Q5 LONG ANSWER 10M ★ High-yield

Describe endophthalmitis and panophthalmitis with their management.

Ophthalmology · 3rd Professional

Definitions and Classification

Endophthalmitis is inflammation of the intraocular cavities and their contents — the aqueous and vitreous — infective.
panophthalmitis is inflammation of all the coats of the eye together with the orbital tissues, and is the more advanced and destructive condition.

Type	Setting and organisms
Acute post-operative	Within 1 to 7 days of intraocular surgery, most often cataract surgery. Coagulase-negative staphylococci (Staph. Epidermidis) are the commonest, from the patient’s own lid and conjunctival flora; also Staph. Aureus, streptococci and Gram-negative organisms. Incidence about 0.05 to 0.1%
Chronic (delayed) post-operative	Weeks to months afterwards. cutibacterium (Propionibacterium) acnes, sequestered in the capsular bag as a white plaque; also Candida and coagulase-negative staphylococci. Presents as a low-grade granulomatous uveitis that responds to steroid and relapses when it is stopped — the classical clue
Bleb-associated	Months to years after glaucoma filtering surgery, through a thin avascular bleb. Streptococci and haemophilus; fulminant and with a poor prognosis
Post-traumatic	After penetrating injury, and particularly with a retained intraocular foreign body or with soil or vegetable contamination. bacillus cereus is the feared organism — extremely rapid, with corneal ring abscess, fever and loss of the eye within hours; also Staph. Epidermidis and fungi
Endogenous (metastatic)	Blood-borne, in the immunosuppressed, intravenous drug users, diabetics, those with indwelling catheters, and after abdominal sepsis. candida is the commonest worldwide; and klebsiella, characteristically from a liver abscess, is a well-described and important cause in ASIA. Often bilateral, and a marker of systemic sepsis
Post-injection	After intravitreal anti-VEGF or steroid injection; streptococci are over-represented, and are thought to come from droplet contamination when the operator talks

Clinical Features and Investigation

Symptoms — rapidly worsening pain and profound loss OF vision in an eye that was improving after surgery. Any patient whose vision or comfort deteriorates after cataract surgery has endophthalmitis until proved otherwise.
Signs — lid oedema and chemosis; marked ciliary and conjunctival congestion; corneal oedema; hypopyon; fibrin in the anterior chamber; vitritis with loss of the red reflex, which is the cardinal sign; a relative afferent pupillary defect; and, where the retina can be seen, retinitis and periphlebitis
Panophthalmitis adds — proptosis, restricted or absent ocular movements with pain, marked lid swelling, fever and systemic upset, and eventually orbital cellulitis. The involvement of the orbit and the systemic illness are what distinguish it, and it carries a risk of cavernous sinus thrombosis and meningitis

Treatment

The endophthalmitis vitrectomy study (EVS) governs practice, and its conclusion is decided by the presenting vision:
If vision is perception OF light only — immediate pars plana vitrectomy with intravitreal antibiotics.
If vision is hand movements or better — vitreous tap and intravitreal antibiotics, with vitrectomy reserved for those who fail to improve

Feature	Endophthalmitis	Panophthalmitis
Tissues involved	Intraocular cavities and contents only	All coats plus the orbital tissues
Proptosis	Absent	Present
Ocular movements	Full, though uncomfortable	Restricted and painful
Systemic upset	Usually absent	Fever, malaise, leucocytosis
Prognosis for the eye	May be salvaged with prompt treatment	Almost always lost
Risk to life	Minimal	Cavernous sinus thrombosis, meningitis, brain abscess
Surgery for a blind eye	Not usually needed	Evisceration, not enucleation, to avoid spread along the optic nerve sheath

Prophylaxis and Applied Aspects

Preoperative povidone-iodine 5% into the conjunctival sac is the single best-evidenced prophylactic measure in all of ophthalmic surgery, and takes three minutes
Intracameral cefuroxime at the end of cataract surgery was shown by the ESCRS study to reduce endophthalmitis several-fold, and is now widely standard
Treat blepharitis, dacryocystitis and any lid or lacrimal infection before operating; the organisms come from the patient’s own flora, and an unrecognised dacryocystitis is an absolute contraindication
Assess and act within hours, not days; the outcome depends on the interval from onset to intravitreal antibiotic more than on anything else

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