suppurative endophthalmitis
Introduction
Introduction to suppurative endophthalmitis Suppurative endophthalmitis is due to the avascular tissue of the vitreous body and is rich in water and protein. Once the pathogenic bacteria invade, it is easy to reproduce and cause inflammation and form an abscess. This is called suppurative endophthalmitis. Only the bacteria or fungi are discussed here. Endophthalmitis. It is the most common clinical practice of suppurative endophthalmitis, which is extremely dangerous and has great damage to eye tissue and visual function. If the treatment is not timely, inflammation can develop into the sclera, extraocular fascia and tendon tissue, which is called "full ocular inflammation" and is therefore one of the main diseases requiring ophthalmology for emergency treatment. Another type of suppurative endophthalmitis is caused by lens cortical allergy or copper rust. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: edema, retinal detachment
Cause
Causes of suppurative endophthalmitis
Bacterial infection (45%):
The pathogens of suppurative endophthalmitis are mainly bacteria and fungi, and bacteria are more common. In the past, endophthalmitis has more toxic pathogenic bacteria such as Staphylococcus aureus, hemolytic streptococcus and Pseudomonas aeruginosa. More common, nearly half a century, due to the widespread use of antibiotics, hormones and immunosuppressive drugs, the popularity of intraocular lens implantation and the improvement of laboratory testing techniques, the types of endophthalmitis pathogens have become numerous, The pathogens have also changed. Some conditional pathogens such as Staphylococcus epidermidis, Staphylococcus aureus, and Bacillus cereus gradually occupy a prominent position, and fungal infections are also increasing. According to the statistics of the Eye, Otolaryngology Hospital of Shanghai Fudan University, in the eye Inflammatory vitreous specimens totaled 207 (eyes), 81 culture-positive samples (positive rate 39.1%), followed by Staphylococcus epidermidis 18 eyes (22%), fungi (mainly Aspergillus and Candida albicans) 12 Eye (15%), Streptococcus 12 eyes (15%), Staphylococcus aureus 11 eyes (14%), Bacillus cereus 10 eyes (12%), Staphylococcus aureus 5 eyes (6%) and patina 3 eyes (4%) of the bacterium, including Staphylococcus epidermidis, fungus , Staphylococcus aureus, Bacillus cereus, etc. are common pathogenic bacteria.
History of trauma or internal eye surgery (15%):
Exogenous endophthalmitis has a history of trauma or internal eye surgery, and has a certain incubation period. Endophthalmitis accounts for 10% to 20% of all endophthalmitis after intraocular surgery, including extracapsular cataract extraction combined with intraocular lens implantation. 0.1%, vitreous surgery 0.1%, anti-glaucoma surgery 5% to 8%, pathogens mainly from the eyelids and conjunctival sac, mainly Gram-positive cocci, accounting for 70%, of which Staphylococcus epidermidis 40%, Staphylococcus aureus 20 %, Streptococcus 10%; perforation (including intraocular foreign body) after endophthalmitis accounted for more than 40% of all endophthalmitis, of which bacteria accounted for 74%, fungi accounted for 26%, agricultural trauma may consider fungal infection.
Fungal infections (18%):
Infected lesions such as the skin or body such as the meninges, endocardium, digestive tract, urethra and lungs, pathogenic bacteria are transferred to the eye through the blood circulation, often accompanied by fever, white blood cell count and neutrophil increase, etc. History of sepsis, common pathogens are streptococcus, influenza acidophilus, Neisseria meningitidis, etc. After major surgery, diabetic patients, low immune function and long-term application of hormones and antibiotics are high-risk groups of endophthalmitis, especially Be alert to fungal infections.
Prevention
Suppurative endophthalmitis prevention
1. Prevention of endophthalmitis after perforation
1 Immediately suture the wound immediately after injury;
2 Remove the foreign body in the eye as soon as possible and carry out bacterial culture;
3 antibiotics were selected systemically or locally and closely observed for more than 3 days.
2. Prevention of endophthalmitis after surgery
1 have acute conjunctivitis, chronic dacryocystitis or facial paralysis, sputum and other infections, need to be in the control of inflammation, culture after negative for internal eye surgery;
2The intraocular eye should be given antibacterial eye drops for more than 3 days before surgery, and the eyelashes should be cut for lacrimal passage;
3 It is recommended to use iodophor to disinfect the surgical field (including the eye skin and conjunctival sac, especially the root of the eyelashes);
4 Advocate plastic disinfection towel to completely wrap the eyelid skin and eyelashes, and not in contact with the surgical field;
5 surgical instruments are strictly disinfected to avoid contamination during surgery;
6 At the end of the operation, a broad-spectrum antibiotic is injected under the ball or under the conjunctiva.
3. Where the eyeball penetrating injury, internal eye surgery, accompanied by fever, white blood cell count and other systemic symptoms, if there is eye pain and uveitis performance, especially when it is increasingly serious, it is highly suspected of endophthalmitis Actively take appropriate measures and closely observe the development of the disease every day.
Complication
Suppurative endophthalmitis complications Complications edema retinal detachment
Postoperative and post-traumatic endophthalmitis can cause a variety of complications, such as low intraocular pressure, macular edema, retinal detachment, post-iris adhesion, pre-irisal adhesions, corneal edema, lens posterior sac opacity, if not treated in time can lead to eyeballs Shrinking.
Symptom
Suppurative intraocular inflammation symptoms Common symptoms Eye pain abscess Lens opacity tear eyeball prominent young man's eye bag photophobia purulent secretion fungal infection eyeball perforation
Incubation period
After the pathogenic bacteria enter the eye, they grow and multiply in the eye and produce exotoxin and endotoxin, causing a severe inflammatory reaction in the eye tissue and a series of clinical symptoms. The length of this incubation period is due to the virulence of the pathogenic bacteria, and the infected person reacts. Sexuality and degree of control vary, usually about 3 days, Staphylococcus epidermidis, Staphylococcus aureus and other pathogenic bacteria, antibiotic treatment and fungal infections have a longer incubation period of up to several weeks; and virulence The incubation period of Staphylococcus aureus, hemolytic streptococcus, Pseudomonas aeruginosa, and Bacillus cereus infection can be as short as several hours, and the symptoms are severe and develop rapidly.
2. Symptoms and signs
Typical suppurative endophthalmitis has significant manifestations, such as redness and swelling of the eyes, pain, photophobia, sharp vision loss, eyelid and conjunctival congestion and edema, corneal edema, turbidity and even matrix abscess, aqueous humor or empyema, iris swelling The texture is unclear, the pupil is reduced or accompanied by exudation membrane, the lens may be turbid or even cortically dissolved. The vitreous body is grayish white particles or fragmented turbidity or even forms abscess. The pupil area yellowish white or grayish white reflective replaces the normal orange red fundus reflection, and the fundus is blurred. clear.
In the case of perforation of the eyeball, it is often found that there is purulent secretion or necrotic tissue in the corneoscleral wound; after cataract surgery, purulent secretion can be found in the corneoscleral incision or suture, and there is accumulation of purulent secretion in the lens capsule. The occurrence of endophthalmitis after glaucoma surgery is mostly delayed, due to excessive filtration bleb or secondary infection of the fistula. It can be seen that the filter bleb becomes cloudy and perivascular congestion, and sometimes purulent opacity is also seen. It is diffused into the anterior chamber by the filtration port; the fundus is often seen in the early stage of endogenous disease: retinal edema, vasodilatation, isolated or fused gray or yellow-white lesions, often accompanied by systemic bacteremia or venom. And may find the primary infection and its corresponding symptoms and signs.
According to the degree of clinical manifestations, endophthalmitis can be divided into three types:
1 acute endophthalmitis, the incubation period is about 3 days, the short is only a few hours, the symptoms are heavy and rapid development, often caused by the virulence of Staphylococcus aureus, Pseudomonas aeruginosa and Bacillus cereus.
2 subacute endophthalmitis: the incubation period is about 1 week, there are more obvious symptoms, often caused by streptococci, pneumococci and so on.
3 chronic endophthalmitis: the incubation period often exceeds 1 to 2 weeks, the symptoms are mild, the disease progresses slowly or repeatedly, and is easily misdiagnosed. The pathogenic bacteria are often less viable Staphylococcus epidermidis, Staphylococcus aureus, fungus or propionic acid. Acne bacillus and the like.
In recent years, endophthalmitis caused by Bacillus cereus often causes disease, which should be given enough attention. Its clinical features are:
1 There is a history of eye penetration, and the wound is contaminated with dirt or grass clippings.
2 The incubation period is short, and even a few hours can occur.
3 symptoms are heavy and rapid development, intraocular tissue hemorrhage and necrosis, treatment does not promptly develop into full eye inflammation.
4 can be associated with systemic symptoms, such as fever, elevated white blood cell counts.
3. Return
Suppurative endophthalmitis can seriously damage the eyeball tissue, leading to corneal scleral ulceration, lens opacity, vitreous opacity, traction retinal detachment, optic atrophy, etc., and finally end with eyeballs, acute cases, sometimes need Eyeball removal or eye content excavation, inflammation in some cases can spread to the fascia of the surface of the eyeball, and even to the tissue of the iliac crest, leading to full ocular inflammation and sputum cellulitis. At this time, eye pain is intensified, and the eyelids and conjunctiva are highly congested and edematous. It is prominent and often accompanied by systemic symptoms such as fever. If inflammation invades the brain, it can cause life-threatening cavernous sinus thrombosis and purulent meningitis.
Examine
Examination of suppurative endophthalmitis
Immediately after the aqueous humor and vitreous body are collected, they should be dripped on blood agar and chocolate agar culture dish. After being dried, they should be placed in a CO2 incubator and cultured at 37 °C. When the fungal infection is suspected, the specimen should be inoculated into Sabromo agar. The culture is carried out at 25 ° C. When anaerobic bacteria are suspected, the medium suitable for the growth of anaerobic bacteria (such as beef culture medium) should be selected for cultivation. At the same time as the culture, the specimen should be subjected to Gram. Staining and Giemsa staining, for those suspected of having fungal infections, silver staining of urotropin should be performed.
If the patient undergoes diagnostic vitrectomy, the specimen obtained before the resection can be directly cultured as described above, but the specimen obtained during the vitrectomy is affected by the dilution of the perfusate to affect the culture result, in order to increase the positive rate of the culture, The sample taken can be filtered through a sterile filtration membrane, and then the membrane is directly cultured on a suitable medium.
In the absence of a sterile filtration membrane, the vitrectomy specimen can be directly inoculated into a blood culture bottle, and the positive rate is similar to that obtained after filtration through the filtration membrane, but the blood culture flask is separated from Haemophilus influenzae and acne. The sensitivity of the bark vaccine is low, and further experiments are needed to identify the pathogen after the blood culture bottle is found and to determine its sensitivity to the drug.
The number of pathogens in the specimen or the antibiotics used in the past can affect the results of the culture, so the culture should last for more than 14 days to increase the positive rate of culture.
Ultrasound examination can understand the extent and location of vitreous opacity, whether there is retinal detachment and the presence or absence of a wall or post-ball abscess. It plays an important role in the diagnosis and treatment of endophthalmitis. Dynamic ultrasound examination throughout the course of the disease can grasp the condition. Progress helps to judge treatment outcomes and prognosis.
Diagnosis
Diagnosis and diagnosis of suppurative endophthalmitis
Diagnostic criteria:
The diagnosis of endophthalmitis after surgery and trauma is mainly based on the patient's history of internal eye surgery, history of eye penetrating injury, typical clinical manifestations and laboratory tests, and laboratory tests have a diagnostic effect on diagnosis.
Aqueous and vitreous bacterial culture and smear staining examinations are of great value in determining the diagnosis. These tests should be performed for patients suspected of endophthalmitis. If suspected to be infected in the capsular bag, the contents of the capsular bag should be taken out as much as possible. Culture and staining.
Although the positive rate of bacterial culture in aqueous humor is lower than the positive rate of vitreous culture, it is convenient to use aqueous humor. Therefore, the culture of aqueous humor and the staining of smears have become common methods of examination, and often with vitreous culture and coating. Tablet staining is performed simultaneously, which increases the positive rate.
Differential diagnosis:
The disease should be differentiated from postoperative aseptic endophthalmitis, intraocular foreign body retention, introduction of chemicals (such as residual lens polishing compound or disinfectant residue), lens cortex or nucleus remaining in the eye, complicated surgery Operational damage to the ocular tissue, the patient's susceptibility (such as diabetes) can cause severe intraocular inflammation after surgery, and even anterior chamber empyema, this significant inflammatory reaction occurs on the first day after surgery, but Generally no serious eye pain and decreased vision, no swelling of the eyelids and conjunctival edema, although endophthalmitis caused by highly virulent bacteria can also occur on the first day after surgery, but most occur on the second day after surgery. After that, patients often have severe eye pain, obvious eyelid swelling, conjunctival edema and significant vision loss. Frequent eyesight with glucocorticoids and non-steroidal anti-inflammatory eye drops can often reduce postoperative aseptic intraocular inflammation. However, it has no obvious effect on bacterial endophthalmitis.
Post-exposure endophthalmitis should be associated with lens-like uveitis (lens allergic endophthalmitis), Behcet's disease uveitis, acute anterior uveitis, intermediate uveitis, tuberculous uveitis, syphilis Uveitis, acute retinal necrosis syndrome, Lyme's disease uveitis, ocular toxoplasmosis, etc.
