This document discusses metastatic endophthalmitis, which is inflammation of the eye resulting from a distant infection elsewhere in the body. It can be classified as focal or diffuse depending on the extent and location of inflammation in the anterior or posterior segment of the eye. Common predisposing factors include immunocompromise and intravenous drug use. Bacteria such as staphylococci and streptococci are frequent causes, as well as fungi like Candida. Evaluation may involve blood and imaging tests to identify the source of infection. Treatment involves antibiotics, vitrectomy, and sometimes silicone oil implantation.

1. Metastatic Endophthalmitis
Presenter-Dr Shubhangini J
Moderator-Dr Sachin Fegde

2.  Definition
 Classification
 Predisposing factors
 Histo-pathological description
 Organism causing metastatic endophthalmitis
 Investigation
 Management

3. Definition-
 Inflammation within the anterior segment or
posterior segment or both, concurrent with partial
thickness involvement of an adjacent ocular wall
 Associated with-
 Decreased vision
 Pain
 Conjunctival hyperemia
 Lid oedema
 Anterior chamber & vitreous cellular reaction
 Hypopyon

4. Classification of
Endophthalmitis
Infectious
Exogenous
Post surgical
1. Acute Onset
2. Delayed Onset
3. Bleb associated
Non surgical
1. Post-traumatic
Endogenous
Hematogenous Spread
Sterile
Lens Induced
Toxic
S Michael Kresloff, Endophthalmitis survey of ophthalmology vol
43:no.3:nov-dec 1998

5. Case
 Mrs K P 45 yrs old female housewife from panvel
presented to us on 3-9-2013
 Chief complaint –
 RE Diminution of vision since 1 month
RE Pain since 1 month

6. History
 Diminution of vision:
 gradual
 No h/o flashes of light
 Pain
 Dull aching

7. History
 Past Ocular history:
 H/o spectacle use since 7yrs
 No h/o ocular surgery
 No h/o ocular trauma
 No h/o similar complaints in the past
 h/o of hospitalisation 3 months back for fever&
generalised bodyache
 Personal history insignificant
 Family history insignificant

8. Examination-
 Head posture normal
 Orthophoria
 Extraocular movements: Full & free
 Visual acuity
RE LE
Visual Acuity CF FC, <N36 6/9, N6
Refraction Plano +1.00 DS
Intra ocular Pressure 10 18

9. Ocular Examination-
 On anterior segment examination
RE LE
Lids N N
Conjunctiva N N
Cornea Clear Clear
AC Cells ++++ ND Quiet
Pupil TAPD NSRL
Lens Clear Clear

10. Fundus RE LE
Impression-Endogenous
Endophthalmitis

11. Differential Diagnosis-
 Tuberculosis
 Toxoplasma
 Toxocara
 Sarcoidosis
 Harada’s disease
 Syphilitic uveitis
Investigation-
Hb/CBC/ESR
LFT/RFT
HIV/VDRL
Vitreous tap
Mantoux test
RBS,Blood culture

13. Treatment-
 Predforte eye drop 6t/day
 Atropine eye drop 3t/day
 Vitrectomy+BB + EL+silicon oil implantation NVP

14. Discussion
 Intraocular infection caused by haematogenous
spread of microorganism from distant foci to the eye
from site of infection elsewhere in the body or from
contaminated catheters & needles
 Epidemiology-
 Accounts for 2-8%
 Affects any age & sex
 RE more commonly involved
 Most common is bacterial metastatic endophthalmitis
fungal metastatic endophthalmitis
Okada AA et al Endogenous bacterial endophthalmitis 10 yr retrospective study 101:832-838,1994

15. Discussion-
 Most common site- uveal tract,choroid which are
most vascular tissues
 Study on ocular oncology service of wills eye hospital,
philadelphia(1996) , in a sample size of 420 patients
had observed breast cancer(47%) most common
tumor forming ocular metastatis followed by
lung(21%)

16.  Predisposing factors-
 Immunocompromised patients
 Intravenous drug abuse
 Diabetes milletus
 Chronic renal failure
 Malignancy
 Dental surgery
 Contaminated intravenous fluid
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct
1999

17.  Metastatic endophthalmitis classified based on
Metastatic
Endophthalmitis
Extent
Focal Diffuse
Location
Anterior sement
Posterior
segment
Surv Ophthalmol 31:81-101,2000 greenwald et al

18. Focal endophthalmitis-
 Mild external evidence of inflammation
 1 or more discrete foci of whitish nodule or plaque
 Measures 1-3mm in iris
 Cell reaction , hypopyon, photophobia, irritation
 Retina –Whitish emboli seen in multiple retinal
arterioles
 Perivascular haemmorrhages
 Roth Spot (inflammatory infiltration)
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct
1999

19. Diffuse endophthalmitis-
 Anterior diffuse inflammation
 Generalised sign of inflammation
 Conjunctival injection
 Hypopyon
 Corneal oedema
 Fibrinous clot in AC
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct
1999

20. Diffuse endophthalmitis-
 Posterior diffuse inflammation
 Intense inflammatory reaction
 Vitritis
 Bscan shows vitreous echoes
 Whitish emboli in multiple retinal arteries
 Perivascular haemorrhage
 Diffuse narrowing & sclerosed vessels
 panophthalmitis
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct
1999

21. Histopathological features-
 Focal inflammation
 Inflammatory cells occluding
the lumen of vessels
surrounding tissue
 Diffuse inflammation
 Inflammatory cells
 Necrosis
 Haemmorhage of involved
tissue
Infitration of all the intraocular structure by inflammatory
cells

22. Pathogenesis-
Metastatic
Embolization
Ocular blood vessel
Blood ocular barrier
Ocular Tissue
Inflammatory response
Ocular fluidsJ Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct 1999

23. Summary-
Ant Focal Post Focal Ant diffuse Post Diffuse Panophthal
mitis
Orbit/EOM Normal Limited
motility
Normal No proptosis Proptosis
Lids Mild oedema Mild
oedema/
ptosis
Mild-mod
oedema
Mild –mod,
oedema/
Ptosis
Marked
oedema/ptos
is
Conjunctiva Mild-mod
reaction
Normal-mild
reaction
Marked
reaction
Mild-mod
reaction
Marked
reaction
Cornea Mild haze Clear
/precipitates
Marked haze Clear to mild
haze
/precipitates
Mod-marked
haze
J Mark,M.D. Greenwald metstatic bacterial endophthalmitis: survey of ophthalmology vol 31:no.2/;sept-oct
1999

24. Ant Focal Post Focal Ant diffuse Post Diffuse Panophthal
mitis
AC Marked
reaction/
Hypopyon
Mild-Marked
reaction/
Hypopyon
Marked
reaction/
Hypopyon
Marked
reaction/
hypopyon
Marked
reaction/
hypopyon
Iris/Pupil Abscess/
poor
movement/
late
synechiae
Normal ,mild
movement
no synechiae
Poorly seen
no
movements/
late
synechaie
Mild-marked
limited
movements/
late
synechiae
Poorly seen
no
movement
Vitreous Ant
opacity/post
echoes
Marked
cells/mod
haze
Ant
opacity/post
echoes
Marked
cells,totally
opaque/post
echoes
Poorly
seen,totally
opaque/post
echoes
Fundus Normal Discrete
lesion
;normal ares
Normal White
retina/
emboli
Necrotic
retina
Prognosis Excellent Good Good poor Very poor

25. Most common organism responsible for endophthalmitis
Gram positive bacteria 75%-85% Gram negative bacteria 10%-15%
Staphylococcus 43% Pseudomonas 8%
Streptococcus spp 20% Proteus 5%
Staphylococcus aureus 15% Haemophilus influenzae 0-1%
Propionibacterium acnes 30 reports Klebsiella 0-1%
Bacillus cereus 1% Coliform spp 0-1%
Fungi
Candida parapsilosis
Aspergillus
Cephalosporium spp.

26. Gram positive organism-
 Streptococcus pneumoniae(m/c) &
 Staphylococcus epidermis- linked to non
inflammatory fundus lesion (R. Haemorrhage, cotton
wool spot)
 secondary to meningitis
 Endocarditis
 Malignant neoplasm(breast cancer m/c)

27. Gram positive organism-
 Clostridium species-
 M/c seen in I.V. drug abuser
 Secondary to bowel carcinoma
 Characteristic-
 Conjunctival injection
 Decreased vision
 Chocolate brown exudate
 Ring shaped white infiltrate in cornea

28. Gram positive bacilli-
 Listeria monocytogenes
 Mild external inflammation
 Absent systemic signs of infection
 Indolent infection
 Brown hypopyon
 Without corneal involvement

29. Gram negative organism-
 Haemophilus influenzae
 Present in a manner similar to meningococcus with
bacteremia
 Meningitis
 Anterior diffuse inflammation of eye
 Post subretinal abscess confusing it with disciform scar
or a choroidal tumor

30. AF Bacilli-
 Nocardia asteroides(AF bacilli)
 Lead to BEE secondary to dissemination from
pulmonary foci
 Infecting choroid
 Proliferating to produce chorioretinitis& vitritis
 Posterior subretinal abscess
 Seen in immunocompromised patients

31. AF Bacilli-
 Mycobacterium Tuberculosis(AF bacilli)
 Disseminates from pulmonary focus
 Infecting & proliferating chorioretinitis
 Vitritis
 Acute endophthalmitis

32. AF Bacilli-
 Anterior uveitis,mutton fat KP,posterior synechiae
 The main types of choroidal involvement in
tuberculosis include
 choroiditis, subretinal abscess, tubercles,
tuberculomas
 Yellowish subretinal abscesses can occur from
liquefaction necrosis within a tubercular granuloma
 A tubercle may grow into a large tumor-like mass up
to 14 mm, called a choroidal tuberculoma, which
often has a surrounding exudative retinal detachment

33. Fungii-
 Candida albicans
 75-80%
 It forms germ tube in serum that embolize and lodges
in choriocapillaries
 Creamy retinal infiltrate extends in vitreous
 Intraretinal haemmorhage
 Papillitis
 Focal choroiditis
 String of pearls(white opacities/snowball)

34. Fungii-
 Aspergillus
 15%
 Immunocompromised patients
 Transplants of stem cell
 Endocarditis
 Leukemia
 I.V. drug abuse,contaminated Dextrose infusion fluid
 COPD on corticosteriod therapy

35. Parasite-
 Taenia solium is the most common species causing
cysticercosis in humans
 Caused by consumption of the adult worm
 Symptoms may include periorbital pain, diplopia,
ptosis, blurring or loss of vision, distortion of images,
and the sensation of light flashes

36. Parasite-
 On fundus examination living form of cysticercosis
has the features of an undulating, expanding and
contracting “pearl” with intermittent evagination and
invagination of the protoscolex
 This may result in an inflammatory chorioretinitis
Ocular ultrasonography- subretinal cyst
 Assays for eosinophilia in anterior chamber fluid
sample

37. Evaluation-
 Complete history
 Physical examination
 Specific evaluation
 E.C.G. for endo carditis,
 CXR PA View,CT Scan,
 Sputum ,urine for culture sensitivity
 ESR,BUN,Creatinine
 CT/MRI Orbit
 PCR
 Culture of CSF,throat swab, stool,indwelling catheter

38. When to culture…..??
 Presence of systemic infection
 Signs of acute or chronic intraocular inflammation in
absence of extraocular culture
 In presence of culture positive-systemic infection with
sign of inflammation, unresponsive to antibiotic
therapy
 To rule out suspected malignancy after a negative
systemic work up

39. What to culture…??
 Culture of blood, urine, aqueous, vitreous, CSF &
wound culture & smear indicated
 To locate site of original infection
 Document systemic involvement

40. How to culture….???
 Aqueous material can be obtained by
 30 gauge needle in tuberculin syringe
 Limbal stab incision required
 0.1-0.2ml of fluid to be aspirated
 Vitreous biopsy performed via-
 Pars plana,1,2,3,port vitrectomy probe OR
 By 25-27gauge needle in tuberculin syringe
 0.1-0.2ml aspirated.

41. Treatment-
 Managed similar to acute post operative infectious
endophthalmitis
 Non ocular culture sensitivity data to guide initial
therapy
 Specific therapy to begun after ocular culture

42. Treatment-
 Mild endogenous endophthalmitis- focal metastatic
abscess in anterior & posterior segment
 Topical & systemic therapy
 Vitrectomy done for removal of infecting organism
,endotoxin, exotoxin & vitreous membrane , vitreous
opacities , better distribution of intravitreal antibiotic

43. Treatment for gram positive organism-
 Because most cases are caused by gram positive
organisms, vancomycin- (broad-spectrum activity
against most gram positive species) has become
an agent of choice
 Non toxic in recommended clinical dosage.
 Thus vancomycin 1 mg in (0.1 ml) BD is given
intra vitreally after blood culture & vitreous tap
Arch Ophth 1999; 117: 1023-1027

44. Treatment for gram negative
organism-
 Ceftazidine has emerged as on alternative
 More effective than aminoglycosides
 Retinal toxicity studies in primates reveal concentration of
2.25 mg/0.1 ml to be safe after vitreous tap
 Excellent ocular penentration
 After 2 weeks to shift on oral tab cefuroxime 500mg BD
Arch Ophthalmol 1994; 112: 48-53
Br. J. Ophth 97; 81: 1006-15

45. Treatment for fungal endophalmitis-
 If vitreous is minimally involved culture/smear is
positive for fungus- oral Fluconazole /vitrectomy to
be considered
 In metastatic aspergillus endophthalmitis
 IntraVitreal. amphotericin B (5-10µg) with IntraVitreal.
Dexamethasone(400µg)
 Repeated for persistance disease after5-7 days in
nonvitrectomised eye & after 2 days in vitrectomised
eye
 Systemically I.V. amphotericin(0.005mg/0.1ml)/
itraconazole is advocated
 Forvitreous seeding- vitrectomy

46. Treatment for TB -
 For metastatic ocular TB approach to neuro physician
is mandatory to start empirical therapy of ATT
 in cases in which ,uncertainty about TB remains,
biopsy of the eye for culture, histologic examination,
is useful to establish the diagnosis of ocular TB.

47. Treatment for parasitic endophthalmitis-
 Praziquantil ,Metrifonate
 Spontaneous extrusion of cystercerci from the eye
may occur
 Vitrectomy along with photocoagulation has shown
some success in removing cystercerci from the
vitreous cavity

48. Conclusion-
 Metastatic endophthalmitis is dreaded ocular
condition ,high index of clinical suspicion is necessary
along with a co-ordinated multidisciplinary approach
to handle this difficult situation

49. Thank you

50. Fungii-
 Presentation-
 Pain
 Severe visual loss
 Presents with pneumonia
 Seeding of end organs
 Vitritis
 Choroidal lesions
 Chorioretinal abscess
 Subhyaloid or sub retinal hypopyon

51.  Indicated-
 Inflammatory focus in AS
 Aphakic eye,dehiscence of post. Cap
 Vitritis,no improvement in vision, non ocular culture are
negative