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Picture of the Month
Gesche Düker, MD;
Michael J. Lentze, MD;
Stefan Zielen, MD
From the Zentrum für Kinderheilkunde, Allgemeine Pädiatrie
und Poliklinik, Rheinische Friedrich-Wilhelms-Universität, Bonn, Germany.
Arch Pediatr Adolesc Med. 2001;155:1169-1170.
A 1-YEAR-OLD CHILD had a 2-day history of redness of the right eye and
a 1-day history of fever. There was no report of trauma to the eye, nor was
there a history of upper respiratory tract infection, tonsillitis, otitis
media, or other infection. The medical and family histories were unremarkable.
On physical examination, mild periorbital swelling and hyperemia of the conjunctiva
of the right eye were present (Figure 1
and Figure 2). There was no purulent
discharge from the eye. A slitlamp examination disclosed evidence of uveitis
and presence of a hypopyon. The left eye did not appear to be involved.
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Figure 1.
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Figure 2.
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Denouement and Discussion: Endogenous Endophthalmitis
Figure 1. The conjunctiva of the right eye are injected.
Figure 2. The anterior chamber of the eye appears slightly cloudy.
Endophthalmitis refers to infection, most commonly bacterial or fungal,
of intraocular tissues and fluids. Endophthalmitis may be exogenous, a rare
complication of eye surgery or trauma, or endogenous, a less common occurrence.1 Endogenous endophthalmitis is of hematogenous origin
and most commonly affects adults with predisposing conditions such as diabetes,
urogenital and gastrointestinal tract disorders, or endocarditis.2 Relatively few cases of this infection have been
reported in the pediatric age group, most of whom were neonates with group
B streptococcal or Candida albicans septicemia, or
children with meningitis.
CLINICAL MANIFESTATIONS
The clinical presentation of endogenous endophthalmitis may be acute
or slowly progressive. Clinical and laboratory signs of systemic infection
may be lacking. The diagnosis is often delayed by an earlier diagnosis and
treatment for conjunctivitis, or it is diagnosed later because of the suspicion
of retinoblastoma.3 The spectrum of clinical
features varies from minimal signs of inflammation with conjunctival hyperemia
and mild anterior uveitis; small focal vitreal abscesses; white "snowball"
opacities; or the presence of hypopyon with suppurative reaction of the sclera,
conjunctiva, and orbit. Decreased visual acuity and eye pain are other complaints
that may be present. The inflammatory response of intraocular tissue results
in the layering of leukocytes in the anterior chamber, resulting in the hypopyon.
EPIDEMIOLOGY
Exogenous endophthalmitis is mainly caused by gram-positive bacteria,
including Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and other streptococcal species.4
Gram-negative and gram-positive organisms may be responsible for hematogenously
spread infections. Organisms reported to have caused endophthalmitis in children
include Neisseria meningitidis, Serratia marcescens, Salmonella typhimurium,
and Escherichia coli (the cause of the infection
in our patient).5, 6, 7, 8, 9
Candida albicans intraocular infections are
most often associated with predisposing factors, including prematurity, especially
associated with low birth weight and pulmonary disease, intravenous catheters,
immunosuppressive therapy, malignancy, and diabetes. In one study of 47 children
with deep-seated fungal infections, 6 had evidence of endophthalmitis.10
DIAGNOSIS AND TREATMENT
In a child with an identified systemic infection, it may not be necessary
to obtain ocular fluid for culture. If a source of infection is not known,
aqueous and/or vitreous aspirations must be performed in attempt to identify
the responsible organism. Intravitreal injection of antibiotics is considered
the most important route of treatment of endophthalmitis to rapidly achieve
high concentrations of antibiotics within the eye.11
Despite treatment, the visual outcome of most patients with endogenous bacterial
endophthalmitis is poor. In a series of 28 patients with this infection, 12
of 32 affected eyes had no final light perception.2
REFERENCES
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1. Hassan IJ, MacGowan AP, Cook SD. Endophthalmitis at the Bristol Eye Hospital: an 11-year review of 47
patients. J Hosp Infect. 1992;22:271-278.
FULL TEXT
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2. Okada AA, Johnson RP, Liles WC, D'Amico DJ, Baker AS. Endogenous bacterial end-ophthalmitis: report of a ten-year retrospective
study. Ophthalmology. 1994;101:832-838.
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3. Shields JA, Shields CL, Eagle RC Jr, Barrett J, De Potter P. Endogenous endophthalmitis-simulating retinoblastoma. Retina. 1995;15:213-219.
FULL TEXT
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4. Weinstein GS, Mondino B, Weinberg R, et al. Endophthalmitis in a pediatric population. Ann Ophthalmol. 1979;11:935-943.
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5. Hatamo H, Inoue K, Matobe H, et al. Endophthalmitis in Japan: a nationwide study with reference to type
and etiology. Nippon Ganka Gakkai Zasshi. 1991;95:369-376.
PUBMED
6. Malhotra A, Krilov LR. Isolated Neisseria meningitidis endophthalmitis. Pediatr Infect Dis J. 1999;18:839-840.
FULL TEXT
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7. De Groot V, Stempels N, Tassignon MJ. Endogenous pneumococcal endophthalmitis after splenectomy: report of
two cases. Bull Soc Belge Ophtalmol. 1992;243:147-149.
PUBMED
8. Al Hazzaa SA, Tabbara KF, Gammon JA. Pink hypopyon: a sign of Serratia marcescens
endophthalmitis. Br J Ophthalmol. 1992;76:764-765.
FREE FULL TEXT
9. Shohet I, Davidson S, Boichis H, Rubinstein E. Endogenous endophthalmitis due to Salmonella typhimurium. Ann Ophthalmol. 1983;15:321-322.
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10. Enzenauer RW, Calderwood S, Levin AV, et al. Screening for fungal endophthalmitis in children at risk. Pediatrics. 1992;90:451-457.
FREE FULL TEXT
11. Brod RD, Flynn HW. Endophthalmitis. In: Schlossberg D, ed. Current Therapy of Infectious
Disease. St Louis, Mo: Mosby Inc; 2000:45-50.
SECTION EDITOR: WALTER W. TUNNESSEN, JR, MD
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