Major ReviewPost-traumatic Infectious Endophthalmitis
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)
- et al.
Nosocomial acute-onset postoperative endophthalmitis survey. A 10-year review of incidence and outcomes
Ophthalmology
(1998) - et al.
Microbial endophthalmitis resulting from ocular trauma
Ophthalmology
(1987) - et al.
Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair
Am J Ophthalmol
(1995) - et al.
Human vitreous levels of selected antistaphylococcal antibiotics
Am J Ophthalmol
(1985) - et al.
Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases
Am J Ophthalmol
(2004) - et al.
Endophthalmitis caused by Moraxella species
Am J Ophthalmol
(2001) - et al.
Factors associated with a poor visual result in endophthalmitis
Am J Ophthalmol
(1986) - et al.
Rural endophthalmitis
Ophthalmology
(1989) - et al.
Changing aspects of management of ocular trauma
Am J Ophthalmol
(1982) - et al.
Breakdown of the outer blood–retinal barrier in experimental commotio retinae
Exp Eye Res
(1986)