What is the management and treatment approach for panophthalmitis?

Panophthalmitis: Workup and Management

Immediate Diagnostic Workup

Panophthalmitis requires emergency ophthalmologic consultation with immediate vitreous and aqueous sampling for culture and Gram stain before initiating treatment. 1, 2

Essential Diagnostic Steps

• Obtain intraocular samples immediately via vitreous tap or vitrectomy for culture, Gram stain, and sensitivity testing before antibiotics 2, 3
• Perform dilated fundoscopic examination to assess extent of infection (anterior chamber, vitreous, choroid, sclera) 4
• Assess visual acuity and light perception as baseline prognostic indicator 2, 3
• Evaluate for systemic infection including blood cultures, as endogenous panophthalmitis indicates bacteremia or fungemia requiring internist collaboration 3, 5
• Identify predisposing factors: penetrating trauma with foreign body (especially metallic/soiled), recent intraocular surgery, immunocompromise, or candidemia 1, 5

Imaging Considerations

• CT or MRI to identify intraocular foreign bodies and assess orbital extension 1
• B-scan ultrasound if media opacity prevents fundoscopic examination 3

Immediate Medical Management

Initiate broad-spectrum intravitreal antibiotics immediately after sampling, combined with systemic antibiotics and urgent surgical intervention. 2, 3

Intravitreal Antibiotic Therapy (First-Line)

• Vancomycin 1 mg/0.1 mL PLUS ceftazidime 2.25 mg/0.1 mL OR amikacin 0.4 mg/0.1 mL injected intravitreally 2, 3, 6
• This combination provides broad-spectrum coverage against gram-positive (including MRSA) and gram-negative organisms 2, 6
• Do not delay treatment waiting for culture results, especially with Bacillus cereus suspected (post-traumatic with metallic foreign body) 1

Systemic Antibiotic Therapy

• Vancomycin IV (dose per renal function) PLUS ceftazidime IV OR ciprofloxacin 400 mg IV twice daily 2, 3
• Continue systemic antibiotics for minimum 6 weeks post-surgical intervention 4
• For endogenous fungal panophthalmitis: Liposomal amphotericin B 5 mg/kg IV daily with or without flucytosine 25 mg/kg PO four times daily 4

Adjunctive Topical and Subconjunctival Therapy

• Fortified vancomycin and ceftazidime/amikacin topically every 1-2 hours 3
• Subconjunctival vancomycin and ceftazidime/amikacin at time of initial intervention 3

Anti-inflammatory Therapy

• Systemic corticosteroids (e.g., prednisone 1 mg/kg) starting 24 hours after antibiotic initiation to reduce inflammatory ocular destruction 2, 3
• Intravitreal dexamethasone may be considered but remains controversial 3

Surgical Management

Immediate pars plana vitrectomy is indicated for all cases of panophthalmitis to reduce organism burden, remove inflammatory debris, and obtain diagnostic material. 1, 3, 5

Surgical Indications and Timing

• Emergency vitrectomy should be performed as soon as possible, ideally within hours of presentation 1, 3
• Remove intraocular foreign bodies during vitrectomy if present 1, 3
• Consider posterior capsulotomy and removal of intraocular lens if chronic infection or fungal etiology 3
• Vitrectomy is mandatory even before culture results in post-traumatic cases with soiled foreign bodies 1

Fungal Panophthalmitis Considerations

For Candida species with vitreal involvement:

• Intravitreal amphotericin B deoxycholate 5-10 μg/0.1 mL sterile water OR voriconazole 100 μg/0.1 mL at time of vitrectomy 4
• Pars plana vitrectomy to decrease organism burden and remove fungal abscesses 4
• Note: Vitrectomy shortens half-life of intravitreal antifungals, requiring potential repeat injections 4

Treatment Modification Based on Culture Results

When Cultures Are Positive

• Continue initial regimen if clinical improvement occurs, regardless of in vitro sensitivities 4, 2
• Modify antibiotics only if no improvement at 48 hours or organism resistance documented 4, 6
• All isolated bacteria in one study were sensitive to vancomycin/amikacin/ciprofloxacin combination 2

When Cultures Are Negative

• Continue empiric broad-spectrum therapy if clinical improvement 4
• Consider atypical organisms (fungi, mycobacteria) and obtain repeat cultures with specialized media if no improvement 4
• Discontinue antibiotics 12-24 hours before reculture to increase yield 4

Duration of Therapy

• Minimum 4-6 weeks of systemic antifungal therapy for fungal panophthalmitis, with duration guided by serial ophthalmologic examinations 4
• Minimum 6 weeks of systemic antibiotics for bacterial panophthalmitis post-surgical intervention 4
• Taper topical antibiotics according to clinical response, avoiding subtherapeutic dosing that promotes resistance 4

Prognosis and Outcomes

Visual prognosis remains poor despite aggressive treatment, with 55% of post-surgical and 40% of post-traumatic cases achieving final acuity of 6/60 or worse. 2

• Better outcomes correlate with early diagnosis, immediate treatment, and absence of macular involvement 4, 2
• Evisceration or enucleation may be necessary if infection uncontrolled or phthisis bulbi develops 1, 5
• Routine ophthalmologic screening of all bacteremic patients could improve outcomes by detecting endogenous infection earlier 5

Critical Pitfalls to Avoid

• Never delay treatment for culture results in suspected Bacillus cereus infection (fulminant course with rapid vision loss) 1
• Do not use intravitreal echinocandins for fungal panophthalmitis—they achieve inadequate vitreous concentrations 4
• Avoid medication toxicity from prolonged topical antibiotics causing corneal melting or persistent epithelial defects 4
• Do not miss systemic infection: endogenous panophthalmitis mandates search for primary source and internist involvement 3, 5
• Recognize that delayed diagnosis leads to irreversible vision loss and potential loss of the eye 1, 5