Management and Treatment of Panophthalmitis
Panophthalmitis requires immediate aggressive multimodal therapy combining intravitreal antibiotics, systemic antibiotics, and urgent ophthalmologic surgical intervention to prevent mortality and preserve any possibility of vision, though anatomic loss of the eye is common.
Immediate Diagnostic Approach
- Obtain vitreous and aqueous humor cultures immediately via diagnostic tap before initiating treatment to identify the causative organism 1
- Perform direct ophthalmoscopic examination to assess extent of intraocular and orbital involvement 2
- Order blood cultures and imaging (CT/MRI) to identify the source of infection, as endogenous panophthalmitis typically originates from systemic sources 3
- Investigate for underlying predisposing conditions: diabetes mellitus (present in 93.3% of cases), pyogenic liver abscess (66.7%), infective endocarditis, pneumonia, or occult malignancy 3, 4
Primary Treatment Algorithm
For Bacterial Panophthalmitis (Most Common)
Intravitreal Antibiotic Therapy:
- Administer multiple intravitreal injections of antibiotics (average 5.8 injections required) combined with dexamethasone 5
- For empiric coverage pending cultures: intravitreal vancomycin plus ceftazidime or an aminoglycoside 1
- Periocular injections of antibiotics and dexamethasone (average 2.2 injections) are also necessary 5
Systemic Antibiotic Therapy:
- Initiate broad-spectrum intravenous antibiotics immediately, targeting the most common organism Klebsiella pneumoniae (80% of cases), followed by Streptococcus species, Pseudomonas aeruginosa, and Staphylococcus aureus 3, 5
- Adjust antibiotics based on culture results and source control 3
Surgical Intervention:
- Pars plana vitrectomy should be performed urgently when feasible to remove inflammatory debris and infectious organisms, as this is sight-saving 2, 1
- Remove any intraocular foreign body immediately, especially in post-traumatic cases with metallic foreign bodies contaminated with soil (high risk for Bacillus cereus) 6
- Vitrectomy eligibility depends on systemic stability; only perform once the patient's medical condition is controlled 3
For Fungal Panophthalmitis (Aspergillus or Candida)
Aspergillus:
- Administer intravenous amphotericin B plus intravitreal amphotericin B (5-10 μg/0.1 mL sterile water) following diagnostic vitreal tap 2, 1
- Voriconazole (intravitreal 100 μg/0.1 mL or systemic) is an alternative regimen 2
- Perform pars plana vitrectomy as this may be sight-saving 2
Candida:
- For fluconazole/voriconazole-susceptible isolates: fluconazole 800 mg loading dose, then 400-800 mg daily OR voriconazole 400 mg IV twice daily for 2 doses, then 300 mg IV/oral twice daily 2, 1
- For resistant isolates: liposomal amphotericin B 3-5 mg/kg IV daily with or without oral flucytosine 25 mg/kg four times daily 2, 1
- Add intravitreal amphotericin B or voriconazole for macular involvement 2, 1
- Continue treatment for at least 4-6 weeks, with final duration based on resolution of lesions 2, 1
Multidisciplinary Management
- Admit patients to medical or surgical wards (not ophthalmology) for systemic source control until medically stable 3
- Coordinate care between ophthalmology, infectious disease, and relevant specialists (hepatology for liver abscess, cardiology for endocarditis, etc.) 3
- This interdisciplinary approach has been shown to reduce mortality to 0% in recent series 3
Prevention of Evisceration/Enucleation
- Multiple intravitreal and periocular injections of antibiotics plus dexamethasone can prevent eye removal even in cases with no light perception and scleral abscess 5
- This approach prevents spread of infection to contiguous sites and avoids sympathetic ophthalmia in the fellow eye 5
- However, evisceration or enucleation remains necessary when all salvage options are exhausted 5
Critical Pitfalls to Avoid
- Do not delay treatment waiting for culture results in post-traumatic cases with soiled metallic foreign bodies or severe inflammatory signs—begin vitrectomy, foreign body removal, and antibiotics immediately 6
- Subconjunctival injections alone are ineffective and should not replace intravitreal administration 2, 1
- Do not manage patients solely in ophthalmology until systemic infection is controlled, as mortality risk is high 3
- Routine ophthalmologic examination of all bacteremic patients is essential for early detection, as delayed diagnosis leads to vision loss and anatomic loss of the eye 6, 7