Infantile Endophthalmitis

Presentation

2 months Female infant, brought by her mother for change in the color of
the eye and lid edema. Progressive course over 3 days.
H/O of ASD
Further Examination showed

Left Foot Cellulitis

Investigations

Full Labs
Blood Culture
Occular U/S
CBC
CBC with Differential
Blood Culture >>> Pending
U/S
Treatment

Intravitreal Vancomycin and Fortum with paracentesis

Admission in Pediatrics ward for Systemic IV anitbiotics:
Unasyn, Vancomycin (Adding Flagyl was recommended)
Follow Up Daily >>> Improved Cellulitis
 U/S repeated 2 days after injection

No Improvement in Vitreous Floaters compared to previous U/S

Endophthalmitis in Newborn

0.1 - 4 % of all endophthalmitis

Incidence around 1 in 1000 admitted babies in NICU
Route of Infection:
Most of cases are Endogenous (with septicemia)
Rare cases are traumatic
Rare cases 2ry to keratitis eg: gonococcal Kerato-
conjunctivitis
 Clinical Picture and Causative
organism
It Varies according to the Causative organism
Acute aggressive Fulminant Course
Low grade discovered by Routine exam
Untermediate
Fulminant Picture

Peri-orbital edema, Chemosis,

Corneal Edema, Exudates in AC
Ultrasonography: shows vitreous
echoes, choroidal thickening,
low reflective retinal detachment
Causative Organisms:
Gram-negative organisms are the commonest
eg: Pseudomonas, Klebsiella, E. coli, Acinetobacter
Gram-positive organisms: MRSA, Bacillus, Streptococcus, VRSE
Rare cases with fulminant picture are fungal in origin (Fusarium)
Or HSV infections
 Low Grade Picture
Yellow-white lesions varying minimally elevated
from the retinal surface or as a small subretinal abscess
Very minimal Vitritis that builds up slowly

Causative organism:
Mostly Fungal : Candida
Sometimes Viral : HSV, CMV
Intermediate

In between Clinical Picture

Mostly due to partially resolved Septicemia
Risk Factors
Premature and low birth weight (especially less than 1500 g)
Compromised immune status
Hospital admission
Indwelling catheters, infusion pumps, ventilators, implants
Poor handwashing and hygiene of healthcare workers not
practicing good barrier nursing
Umbilical sepsis
Bacteremia/candidemia
Blood transfusion
Pneumonia/septic abscesses/meningitis
Cross contamination from other infected babies
Nursery infection outbreaks such as Candida, Meningococcus, etc.
Diagnostic Criteria:
Any 2 of the Following
1. Inflammation of intraocular tissues where except for an infective
etiology, no other underlying cause is detected
2. Clinical involvement of retina or vitreous showing typical features of
exudation and/or inflammation
3. Any intraocular sample shows significant growth on culture
4. Any of the body tissues/fluid shows significant growth or microbial
organisms. Common samples include blood, urine, umbilical cord
stump swab, swab from any abscess, etc. in association with ocular
inflammation
5. PCR is positive for eubacterial or panfungal or specific viral DNA from
ocular sample in presence of ocular inflammation
Differential Diagnosis
Congenital nasolacrimal duct obstruction
Mucopurulent conjunctivitis including gonococcal
Infectious keratitis
Orbital cellulitis
Retinoblastoma
Congenital cataract
Primary hypoplastic primary vitreous (PHPV), other pseudogliomas
like retinal dysplasia, etc.
Investgations

Occular U/S better than CT and MRI

Detect Source of Infection ( Most of cases are endogenous ):
Cultures of Blood, Vitreous, Tubes, Catheters, Maternal Vagina, Urine
Radiology to detect Pneumonia,Liver Abscess, Septic arthritis
Examination of the Other Eye Fundus
Routine Evaluation of Fundus for any baby with Speticemia, Candidemia
Looking for ROP (Many of them are Premature)
Evaluation of General Condition eg: Meningitis
Management

Vitreous Tap followed by Intra-vitreal injection of anti-microbials Under

General Anaesthesia (or Local in very sick babies) Sometimes Steroids are
added to decrease risk of corneal melting and evisceration in Fulminant
Endophthalmitis. Most of the cases end up with Phthisis bulbi
Fungal Cases: Intravitreal Amphotericin B followed by promt lens Sparing
Vitrectomy (before Retinal folds touch the lens) usually gives Good
Outcomes (7 out of 11)
 Challenges
Fragility of child and unfit for general anesthesia
Systemic co-morbidity especially cardiac (PDA), respiratory (pneumonia),
neurological (meningitis), and hematological (anemia, thrombocytopenia)
Retinal detachment and necrosis preexisting due to fulminant bacteria
Unilateral aphakia and dense amblyopia following surgery
Glaucoma/retinal detachment/hypotony after surgery
Concomitant retinopathy of prematurity (ROP) that can worsen rapidly
Sterile Cultures as patient may have received systemic animicrobials
Multidrug resistant nosocomial infections
Coordination with neonatologists/pediatricians and transportation of
babies to ophthalmology operating room
Lack of clinical trial/large series/meta-analysis data.
Lack of drug dosing information for intravitreal and sometimes for systemic
Delayed referral