Elsevier

Survey of Ophthalmology

Volume 56, Issue 3, May–June 2011, Pages 214-251
Survey of Ophthalmology

Major Review
Post-traumatic Infectious Endophthalmitis

https://doi.org/10.1016/j.survophthal.2010.09.002Get rights and content

Abstract

Post-traumatic endophthalmitis is an uncommon yet devastating complication of an open globe injury. Risk factors include presence of an intraocular foreign body (IOFB), lens rupture, delayed primary globe repair, rural trauma, and trauma with contaminated objects. Visual prognosis in post-traumatic endophthalmitis is affected by the virulence of the microbe, the presence of a retinal break or detachment, the timing of treatment, the presence or absence of an IOFB, and the extent of initial injury. Treatment should be started emergently with systemic and intravitreal antibiotics. In the setting of penetrating ocular trauma, antibiotic prophylaxis of endophthalmitis should be considered. The best treatment regimen has not been determined. The most frequent prophylactic regimens are: treatment with oral antibiotics, a short course of intravenous antibiotics followed by oral antibiotics, or intravitreal antibiotics plus oral antibiotics.

Introduction

Post-traumatic infectious endophthalmitis is an uncommon but severe complication of ocular trauma. The United States Eye Injury Registry reports that 3.4% cases of open globe injuries are associated with endophthalmitis.59 The pathogens that cause post-traumatic endophthalmitis are distinct from those in other types of endophthalmitis, and thus it is useful to analyze this condition separately.239, 322 The course of post-traumatic endophthalmitis is affected by factors including, but not limited to, the type of injury, the microorganisms involved, the presence or absence of an intraocular foreign body (IOFB), and the time between injury and treatment4, 7, 12, 59, 341

We review the literature and the practices employed commonly in prophylaxis and treatment of post-traumatic endophthalmitis and address the controversial issues such as antibiotic prophylaxis for endophthalmitis in the setting of ocular trauma. Ultimately, rationally conceived and validated treatment and prophylaxis will improve the visual prognosis of individuals who present with eye injuries and are at high risk for developing endophthalmitis.

Section snippets

Types of Endophthalmitis

Endophthalmitis may be infectious or non-infectious, and the infectious cases may be a result of endogenous or exogenous sources.259 Each type of infectious endophthalmitis differs in its microbial profile, symptoms, and clinical course as described herein.

Post-traumatic Endophthalmitis

To evaluate and report eye injuries effectively and accurately, a standardized and clear classification of ocular trauma is necessary.180, 181 The Birmingham Eye Trauma Terminology System is approved by many ophthalmic organizations.180, 278 Ocular trauma is classified broadly as either a closed-globe injury or an open-globe injury. Closed-globe injuries are injuries to the sclera and the cornea, that do not make a full-thickness defect.24 An open globe injury is a full-thickness laceration of

Pediatric Post-traumatic Endophthalmitis

Similar to adults, the majority of children suffering from ocular trauma and post-traumatic endophthalmitis are male.219, 221, 301 Clinical signs of endophthalmitis are similar in the pediatric and adult populations. Assessment of symptoms of post-traumatic endophthalmitis may be challenging because children may have difficulty appreciating a change in visual acuity, and once they recognize the problem, they may not bring it to the attention of an adult. This behavior can result in a delay in

Organisms

Several pathogens have been implicated as causative agents in endophthalmitis following ocular trauma.39, 269 As mentioned earlier, the presence of positive cultures for a particular organism does not necessarily mean that a clinical infection will result in that patient.18, 211 Both Gram-positive and Gram-negative organisms can cause post-traumatic endophthalmitis. Polymicrobial infections and fungal infections also have been reported.4, 50

If infection progresses despite treatment,

Treatment guidelines for post-traumatic endophthalmitis

Initial treatment of post-traumatic endophthalmitis is based on clinical findings and is, of necessity, empirical. Initial treatment is influenced by selected features of the case, including the nature of trauma, the trauma setting, and/or the presence of an IOFB. It is generally agreed that prompt treatment is important for all cases of post-traumatic endophthalmitis.239 Once culture results are available, treatment can be modified, if necessary, based on the antibiotic sensitivities of the

Conclusion

Post-traumatic endophthalmitis is an uncommon yet devastating complication of penetrating ocular trauma. Clinicians should maintain a high index of suspicion for infection so that cases of endophthalmitis can be recognized and treated promptly.

Diagnosis of post-traumatic endophthalmitis can be difficult because the infection may not develop immediately after the trauma. If weeks and months lapse between trauma and symptoms/signs of infection, obtaining an adequate and accurate history may be

Method of Literature Search

The literature search for this review article was performed using the online electronic Medline Ovid database dated 1950 to September 2010, Week 4, and PubMed search up to September 2010. The keywords searched included: ocular trauma, penetrating eye injuries, traumatic endophthalmitis, perforating eye injuries, open globe, ruptured globe, ocular injury, corneal laceration, scleral laceration, intraocular foreign body, prophylaxis, vitritis, ocular trauma score, ocular trauma classification,

Disclosure

Supported in part by an unrestricted grant from the Research to Prevent Blindness, Inc., the New Jersey Lions Eye Research Foundation, and the Eye Institute of New Jersey. The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

References (343)

  • J.A. Cardillo et al.

    Post-traumatic proliferative vitreoretinopathy. The epidemiologic profile, onset, risk factors, and visual outcome

    Ophthalmology

    (1997)
  • C.M. Cebulla et al.

    Endophthalmitis after open globe injuries

    Am J Ophthalmol

    (2009)
  • S. Chhabra et al.

    Endophthalmitis after open globe injury: microbiologic spectrum and susceptibilities of isolates

    Am J Ophthalmol

    (2006)
  • T.A. Ciulla

    Update on acute and chronic endophthalmitis

    Ophthalmology

    (1999)
  • D.J. Coleman et al.

    Management of intraocular foreign bodies

    Ophthalmology

    (1987)
  • E. De Juan et al.

    Penetrating ocular injuries. Types of injuries and visual results

    Ophthalmology

    (1983)
  • B.H. Doft et al.

    Additional procedures after the initial vitrectomy or tap-biopsy in the Endophthalmitis Vitrectomy Study

    Ophthalmology

    (1998)
  • S.P. Donahue et al.

    Vitreous cultures in suspected endophthalmitis. Biopsy or vitrectomy?

    Ophthalmology

    (1993)
  • W.T. Driebe et al.

    Pseudophakic endophthalmitis. Diagnosis and management

    Ophthalmology

    (1986)
  • M.L. Durand et al.

    Successful treatment of Fusarium endophthalmitis with voriconazole and Aspergillus endophthalmitis with voriconazole plus caspofungin

    Am J Ophthalmol

    (2005)
  • C.W. Eifrig et al.

    Endophthalmitis caused by Pseudomonas aeruginosa

    Ophthalmology

    (2003)
  • F.Z. el Baba et al.

    Intravitreal penetration of oral ciprofloxacin in humans

    Ophthalmology

    (1992)
  • R.W. Essex et al.

    Post-traumatic endophthalmitis

    Ophthalmology

    (2004)
  • J.L. Federman et al.

    Complications associated with the use of silicone oil in 150 eyes after retina–vitreous surgery

    Ophthalmology

    (1988)
  • R.G. Fiscella et al.

    Aqueous and vitreous penetration of levofloxacin after oral administration

    Ophthalmology

    (1999)
  • A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group

    Arch Ophthalmol

    (1995)
  • J.T. Aaberg et al.

    Trauma: principles and techniques of treatment

  • A.M. Abu el-Asrar et al.

    Post-traumatic endophthalmitis: causative organisms and visual outcome

    Eur J Ophthalmol

    (1999)
  • A.M. Abu el-Asrar et al.

    Clostridium perfringens endophthalmitis

    Doc Ophthalmol

    (1994)
  • F.A. Adeyemi-Doro et al.

    Comparison of the in vitro activity of ofloxacin and gentamicin against isolates from hospitalised patients

    Infection

    (1986)
  • A. al-Hemidan et al.

    Bacillus cereus panophthalmitis associated with intraocular gas bubble

    Br J Ophthalmol

    (1989)
  • A.M. Al-Omran et al.

    Microbiologic spectrum and visual outcome of posttraumatic endophthalmitis

    Retina

    (2007)
  • D.V. Alfaro et al.

    Experimental Bacillus cereus post-traumatic endophthalmitis and treatment with ciprofloxacin

    Br J Ophthalmol

    (1996)
  • D.V. Alfaro et al.

    Systemic antibiotic prophylaxis in penetrating ocular injuries. An experimental study

    Retina

    (1992)
  • D.V. Alfaro et al.

    Posttraumatic endophthalmitis. Causative organisms, treatment, and prevention

    Retina

    (1994)
  • D.V. Alfaro et al.

    Paediatric post-traumatic endophthalmitis

    Br J Ophthalmol

    (1995)
  • E. Aliprandis et al.

    Comparative efficacy of topical moxifloxacin versus ciprofloxacin and vancomycin in the treatment of P. aeruginosa and ciprofloxacin-resistant MRSA keratitis in rabbits

    Cornea

    (2005)
  • C.M. Andreoli et al.

    Low rate of endophthalmitis in a large series of open globe injuries

    Am J Ophthalmol

    (2009)
  • G.L. Archer

    Staphylococcal infections

  • C.R. Arciola et al.

    Detection of biofilm-forming strains of Staphylococcus epidermidis and S. aureus

    Expert Rev Mol Diagn

    (2002)
  • R. Azad et al.

    Pars plana vitrectomy with or without silicone oil endotamponade in post-traumatic endophthalmitis

    Graefes Arch Clin Exp Ophthalmol

    (2003)
  • J.A. Balfour et al.

    Moxifloxacin

    Drugs

    (1999)
  • E. Bali et al.

    Vitrectomy and silicone oil in the treatment of acute endophthalmitis. Preliminary results

    Bull Soc Belge Ophtalmol

    (2003)
  • C.C. Barr

    Prognostic factors in corneoscleral lacerations

    Arch Ophthalmol

    (1983)
  • A. Bauernfeind

    Comparison of the antibacterial activities of the quinolones bay 12-8039, gatifloxacin (AM 1155), trovafloxacin, clinafloxacin, levofloxacin and ciprofloxacin

    J Antimicrob Chemother

    (1997)
  • J. Baum et al.

    Intravitreal administration of antibiotic in the treatment of bacterial endophthalmitis. III. Consensus

    Surv Ophthalmol

    (1982)
  • W. Behrens-Baumann et al.

    Intraocular foreign bodies. 297 consecutive cases

    Ophthalmologica

    (1989)
  • E. Bergogne-Bérézin

    Pseudomonads and miscellaneous Gram-negative bacilli, in Cohen, Powderly. Infectious Diseases

    (2004)
  • B. Billi et al.

    Copper intraocular foreign body: diagnosis and treatment

    Eur J Ophthalmol

    (1995)
  • A.L. Bisno et al.

    Classification of streptococci

  • Cited by (0)

    View full text