Endogenous Endophthalmitis: A Review of Case Series Published between 2011 and 2020

Abstract

This is a literature review of 31 case series of endogenous endophthalmitis (EE) published in the last ten years, identified from a literature search of several databases (PubMed, EMBASE, and the Cochrane Library). While diabetes mellitus and malignancies remain the most frequently associated medical conditions, intravenous drug use is a significant risk factor (especially in the last years, in studies from Western countries). Ophthalmologic screening is recommended for candidaemia, but not in patients with sepsis of other aetiologies (however, the physician treating patients with sepsis must be well aware of EE). The most frequent Gram-positive microorganisms that cause EE are Staphylococcus and Streptococcus; the most frequent Gram-negative organism is Pseudomonas, and yeasts, probably Candida, usually cause fungal infections. In all-cause EE, prognostic factors of better visual outcomes are initial VA better than counting fingers, performing a pars plana vitrectomy (PPV), performing an intravitreal injection within the first 24 hours after clinical diagnosis, and the presence of a focal type of EE. In endogenous fungal endophthalmitis, more than 1/4 of patients have bilateral involvement. Blood samples have a low rate of positivity. Yeasts remain the most prevalent cause. Many authors report using azoles and echinocandins for systemic therapy (and voriconazole for intravitreal injections). Although PPV was performed in small proportions of eyes, the anatomical success rate is quite high. Klebsiella pneumoniae is an important cause of EE in Southeast Asia (and probably an emergent etiology in other regions), which is frequently associated with diabetes. There is a robust association with pyogenic liver abscess (PLA) (but in up to half of the cases, the diagnosis of EE precedes that of PLA). Blood cultures have a high diagnostic yield, while vitreous samples have a low yield. K. pneumoniae may carry antibiotic resistance. Anatomical and functional success rates are small, but they may be improved with PPV.

Hypervirulent Klebsiella pneumoniae Endogenous Endophthalmitis—A Global Emerging Disease

“…Since the first case described in 1986, EKE has become currently the most frequent cause of endogenous endophthalmitis in Asian countries, with an incidence of up to 9%, and with an emergent trend in US, Australia, and European countries [ 22 , 54 ]. Epidemiological studies evidenced an incidence of 100 higher of metastatic spread in hvKp vs. other microorganisms.…”

Clinical Characteristics and Outcomes in 314 Japanese Patients with Bacterial Endophthalmitis: A Multicenter Cohort Study from J-CREST

“…BCVA in patients with endophthalmitis improved significantly after treatment, and the percentage of patients with final BCVA ≤ 1.0 logMAR was 76.6%, which suggests that our treatments for endophthalmitis in J-CREST were not inferior to those in other reports (33.3% (Snellen 20/31 or better) [ 5 ], 28% (Snellen 20/120 or better) [ 6 ], 44% (Snellen 20/40 or better) [ 18 ], 32.7% (Snellen 20/40 or better) [ 22 ], 71% (Snellen 5/200 or better) [ 43 ], 34.5% (Snellen 20/400 or better) [ 44 ], and 34.5% (Snellen 20/60 or better) [ 45 ]). Additionally, the ophthalmologists in J-CREST (all are retina specialists) tended to perform a vitrectomy as a primary treatment for endophthalmitis, which is likely a worldwide trend [ 4 , 24 , 46 , 47 ].…”

“…Bacterial endophthalmitis is classified into two groups on the basis of the infection route (exogenous or endogenous). Exogenous endophthalmitis (ExE) is mainly caused by eye surgery [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ] and trauma [ 24 , 25 , 26 ] due to the direct infection of pathogens into the eye from outside. Acute endophthalmitis appears as a postoperative complication within 1–2 weeks after the surgical intervention, most commonly on the third to fifth postoperative day [ 1 , 2 ].…”

A Review of Ocular Drug Delivery Platforms and Drugs for Infectious and Noninfectious Uveitis: The Past, Present, and Future

“…Until a large, randomized study using newer, better intraocular penetrating systemic antibiotics is performed, the use of adjuvant oral or intravenous antibiotics will remain controversial. We hypothesize by extrapolating from the EVS and much like the treatment of endogenous endophthalmitis or sight-threatening fungal chorioretinitis ( Figure 3 ), where both intravitreal and systemic antibiotics are utilized, cases of post-procedural and -traumatic endophthalmitis may benefit from the addition of systemic antimicrobials that rapidly equilibrate to high concentrations within the vitreous after intravitreal antimicrobials have been administered [ 43 ]. However, a randomized, controlled trial is needed with newer generation systemic antibiotics to evaluate their benefit in endophthalmitis of any cause.…”