Endogenous endophthalmitis: the organism predicts the eye's fate

Design

Retrospective multicentre cohort, 2012–2024

Population

305 eyes (261 patients) with culture-positive endogenous endophthalmitis at nine centres

Primary outcome

Final visual acuity, retinal detachment, enucleation

Effect

Blood cultures positive 66.2% vs vitreous 31.1%; enucleation 27.7% with gram-negative organisms

A retrospective cohort from nine academic referral centres reviewed 305 eyes in 261 patients with culture-positive endogenous endophthalmitis between 2012 and 2024.

Staphylococcus aureus caused 37.7% of cases, fungi 19.3%, gram-negative organisms 15.4% and streptococci 13.4%. Blood cultures were positive in 66.2% of eyes, vitreous in 31.1% and aqueous in 8.9%, and blood and eye cultures grew the same organism in only 62% of paired samples. Fungal cases were more often immunosuppressed or injecting drugs; gram-negative cases more often had a urinary source. Fungal eyes presented with better vision. Retinal detachment was commonest with S aureus and streptococci, and enucleation was highest after gram-negative infection (27.7%), driven by Serratia.

Presenting visual acuity was the most consistent predictor of final vision. The practical lessons are that blood cultures often identify the organism when the eye does not, that a gram-negative or Serratia result should prompt early and aggressive management, and that the eye should be examined early in bacteraemic or fungaemic patients with visual symptoms.

• Take blood cultures in every suspected endogenous endophthalmitis; they were positive twice as often as vitreous samples.
• Do not assume the blood isolate explains the eye; organisms matched in only about six in ten paired cultures.
• Look for a urinary source in gram-negative cases and for immunosuppression or drug use in fungal cases.
• Treat gram-negative, especially Serratia, infections as high risk for globe loss.
• Examine the eyes promptly in bacteraemic or fungaemic patients who report visual symptoms.

Why it matters

Vision on presentation largely sets the outcome, so recognising the infection early matters more than anything done later.

Don't overread it

This retrospective cohort from referral centres describes associations, not the effect of any specific treatment.

The statistics, in plain English

logMAR values around 1.3 to 2.1 correspond roughly to counting fingers or worse. Enucleation of 85.7% in Serratia rests on a small subgroup, so the exact figure is uncertain.

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