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      Endophthalmitis

      review-article
      1 , 2 ,
      Korean Journal of Ophthalmology : KJO
      The Korean Ophthalmological Society
      Endogenous, Endophthalmitis, Exogenous

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          Abstract

          Endophthalmitis is a rare but severe form of ocular inflammation due to infection of the intraocular cavity that can lead to irreversible visual loss if not treated properly and timely. It can be classified as exogenous or endogenous based on the transmission route of the infectious source. Exogenous endophthalmitis occurs when infecting organisms gain entry into the eye via direct inoculation, while endogenous endophthalmitis occurs when infectious agents hematogenously spread into the eye from a distant focus of infection. The diagnosis of endophthalmitis depends mostly on the clinical findings on ophthalmological examination. Delayed diagnosis of endogenous endophthalmitis can lead to not only visual loss, but also increased risk of mortality. Since ocular and systemic symptoms of endophthalmitis are usually non-specific, early diagnosis relies on the alertness of clinicians. Early diagnosis and proper treatment are keys to saving the eye. Following advances in vitreoretinal pharmacotherapy and surgical technology, early surgical intervention is the current trend in the management of endophthalmitis.

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          Most cited references47

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          Endophthalmitis

          M Durand (2013)
          Endophthalmitis means bacterial or fungal infection inside the eye involving the vitreous and/or aqueous humors. Most cases are exogenous and occur after eye surgery, after penetrating ocular trauma, or as an extension of corneal infection. An increasing number of cases are occurring after intravitreal injections of anti-vascular endothelial growth factor (VEGF) medications. Endophthalmitis may also be endogenous, arising from bacteraemic or fungaemic seeding of the eye. The infected eye never serves as a source of bacteraemia or fungaemia, however. The most common pathogens in endophthalmitis vary by category. Coagulase-negative staphylococci are the most common causes of post-cataract endophthalmitis, and these bacteria and viridans streptococci cause most cases of post-intravitreal anti-VEGF injection endophthalmitis, Bacillus cereus is a major cause of post-traumatic endophthalmitis, and Staphylococcus aureus and streptococci are important causes of endogenous endophthalmitis associated with endocarditis. In Taiwan and other East Asian nations, Klebsiella pneumoniae causes most cases of endogenous endophthalmitis, in association with liver abscess. Endogenous fungal endophthalmitis in hospitalized patients is usually caused by Candida species, particularly Candida albicans. Acute endophthalmitis is a medical emergency. The most important component of treatment is the intravitreal injection of antibiotics, along with vitrectomy in severe cases. Systemic antibiotics should be used in cases of endogenous endophthalmitis and exogenous fungal endophthalmitis, but their role in exogenous bacterial endophthalmitis is uncertain. Repeated intravitreal injections of antibiotics may be necessary if there is no response to the initial therapy. Many eyes that receive prompt and appropriate treatment will recover useful vision.
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            Systematic review of 342 cases of endogenous bacterial endophthalmitis.

            We review a total of 342 cases of endogenous bacterial endophthalmitis reported between 1986 and 2012. Predisposing conditions were present in 60%, most commonly diabetes, intravenous drug use, and malignancy. The most common sources of infection were liver, lung, endocardium, urinary tract, and meninges. Systemic features such as fever were present in 74%, hypopyon in 35%, and an absent fundal view in 40%. Diagnostic delay occurred in 26%. Blood cultures were positive in 56%, and at least one intraocular sample was positive in 58% (comprising 26% anterior chamber samples, 59% vitreous taps, and 41% vitrectomy specimens). Worldwide, Gram negative infections (55%) were more frequent than Gram positive (45%) infections, particularly in Asia. Over the last decade, 11% of eyes were treated with systemic antibiotics alone, 10% intravitreal antibiotics alone, 36% systemic plus intravitreal antibiotics, and 20% systemic plus intravitreal antibiotics plus pars plana vitrectomy. The most commonly used intravitreal antibiotics were vancomycin (for Gram positive infection) and ceftazidime (Gram negative). The median final visual acuity was 20/100, with 44% worse than 20/200. Among all cases, 24% required evisceration or enucleation, and mortality was 4%. Both intravitreal dexamethasone and vitrectomy were each associated with a significantly greater chance of retaining 20/200 or better and significantly fewer eviscerations or enucleations-these warrant further study. For most patients, treatment should include a thorough systemic evaluation and prompt intravitreal and systemic antibiotics.
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              Endogenous bacterial endophthalmitis: an east Asian experience and a reappraisal of a severe ocular affliction.

              J. Wong (2000)
              To report 32 eyes of 27 patients with endogenous bacterial endophthalmitis seen over a 4 year period. Features and outcomes of this condition in the current series and the cases reported in the literature from 1986-1998 were reviewed. Retrospective noncomparative case series. All patients with this condition seen at the three participating general hospitals were included. A review of the systemic and ocular characteristics, therapeutic methods, and final outcomes in patients afflicted with this condition. Features studied included patients' demographic characteristics, microbiology, source of infection, ocular features, therapeutic interventions, final visual and anatomic outcomes. Nineteen (70%) of the 27 incriminating organisms in this case series were gram negative microbes, with Klebsiella pneumoniae infections alone being responsible in 16 (60%) cases. Hepatobiliary tract infection was the source of bacteremia in 13 (48%) patients. Only nine (28%) eyes obtained good final visual acuity (20/120 or better), and two eyes were enucleated/eviscerated. A literature review of 209 patients with endogenous endophthalmitis over a 12 year period showed a similar increase in the frequency of gram negative microbes as the responsible organism, especially among the East Asian population. Overall, 22% had bilateral involvement; two thirds of patients had predisposing factor(s) or underlying illness(es), and diabetes mellitus was present in 46%. Thirty-four percent of all eyes obtained counting finger or better final vision, and 16% had their eyes eviscerated or enucleated. Infections with virulent organisms (gram negative rods, Serratia, Bacillus) usually denoted a grave visual prognosis; however, a media that was not opaque on presentation was usually associated with a good prognosis. Metastatic ocular infection is not uncommon despite the availability of modern antibiotic therapy. Among the East Asian population, the patient at highest risk is a diabetic patient with Klebsiella pneumoniae hepatobiliary infection. In contrast, in the Caucasian population, this condition occurs in predisposed patients with gram-positive bacteremia arising from endocarditis or skin/joint infections. The final visual outcome in patients with endogenous bacterial endophthalmitis in the recent 12 years has not differed significantly from five decades ago.
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                Author and article information

                Journal
                Korean J Ophthalmol
                Korean J Ophthalmol
                KJO
                Korean Journal of Ophthalmology : KJO
                The Korean Ophthalmological Society
                1011-8942
                2092-9382
                August 2017
                28 June 2017
                : 31
                : 4
                : 283-289
                Affiliations
                [1 ]Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
                [2 ]School of Medicine, National Yang-Ming University, Taipei, Taiwan.
                Author notes
                Corresponding Author: Shwu-Jiuan Sheu, MD, PhD. Department of Ophthalmology, Kaohsiung Veterans General Hospital, #386 Ta-Chung 1st Rd, Kaohsiung 813, Taiwan. Tel: 886-7-346-8217, Fax: 886-7-346-8054, sjiuansheu@ 123456gmail.com
                Article
                10.3341/kjo.2017.0036
                5540982
                28752698
                04dd5ae9-7565-4885-9d32-0e17681dfc20
                © 2017 The Korean Ophthalmological Society

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 14 March 2017
                : 17 March 2017
                Categories
                Review Article

                Ophthalmology & Optometry
                endogenous,endophthalmitis,exogenous
                Ophthalmology & Optometry
                endogenous, endophthalmitis, exogenous

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