Clinical presentation and prognostic factors in emergency department endophthalmitis: a 11-year retrospective study

Background: Endophthalmitis, a serious eye condition that poses a risk to vision and can quickly worsen, is considered a genuine urgent situation for the eyes. This research is concentrated on individuals with endophthalmitis who seek care in the emergency department (ED), with the objective of identifying the clinical signs and microbial properties that may increase the likelihood of needing evisceration. By doing so, the goal is to enhance the early detection and immediate management of this condition. Methods: This is a retrospective study conducted in the ED setting in a tertiary medical center in Northern Taiwan. Between January 2012 to December 2022, a total of 453 ED endophthalmitis patients were enrolled. Detailed chart reviews were done and the data collected included demographic characteristics, clinical symptoms, microbiology culture results, presenting visual acuity (VA), and the rate of evisceration. Results: There were 144 patients (31.8%) with endogenous endophthalmitis and 309 patients (68.2%) with exogenous endophthalmitis in the ED. The most common symptoms were blurry vision (94.3%) and red eye (88.7%). Blood culture was positive in 18.8% of cases, while vitreous or aqueous culture was positive in 59.6% of cases. The most commonly identified pathogens for endogenous and exogenous endophthalmitis were Klebsiella pneumoniae (20.5%) and Staphylococcus epidermidis (23.6%), respectively. The most significant risk factors for evisceration in both endogenous and exogenous groups were impaired initial VA and corneal ulcer. The proportion of patients with endogenous endophthalmitis who underwent evisceration (13.9%) was significantly higher than their exogenous counterparts (5.5%). Conclusions: Timely identification and proper management are essential for patients at risk of developing endophthalmitis in emergency settings. This is particularly important for individuals who exhibit compromised initial visual acuity and suffer from corneal ulcers. Despite intensive therapy, the long-term visual outcomes for endogenous endophthalmitis are generally worse compared to the exogenous form.

Endogenous endophthalmitis; Exogenous endophthalmitis; Vitreous culture; Evisceration; Emergency department

[1] Li X, Zarbin MA, Langer PD, Bhagat N. Posttraumatic endophthalmitis: an 18-year case series. Retina. 2018; 38: 60–71.

[2] Cornut PL, Youssef el B, Bron A, Thuret G, Gain P, Burillon C, et al. A multicentre prospective study of post-traumatic endophthalmitis. Acta Ophthalmologica. 2013; 91: 475–482.

[3] Xie T, Jing M. Haemophilus influenzae-induced corneal ulcer and endophthalmitis triggered by hair dye. Journal of Craniofacial Surgery. 2022; 33: e545–e546.

[4] Samalia PD, Welch S, Polkinghorne PJ, Niederer RL. Endogenous endophthalmitis: a 21-year review of cases at a tertiary eye care centre. Ocular Immunology and Inflammation. 2022; 30: 1414–1419.

[5] Bhurayanontachai P, Klongthanakit P. A 14-year retrospective analysis of endogenous endophthalmitis in a tertiary referral center of southern thailand. Journal of Ophthalmology. 2020; 2020: 6689081.

[6] Muda R, Vayavari V, Subbiah D, Ishak H, Adnan A, Mohamed SO. Endogenous endophthalmitis: a 9-year retrospective study at a tertiary referral hospital in Malaysia. Journal of Ophthalmic Inflammation and Infection. 2018; 8: 14.

[7] Wong MF, Ho MP. Endogenous endophthalmitis associated with pyogenic liver abscess. The American Journal of Emergency Medicine. 2024; 76: 235.

[8] Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases. Survey of Ophthalmology. 2003; 48: 403–423.

[9] Okada AA, Johnson RP, Liles WC, D’Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective study. Ophthalmology. 1994; 101: 832–838.

[10] Schiedler V, Scott IU, Flynn HW III, Davis JL, Benz MS, Miller D. Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. American Journal of Ophthalmology. 2004; 137: 725–731.

[11] Zhang WF, Zhao XY, Chen H, Meng LH, Chen YX. Endogenous endophthalmitis at a tertiary referral center in china: a retrospective study over three decades. Ocular Immunology and Inflammation. 2024; 32: 803–812.

[12] Zhang WF, Zhao XY, Meng LH, Chen H, Chen YX. Endophthalmitis at a tertiary referral center: characteristics and treatment outcomes over three decades. Frontiers in Cell and Developmental Biology. 2022; 10: 952375.

[13] Kuo G, Yen CL, Lu YA, Chen CY, Sun MH, Lin Y, et al. Clinical and visual outcomes following endogenous endophthalmitis: 175 consecutive cases from a tertiary referral center in Taiwan. Journal of Microbiology, Immunology and Infection. 2022; 55: 114–122.

[14] Zhang X, Chen Z, Li X, Zhou Z, Boost M, Huang T, et al. Management and prognosis of acute post-cataract surgery endophthalmitis: a 10-year retrospective analysis in Eastern China. Antibiotics. 2023; 12: 1670.

[15] Chen KJ, Sun MH, Chen YP, Chen YH, Wang NK, Liu L, et al. Endogenous fungal endophthalmitis: causative organisms, treatments, and visual outcomes. Journal of Fungi. 2022; 8: 641.

[16] Kim E, Byon I, Lee JJ, Seol YM, Kwon HJ, Park SW, et al. Endogenous endophthalmitis from a klebsiella pneumoniae liver abscess: the incidence, risk factors, and utility of imaging. American Journal of Ophthalmology. 2023; 252: 69–76.

[17] Chen YH, Li YH, Lin YJ, Chen YP, Wang NK, Chao AN, et al. Prognostic factors and visual outcomes of pyogenic liver abscess-related endogenous klebsiella pneumoniae endophthalmitis: a 20-year retrospective review. Scientific Reports. 2019; 9: 1071.

[18] Wang X, Song Y, Ji Y, Chen A, Si S. Clinical characteristics of k. pneumoniae related endogenous endophthalmitis in China. Risk Management and Healthcare Policy. 2024; 17: 2677–2687.

[19] Yang Y, Lin L, Li Y, Jiang Z, Li C, Liu M, et al. Etiology, microbiological isolates, and antibiotic susceptibilities in culture-proven pediatric endophthalmitis: a 9-year review. Graefe’s Archive for Clinical and Experimental Ophthalmology. 2021; 259: 197–204.

[20] Ng CJ, Yen ZS, Tsai JC, Chen LC, Lin SJ, Sang YY, et al.; TTAS national working group. Validation of the Taiwan triage and acuity scale: a new computerised five-level triage system. Emergency Medicine Journal. 2011; 28: 1026–1031.

[21] Day AC, Donachie PH, Sparrow JM, Johnston RL; Royal College of Ophthalmologists’ National Ophthalmology Database. The royal college of ophthalmologists’ national ophthalmology database study of cataract surgery: report 1, visual outcomes and complications. Eye. 2015; 29: 552–560.

[22] Thangamathesvaran L, Canner JK, Scott AW, Woreta FA, Breazzano MP. National emergency department trends for endogenous endophthalmitis: an increasing public health challenge. Eye. 2023; 37: 1123–1129.

[23] Naik P, Gandhi J, Joseph J. Recent advances and ongoing challenges in the diagnosis of culture negative endophthalmitis. Seminars in Ophthalmology. 2023; 38: 92–98.

[24] Lalitha P, Sengupta S, Ravindran RD, Sharma S, Joseph J, Ambiya V, et al. A literature review and update on the incidence and microbiology spectrum of postcataract surgery endophthalmitis over past two decades in India. Indian Journal of Ophthalmology. 2017; 65: 673–677.

[25] Cheng JH, Chang YH, Chen CL, Chen YH, Lu DW, Chen JT. Acute endophthalmitis after cataract surgery at a referral centre in Northern Taiwan: review of the causative organisms, antibiotic susceptibility, and clinical features. Eye. 2010; 24: 1359–1365.

[26] Lee CY, Sheu SJ, Chen SN, Cheng CK, Kuo HK, Hwang DK, et al. Literature- and experience-based consensus for acute post-operative endophthalmitis and endogenous endophthalmitis in Taiwan. Ophthalmology and Therapy. 2024; 13: 1–19.

[27] Lin J, Huang S, Liu M, Lin L, Gu J, Duan F. Endophthalmitis caused by pseudomonas aeruginosa: clinical characteristics, outcomes, and antibiotics sensitivities. Journal of Ophthalmology. 2022; 2022: 1265556.

[28] Microbiologic factors and visual outcome in the endophthalmitis vitrectomy study. American Journal of Ophthalmology. 1996; 122: 830–846.

[29] Results of the endophthalmitis vitrectomy study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995; 113: 1479–1496.

[30] Welch S, Bhikoo R, Wang N, Siemerink MJ, Shew W, Polkinghorne PJ, et al. Better visual outcome associated with early vitrectomy in the management of endophthalmitis. British Journal of Ophthalmology. 2022; 106: 1145–1149.

[31] Ahmad M, Parikh R, Akhlaq A, Pradeep T, Breazzano MP, Fu R. Risk factors for enucleation or evisceration in endophthalmitis. Orbit. 2023; 42: 279–289.