In The Name of God

Symptoms ,Signs, Differential Diagnosis Infectious Endophthalmitis  Symptoms ,Signs, Differential Diagnosis MR.Ansari MD

Infectious endophthalmitis is a condition in which the internal structures of the eye are invaded by replicating microorganisms . Exogenous endophthalmitis occurs when the outer wall of the eye sustains a break as a result of surgery or trauma. Exogenous endophthalmitis is the most common subtype. 90% of all cases are caused by bacteria.

In certain clinical settings ,there is an increased likelihood of infection by certain groups of bacteria . Endophthalmits following cataract surgery is most often caused by staphylococcus epidermidis. Injured eyes → Gram-positive Bacillus spp.

Allen reviewed 30000 ICCE from 1964 to 1977 and found an incidence of endophthalmitis of 0.057% . Review of 23625 cases of ECCE in Bascom Palmer Eye Institute revealed an incidence of 0.072% Phaco →incidence of 0.03% to 0.04% In Sweden & Norway →0.1% to 0.16% Following open globe injuries→4.2% to 7% .

Symptoms of Acute Endophthalmitis ( within 6 weeks ) Sudden increase in pain 1-7 days after surgery . ↓VA Redness and conjunctival injection. Lid swelling

In EVS 98% with acute endophthalmitis presented with one or more of the four classic symptoms. ↓VA ( 93% ) Conjunctival injection ( 81% ) Pain ( 75% ) Lid swelling ( 33% )

Signs of acute endophthalmitis In fulminant cases conjunctival chemosis and increased injection often with a significant amount of yellowish exudates in the conjunctival cul - de - sac Edematous lids often difficult to open Corneal edema ( variable degrees ) Pigmented cells may accumulate on its posterior surface of cornea. Surgical wound may show signs of dehiscens and in advanced cases exudates can stream from the wound.  

AC reaction ( heavy flare and cells ) Hypopyon ( mixed with a tinge of red blood ) Fibrin membrane is usually present over both surfaces. Heavy cellular debris is present in the vitreous . Focal accumulations of whitish material or sheets of opacification within the vitreous .

IOP → low , normal or high . Pupil often dilates poorly . Retinal prephlebitis has been reported an early sign but in most cases the retinal vessels are seen poorly . Red reflex ?

Rupture of posterior capsule Vitreous wick Time of operation Notice to risk factors Leakage of wound Rupture of posterior capsule Vitreous wick Time of operation Diabetes mellitus Cutting of sutures too early A case – control study demonstrated a threefold greater risk of endophthalmitis with clear corneal incisions than with scleral tunnel incisions .  

Transcleral suture fixation of posterior – chamber IOL . Continuation Temporal incisions were noted to have a higher incidence of infection than superior incision . Transcleral suture fixation of posterior – chamber IOL . Polypropylene haptics Preoperative eyelid abnormalities and blepharomeibomitis . Re – entry of the eye through a previous wound .  

Differential Diagnosis Postoperative inflammation Retained lens material →respond to corticosteroids. Chronic , low grade endophthalmitis may occur secondary to coagulase – negative Gram – positive organisms such as s.epidermidis and also result from infections with the anaerobic species Propionibacterium acnes . ( 40% of cases ) Propionibacterium can present with mild iritis and pigmented KP .  

Continuation On examination , the most common findings are vitritis , white plaques on the posterior capsule or the IOL , beaded fibrin strands , hypopyon ?,granulomatous KP .  

Toxic substance enters the anterior chamber TASS Toxic substance enters the anterior chamber Causes Acute sterile postoperative inflammation Photophobia , ↓VA , corneal edema and marked anterior chamber reaction with hypopyon TASS presents within hours of surgery Pathologic changes limited to AC Pain is much less than that of endophthalmitis ↑IOP Tainted BSS , reusable double cannula , se of preserved solution , subconjunctival injection near the wound .  

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