Vitritis and Endophthalmitis
This refers to acute or chronic intraocular inflammation due to
microbial or immunologic causes. In the strict sense, any intraocular
inflammation is endophthalmitis. However,
in clinical usage and throughout this book,endophthalmitis refers only to
inflammation caused by a microbial action that also involves the vitreous body
(vitritis). On the other hand, isolated
vitritis without involvement of the other intraocular structures is
inconceivable due to the avascularity of the vitreous chamber.
Microbial vitritis or endophthalmitis occurs most frequentlyas a
result of penetrating trauma to the globe. Rarely (in 0.5% of all cases) it is
a complication of incisive intraocular surgery.
Because the vitreous body consists of only a few cellular
elements(hyalocytes), inflammation of the vitreous body is only possible when
the inflammatory cells can gain access to the vitreous chamber from the uveal
tract or retinal blood vessels. This may occur via one of the following
❖ Microbial pathogens, i.e., bacteria, fungi, or viruses, enter the vitreouschamber
either through direct contamination (for example via penetrat-ing trauma or
incisive intraocular surgery) or metastatically as a result of sepsis. The
virulence of the pathogens and the patient’s individual immune status determine
whether an acute, subacute, or chronic inflam-mation will develop. Bacterial inflammation is far
more frequent than viral or fungal inflammation. However, the metastatic form
of endophthalmitis is observed in immunocompromised patients. Usually the
inflammation is fungal (mycotic endophthalmitis), and most often it is caused
by one of the Candida species.
❖Inflammatory (microbial or autoimmune) processes, in structures
adja-cent to the vitreous body, such as uveitis or retinitis can precipitate a sec-ondary
reaction in the vitreous chamber.
Acute endophthalmitis is a serious clinical
syndrome that can result in loss of the eye within a few hours.
Acute vitreous inflammation or
symptoms include acute loss of visual acuity accompanied by deep dull ocular pain
that responds only minimally to analgesic agents. Severe redden-ing of the
conjunctiva is present. In contrast to bacterial or viral endophthal-mitis,
mycotic endophthalmitis begins as a subacute disorder characterized by slowly
worsening chronic visual impairment. Days or weeks later, this will also be
accompanied by severe pain.
Chronic vitreous inflammation or endophthalmitis.The clinical course is farless severe, and the
loss of visual acuity is often moderate.
The patient’s history and the presence of typicalsymptoms
provide important information.
Acute vitreous inflammation or endophthalmitis.Slit-lamp examinationwill reveal massive
conjunctival and ciliary injection accompanied by hypopyon (collection of pus
in the anterior chamber). Ophthalmoscopy will reveal yellowish-green
discoloration of the vitreous body occasionally referred to as a vitreous body abscess. If the view is
obscured, ultrasound stud-ies can help to evaluate the extent of the involvement of the vitreous body inendophthalmitis.
Roth’s spots (white retinal spots surrounded by hemor-rhage) and circumscribed retinochoroiditis with a vitreous
infiltrate will be observed in the initial stages (during the first few days)
of mycotic endoph-thalmitis. In
advanced stages, the vitreous infiltrate has a creamy whitishappearance, and
retinal detachment can occur.
Chronic vitreous inflammation or endophthalmitis.Inspection will usuallyreveal only moderate
conjunctival and ciliary injection. Slit-lamp examina-tion will reveal
infiltration of the vitreous body by inflammatory cells.
A conjunctival smear, a sample of vitreous
aspirate, and (where sepsis is suspected) blood cultures should be obtained for
microbiological examina-tion to identify the pathogen. Negative microbial
results do not exclude possible microbial inflammation; the clinical findings
are decisive. See Chap-ter 12 for diagnosis of retinitis and uveitis.
The diagnosis is made by clinical examination inmost patients.
Intraocular lymphoma should be excluded in chronic forms of the disorder that
fail to respond to antibiotic therapy.
Microbial inflammationsrequire pathogen-specific systemic,topical,
and intravitreal therapy, where possible according to the strain’s documented
resistance to antibiotics. Mycotic
endophthalmitis is usually treated with amphotericin B and steroids.
Immediate vitrectomy is a ther-apeutic option whose indications have yet to be
Secondary vitreous reactions in the presence of underlying retinitis oruveitis should be
addressed by treating the underlying disorder.
Intraocular surgery requires extreme care to avoid
intraocularcontamination with pathogens. Immunocompromised patients (such as
AIDS patients or substance abusers) and patients with indwelling catheters
should undergo regular examination by an ophthalmologist.
Decreased visual acuity and eye pain in
substance abusers and patients with indwelling catheters suggest Candida endophthalmitis.
The prognosis foracute microbial endoph-thalmitis depends
on the virulence of the pathogen and how quickly effectiveantimicrobial therapy
can be initiated. Extremely virulent pathogens such as Pseudomonas and delayed initiation of treatment (not within a few
hours)worsen the prognosis for visual acuity. With postoperative inflammation
and poor initial visual acuity, an immediate vitrectomy can improve the
clinical course of the disorder. The prognosis is usually far better for chronic forms and secondary vitritis in