What are the symptoms of endophthalmitis?

Symptoms of Endophthalmitis

The primary symptoms of endophthalmitis include decreased vision, eye pain, redness, photophobia, and hypopyon (pus in the anterior chamber). These symptoms typically develop rapidly, especially when caused by virulent organisms such as Pseudomonas or Streptococcus species 1.

Clinical Presentation

Cardinal Symptoms

• Decreased vision - Present in nearly all cases and often the first symptom
• Eye pain - Can range from mild to severe
• Redness (conjunctival injection)
• Photophobia (light sensitivity)
• Lid swelling
• Discharge - May be purulent in severe cases

Clinical Signs

• Hypopyon (accumulation of white blood cells in the anterior chamber)
• Vitritis (inflammation of the vitreous) - A hallmark finding in all forms of endophthalmitis 2
• Anterior chamber inflammation
• Corneal edema
• Chemosis (conjunctival swelling)
• Reduced red reflex

Progression and Severity

The rate of disease progression depends on the causative organism:

• Rapid progression (within 24 hours): Highly virulent organisms such as Pseudomonas aeruginosa, Streptococcus pneumoniae, or Neisseria gonorrhoeae 1
• Moderate progression: Staphylococcus aureus
• Indolent course: Coagulase-negative staphylococci, nontuberculous mycobacteria, and Streptococcus viridans species 1

Types of Endophthalmitis

Exogenous Endophthalmitis

• Most common form (>90% of cases)
• Occurs after:
  • Intraocular surgery (especially cataract surgery)
  • Penetrating ocular trauma
  • Intravitreal injections
  • Extension of corneal infection
  • Contaminated ocular medications 3, 4

Endogenous Endophthalmitis

• Less common (2-15% of cases)
• Results from hematogenous spread from distant infection sites
• Often associated with:
  • Endocarditis (Staphylococcus aureus, streptococci)
  • Liver abscess (Klebsiella pneumoniae, especially in East Asia)
  • Candidemia in hospitalized patients 3, 2

Risk Factors

• Recent intraocular surgery
• Ocular trauma
• Immunocompromised state
• Diabetes mellitus
• Intravenous drug use
• Indwelling catheters
• Prolonged hospitalization
• Liver abscess (particularly for Klebsiella endophthalmitis)

Warning Signs Requiring Immediate Attention

Endophthalmitis is a medical emergency that can lead to permanent vision loss if not treated promptly 4. Patients should seek immediate medical attention if they experience:

• Sudden decrease in vision
• Increasing eye pain
• Worsening redness
• Lid swelling
• Discharge from the eye
• Photophobia

Clinical Pitfalls to Avoid

1. Delayed diagnosis - Endophthalmitis progresses rapidly and requires immediate treatment
2. Misdiagnosis as uveitis - Endophthalmitis can be mistaken for non-infectious uveitis
3. Failure to obtain cultures - Cultures should be obtained before initiating antimicrobial therapy
4. Inadequate treatment - Intravitreal antibiotics are the cornerstone of treatment
5. Overlooking endogenous sources - In endogenous cases, identifying and treating the primary infection site is crucial

Untreated or severe bacterial endophthalmitis may result in corneal perforation and has the potential to develop into panophthalmitis, resulting in loss of the eye 1. Early recognition and prompt treatment are essential for preserving vision.