Infectious Disease Compendium

Endophthalmitis

Diagnosis

Painful red eye with decreasing vision.

Epidemiologic Risks

Post operative (usually cataract or bleb formation for glaucoma), trauma and, if you are really filled with bad karma, hematogenous.

Microbiology

Acute post cataract: coagulase negative staphylococcus.

Glaucoma/Bleb-related: Viridans streptococci, Streptococcus pneumoniae, Haemophilus influenzae.

Post traumatic: Bacillus cereus and a huge number of organisms (PubMed)

Hematogenous: S. aureus, streptococci, occasionally gram-negative bacilli. Candida in the IVDA.

Chronic pseudophakic: Propionibacterium acnes.

Fungal: Candida, Aspergillus, Fusarium, the last two especially in the neutropenic host.

Empiric Therapy

Depends on the bug and the host. Usually the ophthalmologist will be injecting antibiotics into the eye (just writing this gives me the willies) with a vitrectomy.

Whether systemic antibiotics (or an ID consult) will add much is uncertain. Usually start with vancomycin and a third generation cephalosporin. See the specific organisms.

Candida loves to go to the back of the eye, and if there is fungal endopthlamitis, may want to avoid echinocandadins as penetration into the eye is negligible. "Fluconazole, voriconazole, and flucytosine achieve therapeutic intravitreal concentrations, whereas the echinocandins and all formulations of amphotericin do not. Most experience has accumulated with fluconazole. There is less experience with voriconazole, but there are data on the efficacy and safety of intravitreal injection of this agent. Flucytosine should be used in combination with amphotericin and not as sole therapy (PubMed)".

My one claim to fame is treating Candida in the rabbit eye (PubMed). Amphotericin nukes it.

Pearls

Candida, especially C. albicans, loves to go the eye and occasionally the diagnosis of disseminated disease in the ICU can be made by finding a fungus ball in the back of the eye. About 30% of patients with Candida in their blood cultures will develop fungus balls in the eye.

Rants

I am so proud I know where to put the 'h' in endhophthalmitis. Whoops.

Curious Cases

Relevant links to my Medscape blog

The Eyes Have It and It Gives Me the Creeps

The Eyes Have It

Peripheral IVz: Homines Non Boni Seriose

Last Update: 06/27/18.