Decreased vision or ocular pain in a patient that is acutely ill (e.g., septic), recently hospitalized, immunocompromised, has an indwelling catheter, history of intravenous drug use, or with a history of a recent systemic procedure (e.g., heart valve replacement or repair, dental procedure). No history of recent intraocular surgery.

Critical

Chorioretinitis, vitreous cells and debris, AC cell and flare, and/or a hypopyon (See Figure 12.17.1).

Figure 12.17.1: Dense vitritis and a chorioretinal lesion in a patient with endogenous endophthalmitis from a skin infection.

Other

Iris microabscesses, absent red reflex, retinal inflammatory infiltrates, flame-shaped retinal hemorrhages with or without white centers, retinal/subretinal/choroidal abscesses, corneal edema, eyelid edema, chemosis, conjunctival injection, and panophthalmitis with orbital involvement (proptosis, restricted ocular motility). May be bilateral.

Organisms

Bacillus cereus (especially in i.v. drug users), streptococci, Neisseria meningitidis, S. aureus, H. influenzae, Klebsiella in East Asia, and others.

• Endogenous fungal endophthalmitis: May see fluffy, white vitreous opacities. Organisms include Aspergillus and Candida. See 12.18, Endogenous Fungal Endophthalmitis.

• Viral retinitis: One or more foci of retinal whitening with variable levels of vitreous inflammation. See 12.13, Acute Retinal Necrosis and 12.12, Cytomegalovirus Retinitis.

• Toxoplasmosis: Typically a unilateral retinitis which may or may not be associated with an adjacent pigmented chorioretinal scar. A dense vitritis may be appreciated over the area of retinitis creating the classic “headlight in a fog” appearance. AC reaction is variable. See 12.9, Toxoplasmosis.

• Noninfectious panuveitis: See 12.4, Panuveitis.

• Neoplastic conditions (e.g., vitreoretinal lymphoma and retinoblastoma).

1. History: Duration of symptoms? Systemic symptoms of underlying disease or infection? Indwelling catheter? Intravenous drug use? Immunocompromised? Recent medical procedures?

2. Complete ocular examination, including a dilated fundus evaluation.

3. B-scan US if there is no view to the fundus to assess for vitritis and chorioretinal abscesses.

4. Obtain an aqueous or vitreous tap with Gram stain and culture, fungal stain and culture, and PCR (if indicated) for HSV, VZV, CMV, and toxoplasmosis.

5. Admit patients to the hospital for comanagement with medicine or infectious disease team for source identification and control.

6. CXR; cultures of blood, urine, all indwelling catheters, and i.v. lines; Gram stain and cultures of any wound or discharge. Consider a transesophogeal or transthoracic echocardiogram to rule out endocarditis. A lumbar puncture is indicated when meningeal signs are present.

All treatment should be coordinated with an internal medicine physician.

1. Hospitalize the patient.

2. Broad-spectrum (i.v. and/or oral) antibiotics are started after appropriate smears and cultures are obtained. Antibiotic choices vary  according to the suspected source of septic infection (e.g., gastrointestinal tract, genitourinary tract, and cardiac) and are determined in consultation with an infectious disease specialist. Dosages recommended for meningitis and severe infections are used. If oral antibiotics are used, confirm that the regimen includes antibiotics with good vitreous penetration.

   NOTE Intravenous drug users are given an aminoglycoside and clindamycin to target B. cereus.

3. Topical cycloplegic (e.g., atropine 1% b.i.d. to t.i.d.).

4. Topical steroid (e.g., prednisolone acetate 1% q1–6h titrated to the degree of anterior segment inflammation).

5. Consider intravitreal antibiotics if there is significant or worsening vitreous involvement (e.g., ceftazidime 2.2 mg in 0.1 mL and vancomycin 1 mg in 0.1 mL; clindamycin 1 mg in 0.1 mL, or amikacin 0.4 mg in 0.1 mL may also be considered for anaerobic coverage, especially if there is high concern for Bacillus, IOFB, or when there is a penicillin allergy). Intravitreal aminoglycosides, including amikacin, may cause macular infarction. The timing of intravitreal antibiotics is controversial although they offer higher intraocular concentrations. Consider intravitreal antifungal agents, if clinically suspicious. See Appendix 11, Intravitreal Tap and Inject, and Appendix 12, Intravitreal Antibiotics.

6. Consider pars plana vitrectomy if severe or nonresponsive to initial therapy. Vitrectomy offers the benefits of reducing infective and inflammatory load and providing sufficient material for diagnostic culture and pathologic study. Additionally, intravitreal antibiotics may be administered at the time of surgery.

7. Periocular antibiotics (e.g., subconjunctival or subtenon injections) are sometimes used. See Appendix 10, Technique for Retrobulbar/Subtenon/Subconjunctival Injections.

1. Daily in the hospital.

2. Peak and trough levels for many antibiotic agents are obtained every few days. Renal function needs monitoring during aminoglycoside therapy. The antibiotic regimen is guided by the culture and sensitivity results, as well as the patient’s clinical response to treatment. Intravenous antibiotics are maintained for at least 2 weeks (pending identification of clinical source and response to treatment).