71 Similar figures were reported
over the preceding 30 years.162 Review of the literature since 1986 also indicates a poor outcome, with
equivalent figures of 32%, 44%, and 25% (Fig. 1).
The studies that investigated prognostic factors in
EBE71 were retrospective, and although selection bias
cannot be excluded, they identified several factors
that adversely effect prognosis. These included delay
in diagnosis;71 use of inappropriate antibiotics;187 diffuse infection of the vitreous and retina, or panophthalmitis;71 infection with virulent organisms;191 and
Gram negative infection.71,191 The present literature
review also suggests that Gram negative infection
carries a poor prognosis and our case series indicates
that poor VA at presentation is associated with poor
visual outcome.
EBE had an appreciable mortality rate with 5% of
patients in our literature review dying as a direct
result of extraocular infection. This may be lower
than expected as a prospective study of patients with
bacteremia reported that those with even minor
ocular lesions had a mortality rate of 32%.17
X. Pathogenesis
EBE occurs when bacteria cross the bloodocular
barrier, resist host defenses, and multiply within the
eye. The bloodocular barrier may prevent many organisms reaching the internal ocular spaces as relatively few bacteremic patients develop EBE. In one
prospective study of 202 patients with bacteremia,
none developed EBE although 12 developed minor
ocular lesions such as cotton-wool spots and microhemorrhages.17 Another prospective study of 101 patients with septicemia131 reported that 24 patients
developed minor ocular lesions and one developed
EBE.
Most studies of EBE failed to differentiate between
community and hospital acquired infection. Seventeen of 19 (89%) patients in our own case series
had community acquired infection. Blood culture
positive EBE accounted for only 0.24% (14/5859) of
all cases of bacteremia in our hospital, and 0.44%
(12/2740) of community acquired bacteremias.
XI. Pathology
Animal experiments suggest that tissue damage results from a combination of direct invasion of ocular
tissue by bacteria, the release of bacterial toxins, and
the host inflammatory response. Callegan et al21
studied the effect of intravitreal injections of rabbit
eyes with live S. aureus, Bacillus cereus, and Enterococcus faecalis, as well as bacterial cell walls and exotoxins. B.cereus directly invaded the retina and cornea,
and both S.aureus and B.cereus reduced the electroretinogram response, indicating functional retinal impairment. In contrast, the supernatant from cultures
of E.faecalis was not directly toxic to the retina but
induced a marked inflammatory response, as did injection of bacterial cell walls, albeit to a lesser degree.
Similar studies with P. aeruginosa,92 Staphylococcus epidermidis,92 and Klebsiella oxytoca122 also suggest that
the host response is an important cause of tissue
damage and that irreversible photoreceptor degeneration may occur within 24 hours of inoculation.122 By
directly inoculating the vitreous cavity, these studies
created exogenous rather than endogenous endophthalmitis. As noted by Greenwald et al,71 the route
419
XIII. Conclusions
EBE has a poor visual prognosis that has not improved in over half a century. There are several possible reasons for this. First, EBE is very uncommon yet
it may mimic several common ophthalmic conditions.
This may explain why many patients are initially misdiagnosed. EBE can be rapidly progressive and delayed
treatment may result in a poor outcome. Second, clinicians may fail to appreciate the overlap of ocular and
extraocular disease. Third, there have been no large
prospective studies of EBE to determine the benefits
of intravitreal antibiotics, intravitreal steroids, and vitrectomy. Lastly, there is a significant increase in reports of klebsiella EBE, which may be associated with
a poor visual prognosis.191
References
1. Abousaesha F, Dogar GF, Young BJ, et al: Endophthalmitis
as a presentation of meningococcal septicemia. Ir J Med
Sci 162:4956, 1993
2. Al-Amro S, Al-Momen A: Endogenous bacterial endophthalmitis in sickle cell anemia. Ann Ophthalmol 29:3168, 1997
3. Al Faran MF: Brucella melitensis endogenous endophthalmitis. Ophthalmologica 201:1922, 1990
4. Al Hazzaa SA, Tabbara KF, Gammon JA: Pink hypopyon: a
sign of Serratia marcescens endophthalmitis. Br J Ophthalmol 76:7645, 1992
5. Algan M, Jonon B, George J, et al: Listeria monocytogenes
endophthalmitis in a renal-transplant patient receiving
ciclosporin. Ophthalmologica 201:237, 1990
6. Alvarez R, Adan A, Martinez JA, et al: Haematogenous Serratia marcescens endophthalmitis in an HIV-infected intravenous drug addict. Infection 18:2930, 1990
7. Ambler JS, Meisler DM, Zakov ZN, et al: Endogenous Mycobacterium chelonae endophthalmitis. Am J Ophthalmol
108:3389, 1989
8. Anand N, Brogden P, Menage MJ: E. coli endophthalmitis.
Eye 10:1423, 1996
9. Arroyo JG, Brinton DA, Zarbin MA: Endogenous endophthalmitis initially misdiagnosed as anterior uveitis. Ann
Ophthalmol 32:199200, 2000
10. Assaf AA, Tabbara KF: Clostridium-perfringens endophthalmitis and orbital cellulitis. Saudi Med J 13:3556, 1992
11. Auerbach SB, Leach CT, Bateman BJ, et al: Meningococcal
endophthalmitis without concomitant septicemia or meningitis. Pediatr Infect Dis J 8:4113, 1989
12. Barza M, Kane A, Baum J: Intraocular penetration of gentamicin after subconjunctival and retrobulbar injection. Am
J Ophthalmol 85:5417, 1978
13. Berkey P, Rolston K: Group G streptococci as a cause of
bacterial endophthalmitis. Arch Ophthalmol 106:1712,
1988
14. Berman AJ, Del Priore LV, Fischer CK: Endogenous
Ochrobactrum anthropi endophthalmitis. Am J Ophthalmol 123:5602, 1997
15. Beynon HLC, Hague S: Meningococcal endophthalmitis
and pericarditis. J Royal Soc Med 83:331, 1990
16. Boisjoly HM, Jotterand VH, Bazin R, et al: Metastatic Pseudomonas endophthalmitis following bronchoscopy. Can J
Ophthalmol 22:37880, 1987
17. Bouza E, Cobo-Soriano R, Rodrguez-Creixems M, et al: A
prospective search for ocular lesions in hospitalized patients
with significant bacteremia. Clin Infect Dis 30:30612, 2000
18. Brian GR, Treplin MCW: Listeria monocytogenes endophthalmitis: a case report. Aust NZ J Ophthalmol 16:329
31, 1988
19. Brod RD, Flynn HW Jr: Endophthalmitis: current approaches to diagnosis and treatment. Curr Opin Infect Dis
6:62837, 1993
20. Buglass TD, Romanchuk KG: Fatal case of group B streptococcal endogenous endophthalmitis. Can J Ophthalmol
30:14950, 1995
21. Callegan MC, Booth MC, Jett BD, et al: Pathogenesis of
gram-positive bacterial endophthalmitis. Infect Immunity
67:334856, 1999
420
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47. De Groot V, Stempels N, Tassignon MJ: Endogenous pneumococcal endophthalmitis after splenectomy: report of two
cases. Bull Soc Belge d Ophtalmol 243:14751, 1992
48. de la Fuente J, Fernandez-Catalina P, Sopena B, et al: Endogenous endophthalmitis caused by Propionibacterium
acnes. Arch Ophthalmol 111:1468, 1993
49. Deighton C: Beta haemolytic streptococci and musculoskeletal sepsis in adults. Ann Rheum Dis 52:4837, 1993
50. Deramo VA, Shah GK, Garden M, et al: Good visual outcome
after Listeria monocytogenes endogenous endophthalmitis.
Retina 19:5668, 1999
51. Detering K, Jenney A, Hall A, et al: Metastatic choroidal
abscess due to Pseudomonas aeruginosa in patients with
cystic fibrosis. Clin Infect Dis 24:5256, 1997
52. Doft BH, Barza M: Ceftazidime or amikacin:choice of intravitreal antimicrobials in the treatment of postoperative
endophthalmitis. Arch Ophthalmol 112:178, 1994
53. Donahue SP, Kowalski RP, Jewart BH, et al: Vitreous cultures
in suspected endophthalmitisbiopsy or vitrectomy?. Ophthalmology 100:4525, 1993
54. Duch ST, Quintana MC, Pujol OG: Listeria monocytogenes
endophthalmitis. Acta Ophthalmologica 69:10810, 1991
55. Ebisuno S, Masahiro M: A case of Klebsiella pneumoniae
endophthalmitis metastasized from prostatitis. Acta Urol
Jpn 40:6257, 2000
56. Eliott D, OBrien TP, Green WR, et al: Elevated intraocular
pressure, pigment dispersion and dark hypopyon in endogenous endophthalmitis from Listeria monocytogenes. Surv
Ophthalmol 37:11724, 1992
57. Endophthalmitis Vitrectomy Study Group: Results of the
Endophthalmitis Vitrectomy Study. A randomized trial of
immediate vitrectomy and of intravenous antibiotics for the
treatment of postoperative bacterial endophthalmitis. Arch
Ophthalmol 113:147996, 1995
58. Faraawi R, Fong IW: Escherichia coli emphysematous endophthalmitis and pyelonephritis. Case report and review
of the literature. Am J Med 84:6369, 1988
59. Ferry AP, Font RL, Weinberg RS, et al: Nocardial endophthalmitis: report of two cases studied histopathologically.
Br J Ophthalmol 72:5561, 1988
60. Fisch A, Salvanet A, Prazuck T, et al: Epidemiology of infective endophthalmitis in France. Lancet 338:13736, 1991
61. Foster RE, Rubsamen PE, Joondeph BC, et al: Concurrent
endophthalmitis and retinal detachment. Ophthalmology
101:4908, 1994
62. Freeman WR, Henderly DE, Lipson BK, et al: Retinopathy
before the diagnosis of AIDS. Ann Ophthalmol 21:468
74, 1989
63. Friedlander SM, Raphaelian PV, Granet DB, et al: Bilateral
endogenous Escherichia coli endophthalmitis in a neonate
with meningitis. Retina 16:3412, 1996
64. Frieling JS, Rosenberg R, Edelstein M, et al: Endogenous
Aeromonas hydrophila endophthalmitis. Ann Ophthalmol
21:1178, 1989
65. Fung CP, Hu BS, Chang FY, et al: A 5-year study of the
seroepidemiology of Klebsiella pneumoniae: high prevalence of capsular serotype K1 in Taiwan and implication
for vaccine efficacy. J Infect Dis 181:20759, 2000
66. Galloway A, Deighton CM, Deady J, et al: Type V group
B Streptococcal septicaemia with bilateral endophthalmitis
and septic arthritis. Lancet 341:9601, 1993
67. Garg SP, Talwar D, Verma LK: Metastatic endophthalmitis:
a reappraisal. Ann Ophthalmol 23:748, 1991
68. Glassman RM, Lieberman TT, Friedman AH, et al: Endogenous Klebsiella endophthalmitis: case report. Mt Sinai J
Med 56:3269, 1989
69. Gonzalez GA, Whitcher JP, Irvine AR, et al: A ring hypopyon
in a patient with meningococcal endophthalmitis: a case
report and review of the literature. J Pediatr Ophthalmol
Strabis 35:32933, 1998
70. Goodner EK, Okumoto M: Intraocular listeriosis. Am J
Ophthalmol 64:6826, 1967
71. Greenwald MJ, Wohl LG, Sell CH: Metastatic bacterial endophthalmitis: a contemporary reappraisal. Surv Ophthalmol 31:81101, 1986
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
421
98. Kronish JW, Johnson TE, Gilberg SM, et al: Orbital infections in patients with human immunodeficiency virus infection. Ophthalmology 103:148392, 1996
99. Lee CC, Chen CY, Chen FH, et al: Septic metastatic endophthalmitis from Klebsiella pneumoniae liver abscess: CT and
MR imaging characteristicsreport of three cases. Radiology
207:4116, 1998
100. Lehav M, Whitcup SM: A 79-year-old man with fever, abdominal pain, and an inflamed right eye. N Eng J Med 321:172
82, 1989
101. Lester H, Erdey RA, Fastenberg DM, et al: Bacillus CalmetteGuerin (BCG) endophthalmitis. Retina 8:1824, 1988
102. Liao HR, Lee HW, Leu HS, et al: Endogenous Klebsiella
pneumoniae endophthalmitis in diabetic patients. Can J
Ophthalmol 27:1437, 1992
103. Lindstrom ST, Healey PR, Chen SC: Metastatic septic endophthalmitis complicating pyogenic liver abscess caused
by Klebsiella pneumoniae. Aust NZ J Ophthalmol 27:77
8, 1997
104. Liu YC, Cheng DL, Lin CL: Klebsiella pneumoniae liver
abscess associated with septic endophthalmitis. Arch Intern
Med 146:19136, 1986
105. Lohmann CP, Gabel VP, Heep M, et al: Listeria monocytogenes-induced endogenous endophthalmitis in an otherwise healthy individual: rapid PCR-diagnosis as the basis
for effective treatment. Eur J Ophthalmol 9:537, 1999
106. Lohmann CP, Linde HJ, Reischl U: Improved detection of
microorganisms by polymerase chain reaction in delayed
endophthalmitis after cataract surgery. Ophthalmology
107:104751, 2000
107. Madhuri V, Mathai E, Brahmadathan KN, et al: An outbreak
of post-streptococcal reactive arthritis. Indian J Med Res
105:24953, 1997
108. Mahdi G, Tutton M, Evans-Jones G: Ophthalmitis in meningococcal disease. Arch Dis Child 63:550, 1988
109. Malhotra A, Krilov LR: Isolated Neisseria meningitidis endophthalmitis. Ped Infect Dis J 18:83940, 1999
110. Maloney JM, Nolte FS, Meredith TA: Listeria monocytogenes endophthalmitis, treatment with vitrectomy and trimethoprim/sulfamethoxazole. Emory J Med 4:2014, 1990
111. Mamalis N, Daily MJ, Ross D: Presumed intraocular nocardiosis in a cardiac-transplant patient. Ann Ophthalmol
20:2716, 1988
112. Marcovich A, Levartovsky S, Van der Walde J, et al: Metastatic
meningococcal endophthalmitis treated by vitrectomy.
Can J Ophthalmol 29:2401, 1994
113. Margo CE, Mames RN, Guy JR: Endogenous Klebsiella endophthalmitis. Report of two cases and review of the literature. Ophthalmology 101:1298301, 1994
114. Marinella MA, Warwar R: Endogenous endophthalmitis due
to Serratia marcescens. South Med J 91:38891, 1998
115. Matsuo K, Nakatuka K, Yano Y, et al: Group B streptococcal
metastatic endophthalmitis in an elderly man without predisposing illness. Jpn J Ophthalmol 42:3047, 1998
116. Maxwell DP, Brent BD, Diamond JG, et al: Effect of intravitreal dexamethasone on ocular histopathology in a rabbit
model of endophthalmitis. Ophthalmology 98:13705, 1991
117. McDonald MI, Corey GR, Gallis HA, et al: Single and multiple pyogenic liver abscesses: natural history, diagnosis and
treatment, with emphasis on percutaneous drainage. Medicine 63:291302, 1984
118. Melamed J, Kwitko S, Barcaro S, et al: Endogenous endophthalmitis due to Listeria monocytogenes. Ocul Immunol
Inflam 2:458, 1994
119. Melzer M, Craven S, Bagg R: A complication of intensive
careNosocomially acquired right eye endophthalmitis
caused by a Staphylococcus aureus bacteraemia secondary
to an infected central line. Postgrad Med J 75:17980, 1999
120. Menon J, Rennie IG: Endogenous Pseudomonas endophthalmitis in an immunocompetent patient: a case for early
diagnosis and treatment. Eye 14:2534, 2000
121. Meredith TA, Aguilar HE, Drews C, et al: Intraocular dexamethasone produces a harmful effect on treatment of experimental Staphylococcus aureus endophthalmitis. Trans Am
Ophthalmol Soc 94:24152, 1996
422
122. MeyersElliot RH, Dethlefs BA: Experimental Klebsiella induced endophthalmitis in the rabbit. Arch Ophthalmol
100:195963, 1982
123. Meyers SM, Vasil ML, Yamamoto L: Pathologic mechanisms
of multifocal choroiditis with retinal detachment after carotid injection of Streptococcus mutans and other bacteria in dogs. Invest Ophthalmol Vis Sci 22:16573, 1982
124. Moffett DGJ, Edward DP: Anterior segment necrosis associated with endogenous endophthalmitis secondary to group
C streptococcal septicemia. Can J Ophthalmol 26:2837,
1991
125. Montecalvo MA, Karmen CL, Alampur SK, et al: Contaminated medicinal solutions associated with endophthalmitis.
Infect Dis Clin Pract 2:199202, 1993
126. Mu SC, Lin CH, Lin MI, et al: Pseudomonas aeruginosa
endophthalmitis in prematurity: report of two cases. Acta
Paediatr Sin 38:15961, 1997
127. Munier F, Othenin-Girard P: Subretinal neovascularization
secondary to choroidal septic metastasis from acute bacterial endocarditis. Retina 12:10812, 1992
128. Nagelberg HP, Petashnick DE, To KW, et al: Group B
streptococcal metastatic endophthalmitis. Am J Ophthalmol 117:498500, 1994
129. Nahata SK, Saffra NA, Genovesi MH, et al: Endogenous
endophthalmitis resulting from sternal wound infection
after coronary artery bypass grafting. J Thorac Cardiovasc
Surg 116:1767, 1998
130. Nangia V, Hutchinson C: Metastatic endophthalmitis caused
by Clostridium perfringens. Br J Ophthalmol 76:2523, 1992
131. Neudorfer M, Barnea Y, Geyer O, et al: Retinal lesions in
septicemia. Am J Ophthalmol 116:72834, 1993
132. Nye AM, Kirchner JT, Lamendola CE: Progressive vision
loss after pneumonia. Hosp Pract 34:150, 1999
133. OBrart DP, Eykyn SJ: Septicaemic infection with group B
streptococci presenting with endophthalmitis in adults. Eye
6:3969, 1992
134. OBrien CJ, Kyle GM: Metastatic Staphylococcus aureus endophthalmitis: a case report. Br J Ophthalmol 72:18991,
1988
135. Okada AA, Johnson RP, Liles WC, et al: Endogenous bacterial endophthalmitis: report of a ten-year retrospective
study. Ophthalmology 101:8328, 1994
136. Okhravi N, Adamson P, Carroll N, et al: PCR-based evidence
of bacterial involvement in eyes with suspected intraocular
infection. Invest Ophthalmol Vis Sci 41:34749, 2000
137. Okhravi N, Adamson P, Lightman S: Polymerase chain
reaction in the diagnosis of bacterial endophthalmitis.
Br J Ophthalmol 83:3789, 1999
138. Okhravi N, Adamson P, Matheson MM, et al: PCR-RFLPmediated detection and speciation of bacterial species
causing endophthalmitis. Invest Ophthalmol Vis Sci 41:
1438, 2000
139. Ormerod LD, Paton BG, Haaf J, et al: Anaerobic bacterial
endophthalmitis. Ophthalmology 94:799808, 1987
140. Palexas GN, Green WR, Goldberg MF, et al: Diagnostic
pars plana vitrectomy report of a 21-year retrospective study.
Trans Am Ophthalmol Soc 93:281308, 1995
141. Park SB, Searl SS, Aquavella JV, et al: Endogenous endophthalmitis caused by Escherichia coli. Ann Ophthalmol
25:959, 1993
142. Park SS, Samiy N, Ruoff K, et al: Effect of intravitreal dexamethasone in treatment of pneumococcal endophthalmitis
in rabbits. Arch Ophthalmol 113:13249, 1995
143. Parver LM, Anker T, Carpenter DO: Choroidal blood flow
as a heat dissipating mechanism in the macula. Am J Ophthalmol 89:641, 1980
144. Phillips WB, Shields CL, Shields JA, et al: Nocardia choroidal
abscess. Br J Ophthalmol 76:6946, 1992
145. Piczenik Y, Kjer B, Fledelius HC: Metastatic bacterial endophthalmitis. A report of four cases all leading to blindness. Acta Ophthalmol Scand 75:4669, 1997
146. Price NC, Frith PA, Awdry PN: Intraocular nocardiosis: a
further case and review. Int Ophthalmol 13:17780, 1989
147. Quirk JA, Beaman MH, Blake M: Community-acquired Pseudomonas pneumonia in a normal host complicated by metastatic panophthalmitis and cutaneous pustules. Aust NZ
J Ophthalmol 20:2546, 1990
148. Rahav G, Levinger S, Frucht-Pery J: Escherichia coli endophthalmitis secondary to pyelonephritis: another complication
of diabetes?. Clin Infect Dis 18:1178, 1994
149. Reed M, Hibberd PL: Endoscopy and endophthalmitis.
N Eng J Med 321:836, 1989
150. Rickman LS, Freeman WR, Green WR, et al: Brief report:
uveitis caused by Tropheryma whipplii (Whipples bacillus).
N Eng J Med 332:3636, 1995
151. Romero CF, Rai MK, Lowder CY, et al: Endogenous endophthalmitis: case report and brief review. Am Family Physician
60:5104, 1999
152. Rosenbaum PS, Mbekeani JN, Kress Y: Atypical mycobacterial panophthalmitis seen with iris nodules. Arch Ophthalmol 116:15247, 1998
153. Rowsey JJ, Newsom DL, Sexton DJ, et al: Endophthalmitis:
current approaches. Ophthalmology 89:105566, 1982
154. Saccente M: Klebsiella pneumoniae liver abscess, endophthalmitis, and meningitis in a man with newly recognized
diabetes mellitus. Clin Infect Dis 29:15701, 1999
155. Sampath R, McKenzie A, Sujatha S: Maternal endophthalmitis: a rare complication of chorioamnionitis: a case report.
Ann Ophthalmol Glaucoma 26:2434, 1994
156. Schlossberg D, Jan AM: Endophthalmitis in intravenous
drug abuse. Ann Ophthalmol 25:778, 1993
157. Schmitz S, Dick HB, Krummenauer F, et al: Endophthalmitis
in cataract surgeryresults of a German survey. Ophthalmology 106:186977, 1999
158. Schulman JA, Peyman GA: Intravitreal corticosteroids as an
adjunct in the treatment of bacterial and fungal endophthalmitis: a review. Retina 12:33640, 1992
159. Schutze GE, Englund JA, Bresee JS: Pseudomonas aeruginosa endogenous endophthalmitis in a neonate. Pediatr
Infect Dis J 8:8935, 1989
160. Sekimoto M, Hayasaka S, Setogawa T, et al: Endogenous
Escherichia coli endophthalmitis in a patient with autosomal-dominant polycystic kidney disease. Ann Ophthalmol
23:4589, 1991
161. Shah GK, Stein JD, Sharma S, et al: Visual outcomes following the use of intravitreal steroids in the treatment of
postoperative endophthalmitis. Ophthalmology 107:4869,
2000
162. Shammas HF: Endogenous E. coli endophthalmitis. Surv
Ophthalmol 21:42935, 1977
163. Shappell KK, Gehrs KM, Keech RV, et al: Meningococcemia
with vitreous opacities: endophthalmitis or vitreous hemorrhage?. Arch Ophthalmol 117:2689, 1999
164. Shields JA, Shields CL, Eagle RCJ, et al: Endogenous endophthalmitis simulating retinoblastoma. The 1993 David
and Mary Seslen Endowment Lecture. Retina 15:2139,
1995
165. Shivaram U, Cash M: Purpura fulminans, metastatic endophthalmitis, and thrombotic thrombocytopenic purpura
in an HIV-infected patient. NY State J Med 92:3134, 1992
166. Shrader SK, Band JD, Lauter CB, et al: The clinical spectrum
of endophthalmitis: incidence, predisposing factors, and
features influencing outcome. J Infect Dis 162:11520, 1990
167. Siddiqui MA, Lester RM: Septic arthritis and bilateral endogenous endophthalmitis associated with percutaneous
transluminal coronary angioplasty. J Am Geriatr Soc 44:
476, 1996
168. Silber N, Kremer I, Gaton DD, et al: Severe sepsis following
extracorporeal shock wave lithotripsy. J Urol 145:10456,
1991
169. Smith KG, Ihle BU, Heriot WJ, et al: Metastatic endophthalmitis in dialysis patients. Am J Nephrol 15:7881, 1995
170. Smith MA, Sorenson JA, DAversa G, et al: Treatment of
experimental methicillin-resistant Staphylococcus epidermidis endophthalmitis with intravitreal vancomycin and
intravitreal dexamethasone. J Infect Dis 175:4626, 1997
423
194. Zeiter JH, Koch DD, Parke DW II, et al: Endogenous endophthalmitis with lenticular abscess caused by Enterobacter
agglomerans (Erwinia species). Ophthalmic Surg 20:912,
1989
The authors wish to thank Andrew Hutchings, London School
of Hygiene and Tropical Medicine, for statistical support. Dr Jackson
was supported by a research grant from the Lady Anne Allerton Fund
and a personal training award from the Special Trustees of St
Thomas Hospital. The authors reported no proprietary or financial
interest in any product mentioned or concept discussed in this
article.
Correspondence: Tim Jackson, Academic Department of Ophthalmology, The Rayne Institute, St Thomas Hospital, London SE1
7EH, United Kingdom.
Outline
I. Methods
A. St Thomas case series
B. Literature review
II. Results
A. St Thomas case series
B. Literature review
III. Patient characteristics
IV. Clinical features
V. Diagnosis
A. Incidence of diagnostic errors
B. Differential diagnosis
1. Adults
2. Children
VI. Investigations
A. Microscopy and culture
1. Blood culture
2. Intraocular cultures
3. Extra-ocular cultures
B. Polymerase chain reaction
VII. Causative organisms
VIII. Treatment
A. Intravitreal antibiotics
1. Role in endogenous endophthalmitis
2. Choice of agent
B. Intravitreal steroids
C. Vitrectomy
IX.
X.
XI.
XII.
Prognosis
Pathogenesis
Pathology
Guidelines for reporting endogenous bacterial endophthalmitis
XIII. Conclusions