What is pan ophthalmitis?

What is Panophthalmitis?

Panophthalmitis is a devastating, vision-threatening infection involving inflammation of all layers of the eye (cornea, sclera, uvea, retina, and vitreous) that extends into the surrounding orbital soft tissues, representing the most severe and extensive form of ocular infection. 1, 2, 3

Clinical Definition and Pathophysiology

• Panophthalmitis represents the most extensive ocular involvement in endophthalmitis, with inflammation extending beyond intraocular structures to involve periocular and orbital tissues 2

• The condition produces irreversible damage including keratitis, uveitis, hypopyon, vitreous abscesses, retinal necrosis and detachment, ultimately destroying the entire eye 1

• Severe inflammation of anterior and posterior segments is frequently accompanied by corneal opacity, scleral abscess, perforation or rupture 2

Etiology and Risk Factors

Panophthalmitis develops through two primary mechanisms: exogenous (post-traumatic or post-surgical) and endogenous (hematogenous spread from systemic infection). 1, 2, 3

Exogenous Causes

• Penetrating ocular trauma with retained intraocular foreign bodies (IOFBs), particularly soiled metallic objects, represents a major risk factor 1, 4

• Both bacterial and fungal organisms enter through penetrating wounds, with Bacillus cereus being particularly aggressive in post-traumatic cases 4

• Coagulase-negative staphylococci and Staphylococcus species are common causative organisms in traumatic cases 1

Endogenous Causes

• Hematogenous spread from distant infection sites including liver abscesses (most common), retroperitoneal infections, pneumonia, infective endocarditis, and occult malignancies 2, 3

• Klebsiella pneumoniae is the predominant organism in endogenous bacterial panophthalmitis, followed by Streptococcus species, Pseudomonas aeruginosa, Escherichia coli, and Staphylococcus aureus 2

• Bacteremic patients are at risk, particularly those with meningitis or systemic sepsis 5

Clinical Presentation

Patients present with severe ocular pain, marked vision loss (often no light perception), profound periorbital swelling, proptosis, chemosis, and purulent discharge. 1, 4, 2

• Important local inflammatory signs include severe eyelid swelling, conjunctival injection and chemosis, corneal opacity, and scleral necrosis 1, 4

• Systemic signs such as fever and signs of sepsis may accompany endogenous cases 4, 5

• The condition can mimic orbital cellulitis in severe presentations 6

Prognosis and Outcomes

The prognosis for panophthalmitis is extremely poor, with loss of both visual function and anatomical integrity of the eye being the typical outcome. 1, 4, 2

• Delay in presentation or treatment by more than 24 hours from time of injury results in particularly poor prognosis 1

• Evisceration or enucleation has traditionally been the only remaining treatment option when all salvage attempts fail 2

• Vision preservation is rarely achieved even with aggressive treatment, though globe preservation may be possible in select cases 2, 3

• Phthisis bulbi (shrinkage and degeneration of the eye) commonly develops even after initial treatment success 5

Management Principles

Immediate aggressive treatment with combined intravitreal, periocular, and systemic antibiotics is essential, along with urgent surgical intervention including vitrectomy and foreign body removal when applicable. 1, 4, 2

• Multiple intravitreal injections of antibiotics (average 5.8 injections) combined with periocular injections (average 2.2 injections) and dexamethasone may prevent evisceration or enucleation in endogenous cases with scleral abscess 2

• Vitrectomy, surgical extraction of foreign bodies, and both intravitreal and systemic antibiotherapy should be initiated immediately, even before bacteriological results are available 4

• Treatment of the underlying systemic source is critical in endogenous cases, requiring multidisciplinary management 3, 5

Critical Pitfalls

• Bacillus cereus panophthalmitis should be suspected in all post-traumatic cases with soiled metallic foreign bodies and requires immediate aggressive treatment 4

• Bacteremic patients should be examined routinely by an ophthalmologist to detect early endogenous endophthalmitis before progression to panophthalmitis 5

• Transportation barriers and delays in seeking care (as seen during COVID-19 lockdowns) significantly worsen outcomes 1

• Bilateral involvement, though rare, can occur in endogenous cases and carries an even worse prognosis 5