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Christopher R. Henry, Harry W. Flynn, Jr., Darlene Miller, Richard K. Forster, Eduardo C. Alfonso; Infectious Keratitis Progressing To Endophthalmitis: A 15-year-study Of Risk Factors, Microbiology, And Clinical Outcomes. Invest. Ophthalmol. Vis. Sci. 2012;53(14):1678.
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To describe the incidence, microbiology, risk factors and clinical outcomes of a consecutive series of patients with infectious keratitis progressing to endophthalmitis.
Non-randomized, consecutive case series. Patients with positive corneal and intraocular cultures (anterior chamber and/or vitreous) between January 1, 1995 and December 31, 2009 were included in the study.
Over the period of the study, a total of 9934 corneal cultures were performed for suspected infectious keratitis. Only 52 of these patients (0.5%) progressed to culture-proven endophthalmitis. All eyes had documented keratitis before the development of endophthalmitis. Fungi (n=28) were the most common responsible organism followed by gram positive bacteria (n=14) and gram negative bacteria (n=10). All gram positive isolates were sensitive to vancomycin and all gram negative isolates were sensitive to amikacin, gentamicin, and ceftazidime. The use of topical steroids was common (39/52 [75%]) and represented the most common risk factor identified in the current study. Other risk factors included previous surgery (33/52 [63%]), dry eye syndrome (15/52 [29%]), relative immune suppression (11/52 [21%]), organic matter trauma (9/52 [17%]) and contact lens wear (5/52 [10%]). There were 27 patients in which a primary infectious keratitis developed into endophthalmitis, and 25 patients in which an infectious keratitis adjacent to a previous surgical wound developed into endophthalmitis. Patients in the primary keratitis group were more likely to be male (22/27 [81%] vs. 9/25 [36%], p<0.001), have a history of organic matter trauma (8/27 [30%] vs. 1/25 [4%]), p=0.016), and have a fungal etiology (21/27 [78%] vs. 7/25 [28%], p<0.001). Patients in the surgical-wound-associated group were more likely to have used topical steroids (22/25 [88%] vs. 17/27 [63%], p=0.037) and to have a bacterial causative organism (18/25 [72%] vs. 6/27 [22%], p<0.001). A visual acuity (VA) of ≥ 20/50 was achieved in 9/52 patients (17%) and a VA≥20/400 was achieved in 15/52 patients (29%), however, 35/52 patients (65%) had a VA < 5/200 at last follow up visit. Enucleation was ultimately performed in 15/52 patients (29%).
Progression of infectious keratitis to endophthalmitis is relatively uncommon. The current study suggests that patients at higher risk for progression to endophthalmitis include patients using topical corticosteroids, patients with a fungal keratitis, and patients with infectious keratitis developing adjacent to a previous surgical wound. Patients with sequential keratitis and endophthalmitis have generally poor visual outcomes.
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