Endophthalmitis

Introduction

Endophthalmitis is a serious eye infection that involves the inner structures of the eye, including the vitreous and aqueous humors. It’s not super common, but when it happens, it can lead to severe vision loss or even blindness if not treated promptly. People might experience pain, redness, and sudden vision changes. In this article, we’ll walk through what endophthalmitis is, its causes, symptoms, how it’s diagnosed, treated, and how you can reduce your risk. 

Definition and Classification

Medically, endophthalmitis is defined as an inflammatory condition of the intraocular cavities (vitreous and/or aqueous humor) usually resulting from infection. It’s generally classified into two main types:

• Exogenous endophthalmitis: Caused by pathogens entering from an external source, often following surgery (like cataract extraction), trauma, or intraocular injections.
• Endogenous endophthalmitis: Pathogens spread through the bloodstream from another body site (e.g., endocarditis, urinary tract infections).

Other subtypes include fungal vs. bacterial, acute vs. chronic, and even post-traumatic categories. The eye’s uveal tract (iris, ciliary body, choroid) and retina often bear the brunt of damage, though the whole globe can become inflamed.

Causes and Risk Factors

Endophthalmitis often arises when bacteria or fungi breach the eye’s natural barriers. In exogenous cases, typical entry points include surgical incisions (like small-gauge vitrectomy), needle tracks from intraocular injections (e.g., anti-VEGF for macular degeneration), or penetrating traumas (e.g., a metal shard in a workshop accident).

In endogenous endophthalmitis, pathogens travel via the bloodstream. Common culprits include Staphylococcus aureus, Streptococcus species, or Candida. For instance, a diabetic patient with a systemic Candida infection might develop fungal endophthalmitis if spores lodge in the eye.

Risk factors fall into modifiable and non-modifiable categories:

• Non-modifiable: Advanced age, immunosuppression (HIV/AIDS, chemotherapy), chronic illnesses like diabetes mellitus or nephrotic syndrome.
• Modifiable: Unsterile surgical technique, poor postoperative eye care, delay in treating systemic infections, or ignoring protective eyewear in high-risk environments.

Sometimes the cause remains idiopathic we don’t fully understand why the eye’s defenses get overwhelmed. That’s a big area of ongoing research. But overall, breaches in the eye’s sealed environment and systemic seeding top the list.

Pathophysiology (Mechanisms of Disease)

Under normal conditions, the eye’s immune privilege and the blood–ocular barrier prevent microbes from entering and causing harm. With endophthalmitis, pathogens circumvent these barriers. For exogenous infection, bacteria or fungi are introduced directly, then adhere to intraocular surfaces, multiply, and release toxins.

The body mounts an inflammatory response: neutrophils and macrophages flood the vitreous cavity, releasing cytokines and proteolytic enzymes. This “battle” can damage retinal tissue, photoreceptor cells, and the optic nerve head. Overzealous inflammation may worsen vision loss more than the pathogens themselves.

In endogenous cases, sepsis or bacteremia allows microbes to cross a disrupted blood–ocular barrier. They form microabscesses within the vitreous gel, propagate, and trigger a similar cascade of inflammation. Elevated intraocular pressure (IOP) can result from clogging of trabecular meshwork by inflammatory debris, compounding tissue damage.

Symptoms and Clinical Presentation

Symptoms can vary widely, but many patients report a rapid onset of eye pain (often severe), redness, light sensitivity (photophobia), and sudden visual decline – from blurred vision to “hand motion” or worse. You might feel as if something is scratching inside your eye.

Early signs (first 24–48 hours) include:

• Conjunctival injection (significant redness)
• Mild to moderate photophobia
• Slight discharge or tearing
• Discomfort localized to the globe

As it progresses (48–72 hours), you could see:

• Intense eye pain (sometimes described as throbbing)
• Hypopyon (layering of white blood cells in front of the iris)
• Marked decrease in vision, maybe only light perception
• Swelling of the eyelids and surrounding tissues
• Elevated IOP leading to headache or nausea

Advanced or untreated cases might lead to panophthalmitis (full-thickness inflammation of all ocular structures), end-stage eyeball destruction, and systemic spread in rare scenarios.

People differ in how they notice symptoms some with high pain tolerance might delay seeking care, while others get alarmed by just a slight blur. Always heed warning signs like rapidly worsening vision, intense pain, or hypopyon.

Diagnosis and Medical Evaluation

Diagnosing endophthalmitis is mostly clinical but supported by laboratory tests and imaging. A thorough eye exam by an ophthalmologist will include slit-lamp biomicroscopy (to look for hypopyon or fibrin) and dilated fundus exam (to assess the vitreous).

Key diagnostic steps:

• Aqueous/vitreous tap: Aspiration of small fluid sample for Gram stain, culture (aerobic, anaerobic, fungal), and sensitivity. This guides targeted antimicrobial therapy.
• Ocular ultrasound (B-scan): Useful when the view is obscured by dense vitritis. Can reveal vitreous opacities, membrane formation, or retinal detachments.
• Blood cultures: In suspected endogenous cases, to identify systemic infection source.
• Complete blood count and inflammatory markers: Elevated white cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) often correlate with severity.

Differential diagnosis might include sterile postoperative inflammation (TASS), uveitis, keratitis, or acute angle-closure glaucoma. But the rapidity and severity of vision loss, along with lab support, help clinch the diagnosis.

Which Doctor Should You See for Endophthalmitis?

If you suspect endophthalmitis, the quickest route is to contact an ophthalmologist especially a retina specialist if available. They’re the go-to experts for intraocular infections. An emergency department visit can get you started, but definitive care usually means an urgent referral to ophthalmology.

Telemedicine can help in the early stages: you can send photos, describe symptoms, or get a second opinion on your test results. It’s great for clarifying concerns after surgery or understanding lab outcomes. But remember, online consults can’t replace a hands-on slit-lamp evaluation or immediate intravitreal injections if needed.

In extreme pain or sudden vision loss, don’t wait for an online slot head to ophthalmic emergency services or the hospital right away. Delays of even a few hours can adversely impact eyesight.

Treatment Options and Management

Immediate, aggressive treatment is crucial. The cornerstone is

• Intravitreal antibiotics: Usually a combination of vancomycin (for gram-positives) and ceftazidime (for gram-negatives). If fungi are suspected, intravitreal amphotericin B or voriconazole is added.
• Systemic antibiotics/antifungals: IV administration for endogenous cases or severe exogenous infections.
• Topical therapy: Intensive fortified antibiotic eye drops (e.g., tobramycin, cefazolin) every hour initially.
• Pars plana vitrectomy: Surgical removal of infected vitreous gel improves drug delivery and decreases microbial load, particularly if vision is hand motion or worse.

Supportive measures include corticosteroids (intravitreal or systemic) to dampen inflammation, though timing is debated. Side effects like raised intraocular pressure, cataract progression, or systemic toxicity must be considered.

Prognosis and Possible Complications

Prognosis hinges on cause, organism virulence, and timing of treatment. Prompt therapy within 24 hours often spares some vision; delays can result in “count fingers” or worse outcomes. Studies show that post-cataract endophthalmitis treated early yields better final visual acuity compared to trauma-related cases.

Possible complications:

• Retinal detachment
• Phthisis bulbi (shrunken, nonfunctional eyeball)
• Chronic uveitis
• Glaucoma due to angle damage
• Corneal decompensation if corneal endothelium is involved

Up to 40% of severe cases may lose functional vision or require enucleation in the worst scenarios, especially with virulent organisms like Pseudomonas.

Prevention and Risk Reduction

Preventing endophthalmitis is partly about strict sterile technique and patient education. Ophthalmic surgeons must follow aseptic protocols: proper sterilization of instruments, use of povidone-iodine drops preoperatively, and maintaining a sterile field.

Patients can reduce risk by:

• Keeping postoperative instructions—avoid rubbing eyes, change dressings if recommended
• Completing any prescribed antibiotics or anti-inflammatories
• Reporting pain or vision changes immediately

For injections (like anti-VEGF), clinics use eyelid speculums, povidone-iodine, and sterile gloves. In systemic disease, early treatment of bacteremia or candidemia can prevent endogenous seeding so prompt doctor visits for fevers and antibiotic stewardship matter.

Regular follow-up after intraocular procedures (first day, one week, one month) helps catch inflammation before it escalates. Screening high-risk groups (diabetics, immunocompromised) for systemic infections may indirectly shield their eyes.

Myths and Realities

There’s a bunch of misconceptions floating around about endophthalmitis. Here’s a quick myth-busting:

• Myth: “It only happens after cataract surgery.”
  Reality: Sure, post-cataract is common, but it can follow any intraocular procedure, trauma, or systemic infection.
• Myth: “If you feel no pain, you’re fine.”
  Reality: Some patients have minimal discomfort but rapid vision loss. Pain level isn’t a reliable gauge of severity.
• Myth: “Home remedies—like saline rinses—can treat it.”
  Reality: No substitute for intravitreal antibiotics. Delays worsen prognosis dramatically.
• Myth: “Steroid eye drops alone will fix it.”
  Reality: Steroids without antibiotics can exacerbate the infection.
• Myth: “A painless red eye is never serious.”
  Reality: Painless hypopyon can sometimes appear in a smoldering chronic endophthalmitis.

Many myths arise from confusing sterile postoperative inflammation (TASS) with infectious processes. Always lean on your ophthalmologist’s guidance.

Conclusion

Endophthalmitis is a vision-threatening emergency that requires prompt recognition and aggressive management. From its origins whether surgical breaching of ocular defenses or bloodstream seeding to the cascade of inflammation in the vitreous, the stakes are high. Modern intravitreal antibiotics, vitrectomy techniques, and systemic therapies have improved outcomes, but delays still carry major risks. If you experience sudden redness, pain, or vision loss after any eye procedure or in the setting of systemic infection, seek professional care immediately. Your sight depends on timely action.

Frequently Asked Questions (FAQ)

• 1. What is endophthalmitis?
  It’s an infection and inflammation inside the eye’s cavities, often caused by bacteria or fungi.
• 2. How quickly do symptoms appear?
  Typically within 24–72 hours after surgery, trauma, or systemic infection.
• 3. Is endophthalmitis contagious?
  No, it doesn’t spread between people; it’s an internal infection.
• 4. What are the earliest warning signs?
  Redness, mild pain, and vision blurring—don’t brush them off!
• 5. How is it confirmed?
  By eye exam, fluid culture (vitreous tap), and sometimes ocular ultrasound.
• 6. What treatments are used?
  Intravitreal antibiotics/antifungals, systemic meds, and often vitrectomy surgery.
• 7. Can it be prevented?
  Strict sterile technique during surgeries/injections and early systemic infection control help a lot.
• 8. What’s the recovery like?
  Recovery varies; some regain useful vision, others unfortunately have lasting deficits.
• 9. When should I call my doctor?
  If you notice sudden eye pain, redness, or vision changes post-op or during systemic illness.
• 10. Are steroids part of treatment?
  They may reduce inflammation but are always paired with antimicrobials.
• 11. Can telemedicine help?
  Yes for initial guidance, second opinions, and interpreting lab results, but not a substitute for in-clinic emergency care.
• 12. How dangerous is it?
  Very—untreated, it can lead to blindness or even loss of the eye.
• 13. Who’s at highest risk?
  People with recent intraocular procedures, ocular trauma, or systemic infections/immunosuppression.
• 14. Will I need multiple surgeries?
  Sometimes, yes. Repeat vitrectomies may be necessary if infection persists.
• 15. Does it ever recur?
  Recurrent or chronic cases occur, particularly with fungi, requiring prolonged therapy.