Major reviewEndogenous bacterial endophthalmitis: A 17-year prospective series and review of 267 reported cases☆
Section snippets
St Thomas' case series
A 17-year prospective study from 1984 to 2001 was conducted in the departments of ophthalmology and microbiology in a London teaching hospital with a dedicated medical eye unit. All patients with a provisional diagnosis of EBE were admitted to the medical eye unit, and those with positive blood or intraocular culture were then prospectively identified. As Gram negative bacteria are rarely contaminants of blood or intraocular culture, their isolation was considered to be significant. Gram
St Thomas' case series
During the study period 19 patients (21 eyes) were diagnosed with EBE (Table 1). There were 12 men and 7 women with a mean age of 60 years (SD 17.0; range 7–77). Four patients have been reported previously.133 Twelve patients presented to an ophthalmologist with ocular symptoms and 7 to a general physician with manifestations of extraocular infection. All adult patients complained of blurred or altered vision at the onset of infection, and 12 had ocular pain or discomfort. Seventeen patients
Patient Characteristics
Although our literature review suggests that the incidence of EBE peaks at about 50 years of age, there is a wide distribution from neonates to patients in their tenth decade. The last major review by Greenwald et al in 198671 reported a lower mean age of 35 years (range 1 week to 85 years) with 24 of 72 patients aged less than 20 years. They also suggested that the right eye was twice as likely to be affected as the left and postulated that this is because of the more proximal and direct
Clinical Features
The classic features of EBE include ocular pain, blurred vision, swollen eyelids, injected and chemosed conjunctiva, anterior chamber inflammation and hypopyon, elevated IOP with associated corneal edema, a reduced or absent red reflex, and poor fundal view secondary to intraocular inflammation. In our case series all adult patients complained of blurred vision and two-thirds had ocular pain. Hypopyon and elevated IOP were inconstant findings in our patients, but when the IOP was raised it was
Incidence of diagnostic errors
Although some of the above clinical features may help identify patients with EBE, most are nonspecific and it remains a difficult diagnosis, especially given its low incidence. Greenwald's review71 found that 16% (11/67) of patients with EBE were initially misdiagnosed, and our literature review suggests a figure of 22%. Both are probably an underestimate as diagnostic errors may be under-reported. In our case series 63% of cases were initially misdiagnosed.
Adults
The differential diagnosis of EBE
Blood Culture
Blood culture is the most reliable way of establishing the diagnosis. In four large series of EBE,36., 102., 135., 191. blood cultures were more likely to be positive than vitreous. Review of all 267 cases shows that blood culture was the commonest means of confirming the diagnosis, and in our own case series almost three-quarters of blood cultures were positive.
Intraocular Cultures
Although useful, blood cultures alone cannot be relied upon to establish the diagnosis. In the absence of positive cultures from
Causative Organisms
Although our literature review suggests that EBE is more commonly caused by Gram negative bacteria, there was considerable regional variation. In a large literature review, Wong et al191 compared cases of EBE reported from East Asian hospitals with those from the world literature. In East Asia, EBE was overwhelmingly caused by Gram negative organisms, particularly Klebsiella spp. Cases reported from outside that region were more likely to be caused by Gram positive organisms. Unusual organisms
Role in endogenous endophthalmitis
Just over half of the patients in our literature review were treated with intravitreal antibiotics. This reflects debate in the literature regarding their role in EBE. Many topical, subconjunctival, and systemic antibiotics do not reach therapeutic levels within the vitreous12 and this may explain why patients can develop EBE while on appropriate systemic antibiotics, despite therapeutic blood levels.169
Wong et al performed univariable analysis of visual outcome in a large literature review of
Prognosis
The visual outcome of EBE has not improved in 55 years. Review of the literature from 1976–1985 showed that 41% of patients had count fingers vision or better, 26% were blind, and 29% required evisceration or enucleation.71 Similar figures were reported over the preceding 30 years.162 Review of the literature since 1986 also indicates a poor outcome, with equivalent figures of 32%, 44%, and 25% (Fig. 1).
The studies that investigated prognostic factors in EBE71 were retrospective, and although
Pathogenesis
EBE occurs when bacteria cross the blood–ocular barrier, resist host defenses, and multiply within the eye. The blood–ocular barrier may prevent many organisms reaching the internal ocular spaces as relatively few bacteremic patients develop EBE. In one prospective study of 202 patients with bacteremia, none developed EBE although 12 developed minor ocular lesions such as cotton-wool spots and microhemorrhages.17 Another prospective study of 101 patients with septicemia131 reported that 24
Pathology
Animal experiments suggest that tissue damage results from a combination of direct invasion of ocular tissue by bacteria, the release of bacterial toxins, and the host inflammatory response. Callegan et al21 studied the effect of intravitreal injections of rabbit eyes with live S. aureus, Bacillus cereus, and Enterococcus faecalis,as well as bacterial cell walls and exotoxins. B.cereusdirectly invaded the retina and cornea, and both S.aureusand B.cereusreduced the electroretinogram response,
Guidelines for reporting EBE
Large randomized studies of EBE are unlikely to be forthcoming in the near future. The quality of case reports is therefore important, as these form the principal evidence base. Some case reports provide inadequate details of the presentation, management, and outcome of EBE. We therefore advocate that the following minimum information is included when reporting cases of EBE: age; sex; affected side(s); ocular clinical features including classification using Greenwald's system;71 systemic
Conclusions
EBE has a poor visual prognosis that has not improved in over half a century. There are several possible reasons for this. First, EBE is very uncommon yet it may mimic several common ophthalmic conditions. This may explain why many patients are initially misdiagnosed. EBE can be rapidly progressive and delayed treatment may result in a poor outcome. Second, clinicians may fail to appreciate the overlap of ocular and extraocular disease. Third, there have been no large prospective studies of EBE
References (194)
- et al.
Endogenous Mycobacterium chelonae endophthalmitis
Am J Ophthalmol
(1989) - et al.
Intraocular penetration of gentamicin after subconjunctival and retrobulbar injection
Am J Ophthalmol
(1978) - et al.
Endogenous Ochrobactrum anthropi endophthalmitis
Am J Ophthalmol
(1997) - et al.
Metastatic pneumococcal endophthalmitis: report of two cases and review of literature
J Infect
(1990) - et al.
Vitreous cultures in suspected endophthalmitis—biopsy or vitrectomy?
Ophthalmology
(1993) - et al.
Elevated intraocular pressure, pigment dispersion and dark hypopyon in endogenous endophthalmitis from Listeria monocytogenes
Surv Ophthalmol
(1992) - et al.
Escherichia coli emphysematous endophthalmitis and pyelonephritis. Case report and review of the literature
Am J Med
(1988) - et al.
Concurrent endophthalmitis and retinal detachment
Ophthalmology
(1994) - et al.
Type V group B Streptococcal septicaemia with bilateral endophthalmitis and septic arthritis
Lancet
(1993) - et al.
Intraocular listeriosis
Am J Ophthalmol
(1967)
Metastatic bacterial endophthalmitis: a contemporary reappraisal
Surv Ophthalmol
Endophthalmitis from mycobacterium bovis-Bacille Calmette-Guérin after intraveicular Bacille Calmette-Guérin injections for bladder carcinoma
Am J Ophthalmol
Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study
Am J Ophthalmol
Endogenous endophthalmitis caused by Streptococcus mitis
Am J Ophthalmol
Endophthalmitis at the Bristol Eye Hospital: an 11-year review of 47 patients
J Hosp Infect
Bilateral endogenous endophthalmitis in a patient with diabetes and renal papillary necrosis
Am J Ophthalmol
Endogenous orbital cellulitis and endogenous endophthalmitis in subacute bacterial endocarditis
Am J Ophthalmol
Metastatic endophthalmitis in a patient with major burns: a rare complication
Burns
Intraocular nocardiosis
Am J Ophthalmol
Identification of bacterial pathogens in patients with endophthalmitis by 16S ribosomal DNA typing
Am J Ophthalmol
Endophthalmitis
Surv Ophthalmol
Orbital infections in patients with human immunodeficiency virus infection
Ophthalmology
Endophthalmitis as a presentation of meningococcal septicemia
Ir J Med Sci
Endogenous bacterial endophthalmitis in sickle cell anemia
Ann Ophthalmol
Brucella melitensis endogenous endophthalmitis
Ophthalmologica
Pink hypopyon: a sign of Serratia marcescens endophthalmitis
Br J Ophthalmol
Listeria monocytogenes endophthalmitis in a renal-transplant patient receiving ciclosporin
Ophthalmologica
Haematogenous Serratia marcescens endophthalmitis in an HIV-infected intravenous drug addict
Infection
E. coli endophthalmitis
Eye
Endogenous endophthalmitis initially misdiagnosed as anterior uveitis
Ann Ophthalmol
Clostridium-perfringens endophthalmitis and orbital cellulitis
Saudi Med J
Meningococcal endophthalmitis without concomitant septicemia or meningitis
Pediatr Infect Dis J
Group G streptococci as a cause of bacterial endophthalmitis
Arch Ophthalmol
Meningococcal endophthalmitis and pericarditis
J Royal Soc Med
Metastatic Pseudomonas endophthalmitis following bronchoscopy
Can J Ophthalmol
A prospective search for ocular lesions in hospitalized patients with significant bacteremia
Clin Infect Dis
Listeria monocytogenes endophthalmitis: a case report
Aust NZ J Ophthalmol
Endophthalmitis: current approaches to diagnosis and treatment
Curr Opin Infect Dis
Fatal case of group B streptococcal endogenous endophthalmitis
Can J Ophthalmol
Pathogenesis of gram-positive bacterial endophthalmitis
Infect Immunity
Aminoglycoside toxicity—a survey of retinal specialists. Implications for ocular use
Arch Ophthalmol
Toxicity of intravitreous ceftazidime in primate retina
Arch Ophthalmol
Aminoglycoside toxicity in the treatment of endophthalmitis. The Aminoglycoside Toxicity Study Group
Arch Ophthalmol
Sudden visual loss associated with clostridial bacteraemia
Br J Ophthalmol
Endogenous endophthalmitis due to Salmonella arizonae and Hafnia alvei
Southern Med J
Kingella kingae endophthalmitis in an infant
Aust NZ J Ophthalmol
Klebsiella pneumoniae liver abscess associated septic endophthalmitis
Arch Intern Med
A clinical study of Klebsiella liver abscess
J Formosan Med Assoc
Endogenous Klebsiella endophthalmitis—a case series
Ann Acad Med Singapore
Septic metastatic lesions of pyogenic liver abscess. Their association with Klebsiella pneumoniae bacteremia in diabetic patients
Arch Intern Med
Cited by (460)
Prostatic abscess Metastasis: A case report of an unusual complication
2023, Urology Case ReportsEndogenous panophthalmitis in a patient with COVID-19 during hospitalization in an intensive care unit: A case report
2022, American Journal of Ophthalmology Case ReportsBacterial endogenous endophthalmitis: Spectrum of pathogens and drug therapy
2024, OphthalmologieMRSA panophthalmitis in a brittle diabetic
2023, Journal of Ophthalmic Inflammation and InfectionAnalysis of pathogenic factors and clinical features of infectious endophthalmitis
2023, Research SquareEndogenous endophthalmitis caused by urinary tract infection: A case report
2023, Medicine (United States)
- ☆
The authors wish to thank Andrew Hutchings, London School of Hygiene and Tropical Medicine, for statistical support. Dr Jackson was supported by a research grant from the Lady Anne Allerton Fund and a personal training award from the Special Trustees of St Thomas' Hospital. The authors reported no proprietary or financial interest in any product mentioned or concept discussed in this article.