endogenous endophthalmitis: diagnosis, management, and prognosisdivinity 2 respec talents

Endophthalmitis is a fatal ophthalmological emergency that needs prompt diagnosis and treatment. Urine culture is particularly helpful in the presence of dysuria, which may suggest that the primary source of infection may be the urinary tract. When symptoms begin quickly like this, it is acute endophthalmitis. Macula-threatening chorioretinitis and cases of endophthalmitis require intravitreal antifungal injections in addition to systemic therapy. It is often a diagnostic challenge because it can manifest at any age and is associated with a number of underlying predisposing factors. EE may be the first manifestation of an underlying occult systemic focus of infection, while the systemic cultures for infective organisms are still negative [3539]. 4. Endogenous endophthalmitis (EE) occurs when infectious agents are hematogenously disseminated into the eye from a remote focus of infection. Ophthalmology 109(1):8084, Basu S, Kumar A, Kapoor K, Bagri NK, Chandra A (2013) Neonatal endogenous endophthalmitis: a report of six cases. Bacteria mainly cause the CVAD-related infections (in 86%). In the case of negative cultures, diagnostics can be aided by molecular techniques, in particular PCR. However, they still suggested the use of surgical intervention, especially in patients with anterior chamber inflammation that did not respond well to intravitreal antibiotics. Candidemia increases the risk of developing EE 15 times [67]. Equi R.A., Green W.R. Endogenous Serratia marcescens endophthalmitis with dark hypopyon: A case report and review. Other rare complications are peritonitis, endocarditis, osteomyelitis, and meningoencephalitis. Blood or vitreous culture for patients already receiving treatment is warranted in the absence of a satisfactory response to therapy. Anterior chamber inflammation with hypopyon, absent red reflex, vitreous cells, and haze may also occur [21, 28]. An endogenous source is responsible for roughly 2% to 8% of all endophthal-mitis.1 Prompt diagnosis and treatment are essential to obtain the best visual outcomes. As in other sources of infection, the factors predisposing the development of EE in the course of infection of soft tissues are diabetes, intravenous drug use, and immunodeficiency [54]. In such situations, ultrasound B-scan can help in identification of retinal detachment (Fig. A However, the vitrectomy procedure has additional benefits. Fungal infections are very rare and occur only in immunocompromised people [58]. Systemic therapy is used to treat the focus of infection causing the metastatic spread of the organism to the ocular cavity. All authors read and approved the final manuscript. Usually, amphotericin or voriconazole is used. In most cases, the primary source of the infection is easy to diagnose as inflammation causes symptoms such as pain, fever, or malaise. Endophthalmitis can be classified as exogenous - following either trauma or an intraocular procedure, or endogenous and hence hematogenous in origin. They include hemorrhage into the vitreous chamber, retinal tear, lens damage, temporary increase in intraocular pressure, and hemorrhagic occlusive retinal vasculitis [86,87]. Visual acuity, as explained above, can be variably affected at the time of presentation, but is generally used as an outcome measure along with a dilated funduscopic examination to follow up the patient after starting treatment. doi:10.1093/cid/cir355, Article There may be a poor view of the fundus due to the presence of exudates and vitreous haze. 2). The analysis of cases published in the years 19862012 indicates that better treatment outcomes were achieved in patients undergoing vitrectomy compared to those treated only with intravitreal injections of antibiotics. Lemons were very often contaminated with Candida albicans, so the dose injected into the bloodstream was remarkably high. Signs such as poor visual acuity ( perception of light), large hypopyon, and choroidal abscess make the diagnosis of endophthalmitis very likely. In the lower part of the anterior chamber there is a hypopyon. Khera et al. Two important groups that need special attention while administering antibiotics are pregnant and breastfeeding women. Following advances in vitreoretinal pharmacotherapy and surgical technology, early surgical intervention is the current trend in the management of . Rarely, untreated intraocular infections extend beyond the confines of the eye to involve the orbit and CNS. OCT shows tractional retinal folds, epiretinal membranes, cystic spaces, and disorganization of the retinal layers. An official website of the United States government. Endogenous endophthalmitis (EE), on the other hand, results from the hematogenous spread of microorganisms from distant foci [57]. Indian J Med Res 139(1):9198, PubMed Central APD afferent pupillary defect, V Age, sex, and race are irrelevant to the risk of developing EE. Journal of Ophthalmic Inflammation and Infection (2015) 5:32 DOI 10.1186/s12348-015-0063 . visual acuity, LP light perception. PubMed Central Rodrigues IA, Jackson TL (2014) A high-definition view of endogenous fungal endophthalmitis. The exact number of drug users is difficult to estimate. Endogenous Ochrobactrum anthropi endophthalmitis. Cunningham E.T., Flynn H.W., Relhan N., Zierhut M. Endogenous Endophthalmitis. Medicine . Sight-threatening lesions involving the fovea, optic nerve head, cornea, limbus, or sclera may require prompt surgical management. For gram-positive infections, vancomycin is the primary drug used because of emergence of many cases of methicillin-resistant organisms [28]. Occasionally, cases of other etiology are also reported [22,23]. It is also not uncommon to cause inflammation of the soft tissues of the orbit [44]. Breazzano M.P., Jonna G., Nathan N.R., Nickols H.H., Agarwal A. Endogenous Serratia marcescens panophthalmitis: A case series. Other prognostic factors found in the same study include rapid onset of ocular symptoms, unilateral involvement, and panophthalmitis. Pizango O., Tejeda E., Buendia M., Lujan S. Bilateral endogenous ophthalmitis due to Candida glabrata after complicated bariatric surgery. Eur J Ophthalmol 24(3):424436. Am J Transplant 6(1):219224. It is often a diagnostic challenge because it can manifest at any age and is associated with a number of underlying predisposing factors. The need for a diagnostic vitrectomy is dependent on the clinicians judgment. Pediatrics 131(4):e1292e1297. Endophthalmitis is a medical emergency because vision prognosis is directly related to the time from onset to treatment. Other reports also stated successful treatment of Fusarium and Aspergillus endophthalmitis using voriconazole [77, 78]. The Lancet Infect Dis 14(4):358. doi:10.1016/S1473-3099(13)70216-0, Adam CR, Sigler EJ (2014) Multimodal imaging findings in endogenous Aspergillus endophthalmitis. Liver abscesses have been noted to be associated with EE, especially those caused by gram-negative rods such as Klebsiella pneumonia [24]. Neonatal endogenous endophthalmitis deserves a special mention. Approach to management of such a patient involves assessment of degree of ocular involvement, identification of the causative organism, and the underlying source of infection and then treatment of both the endophthalmitis and the underlying systemic infection. From a diagnostic point of view, it is extremely important that over 16% of Klebsiella patients with EE have negative blood culture results. Physician Assist. A relative afferent pupillary defect (RAPD) can also be present and can guide the need for a vitrectomy [26]. Damage occurs rapidly, therefore, in order to improve the prognosis, quick and accurate diagnosis and effective treatment are extremely important. This dose appears to be safe and can be repeated after intervals of 48h or more if there is evidence of persistent intraocular infection. Clinical features include conjunctival hyperemia , corneal haziness, hypopyon , and decreased visual acuity . PubMed Central Retin Cases Brief Rep 5(2):136140. We describe the management . During inflammation, bone destruction occurs, and the inflammatory process may also affect the bone marrow, the periosteum, and the surrounding soft tissues. However, in different reports proportions ranged widely due to geographic, genetic or alimentary factors [2]. doi:10.3109/09273940903216891, Greenwald MJ, Wohl LG, Sell CH (1986) Metastatic bacterial endophthalmitis: a contemporary reappraisal. Systemic administration of AMB is associated with dose-limiting nephrotoxicity, hypotension, arrhythmias, and infusion-related fever and chills (shake and bake) [8]. Curr Opin Ophthalmol 12(6):464470, Oude Lashof AM, Rothova A, Sobel JD, Ruhnke M, Pappas PG, Viscoli C, Schlamm HT, Oborska IT, Rex JH, Kullberg BJ (2011) Ocular manifestations of candidemia. In general, among bacterial EEs, meningitis is a source of infection in about 26% of cases [4,14]. Bacterial meningitis is a life-threatening infection due to central nervous system complications. Figure4 depicts a simplified flow chart for the diagnosis and management of EE. doi:10.1111/1469-0691.12118, Article Am J Ophthalmol 151(2):338344. Lancet 364(9443):14391450. Microorganisms associated with this condition vary along a broad spectrum. Damage of ocular tissues is caused by pathogens as well as by the immune response, and is exacerbated by the ischemia caused by septic emboli [5]. Methods: Interventional case report. Endophthalmitis typically causes severe ocular ache and decreased vision. doi:10.1159/000320601, Jalali S, Pehere N, Rani PK, Bobbili RB, Nalamada S, Motukupally SR, Sharma S (2014) Treatment outcomes and clinicomicrobiological characteristics of a protocol-based approach for neonatal endogenous endophthalmitis. However, still 19% of patients required enucleation or evisceration [4]. and J.K.; writingreview and editing, R.K.; supervision, R.K. All authors have read and agreed to the published version of the manuscript. A retrospective 12-year study of 79 eyes of 46 patients. Systematic review of 342 cases of endogenous bacterial endophthalmitis. found no association between the timing of vitrectomy and visual outcome in Klebsiella endophthalmitis [25]. Retina 34(3):592602. This in turn leads to cellular destruction, hypotony, and anterior segment necrosis [33]. J Ophthalmic Inflamm Infect. SS helped analyze the data and revised the manuscript. In Europe, endocarditis is the third most common infectious source in patients with EE [29]. Even though there have been no reports of such cases during human pregnancies, it is recommended to use fluoroquinolones only when other safer alternatives are not available despite their good vitreous penetration [29, 68, 69]. It is an uncommon but visual severe loss cause that may have devastating ocular and systemic complications [ 1 ]. South Med J 100(12):12191220. doi:10.1111/j.1442-9071.2011.02545.x, Wu AY, Oestreicher JH (2011) Endogenous bacterial endophthalmitis after routine colonoscopy. Fluconazole is also a broad spectrum agent with a better side effect profile than AMB. doi:10.1086/596757, Hamada Y, Okuma R, Katori Y, Takahashi S, Hirayama T, Ichibe Y, Kuroyama M (2013) Bibliographical investigation (domestic and overseas) on the treatment of endogenous Candida endophthalmitis over an 11-year period. Clinical review of endogenous endophthalmitis in Korea: A 14-year review of culture positive cases of two large hospitals. In an in vitro study, voriconazole showed 100% activity against Aspergillus species, Paecilomyces species, and Fusarium species [76]. This is the second main type of endophthalmitis. Inflammation is caused by an infection. Endophthalmitis is an ophthalmic emergency that can result in devastating ocular and systemic complications. doi:10.1128/AAC.02413-14, Barza M (1998) Treatment options for candidal endophthalmitis [editorial; comment]. Inflammation and bacterial toxins are responsible for cataracts development and leakage of the lens proteins into the anterior chamber. . Methicillin-resistant Staphylococcus aureus, Khan FA, Slain D, Khakoo RA (2007) Candida endophthalmitis: focus on current and future antifungal treatment options. Int Ophthalmol Clin 47(2):173183. Moreover, elevated blood glucose levels facilitate the multiplication of microorganisms [15]. In some reports, up to 50% of candidemia patients had EE [70]. Posterior adhesions causing pupil irregularities. Jackson T.L., Paraskevopoulos T., Georgalas I. Vitreous involvement by Candida can present as vitritis or fluffy white retinal lesions extending into the vitreous [43]. Graefes Arch Clin Exp Ophthalmol 244(7):816820. There is presence of dense, hyper-reflective echoes in the vitreous cavity suggestive of exudates (yellow arrow). They can also be masked by the medications taken by the patient-mainly over-the-counter painkillers and anti-inflammatory drugs. doi:10.1080/09273940802689396, Binder MI, Chua J, Kaiser PK, Procop GW, Isada CM (2003) Endogenous endophthalmitis: an 18-year review of culture-positive cases at a tertiary care center. The main challenges in the management of EE are early identification and delivering an adequate concentration of the drug in the vitreous cavity. Severe vitreal involvement in bacterial EE can present with a sub-retinal and choroidal abscess [46]. Bethesda, MD 20894, Web Policies In some published case series, up to 50% of EE patients had a history of injecting drug use [66]. (C,D)retinal detachment (green arrow) and numerous hyperechoic densities in the vitreous chamber (blue arrowhead). Since the 1980s, brown heroin has been mixed with lemon juice to increase its potency. The authors declare no conflict of interest. In this review, treatment guidelines based on clinical data and microorganism profile have been proposed. Shikari H., Silva P.S., Sun J.K. Open Access. Due to paucity of the disease, literature on EE mostly comprises of case series or single case reports. This condition may lead to valvular dehiscence and acute heart failure [28]. In a neonate with white reflex, endophthalmitis (along with other considerations such as malignancy) must be kept as a possibility in the differential diagnosis. The dose of amphotericin B (AMB) deoxycholate for intravitreal injection is 5 to 10mcg in 0.1ml sterile water or dextrose. [5]. Currently, no clear guidelines exist regarding the use of corticosteroids in endophthalmitis. In addition, dysfunction of the pigment epithelium and abnormalities of the bloodretinal barrier can lead to persistent macular edema (Figure 14). doi:10.1097/IAE.0b013e31822d3a34, Yoon YH, Lee SU, Sohn JH, Lee SE (2003) Result of early vitrectomy for endogenous Klebsiella pneumoniae endophthalmitis. Table2 lists the most commonly used intravitreal antibiotics. Vitritis is inherent part of EE. DD participated in revising the manuscript. doi:10.1001/archopht.124.4.479, Benz MS, Scott IU, Flynn HW Jr, Unonius N, Miller D (2004) Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. There is corneal edema and opacification superiorly. Qureshi A., Ashworth J., Sharma V., Ivanova T. Favourable outcome in paediatric endogenous endophthalmitis secondary to Neisseria meningitidis following pars plana vitrectomy. Corredores J., Hemo I., Jaouni T., Habot-Wilner Z., Kramer M., Shulman S., Jabaly-Habib H., Al-Talbishi A., Halpert M., Averbukh E., et al. Am J Ophthalmol 139(1):135140. One of the better understood immune privilege mechanisms is the bloodretina barrier. Almost any bone can be the primary site of infection, although the spine, hip, sternum, and ankle are the most commonly described [3,59,60,61]. Sekiguchi T., Inaba A. Endogenous endophthalmitis following streptococcus pneumoniae meningitis. This is well above the percentage of patients reported with similar improvement before this study [11]. Early diagnosis of endogenous endophthalmitis requires a high degree of suspicion and is critical if vision is to be preserved. The disease can develop bilaterally, but most cases (over 70%) affect one eye [11]. The most commonly used antibiotic for Gram-positive infections is vancomycin. In the same study, PCR was able to detect causative fungi in 5 culture negative specimens. Hyperechoic masses are visible under the retina. doi:10.1097/IAE.0b013e3181ecccf0, Vilela RC, Vilela L, Vilela P, Vilela R, Motta R, Possa AP, de Almeida C, Mendoza L (2013) Etiological agents of fungal endophthalmitis: diagnosis and management. Very poor visual acuity (20/400 or worse) occurs in 4090% of EE cases [1]. Patients with concomitant meningitis and EE are usually in a severe general condition. However, treatment with systemic antibiotics tailored to systemic infection alone is not sufficient, and most patients with severe endogenous bacterial endophthalmitis may require intravitreal antibiotics. doi:10.1097/SMJ.0b013e3181581191, Cheng HH, Ding Y, Wu M, Tang CC, Zhang RJ, Lin XF, Xu JT (2011) Endogenous aspergillus endophthalmitis after kidney transplantation. Bjerrum S.S., la Cour M. 59 eyes with endogenous endophthalmitiscauses, outcomes and mortality in a Danish population between 2000 and 2016. Martel A., Butet B., Ramel J.C., Martiano D., Baillif S. Prise en charge mdicale dun abcs sous-rtinien Klebsiella pneumoniae avec rcupration visuelle sans recours la vitrectomie. The prognosis for patients with EE in the course of meningitis is poor. Manifestations are determined by the affected organs. doi:10.1542/peds.2011-3391, Mamandhar A, Bajracharya L (2012) Aspergillus endophthalmitis in a healthy individual. doi:10.3126/nepjoph.v4i1.5873, CAS The study showed that vitreous samples during vitrectomy were taken near the retinal surface, which can potentially explain the lower yield of needle biopsy as early or localized infection located near the retinal surface might be missed by a needle biopsy [16]. Bilateral endophthalmitis as the initial presentation of bacterial meningitis. Quintyn J.C., Poupelin S., Fajoles-Vasseneix C., Brasseur G. Meningococcus endophthalmitis without meningitidis. Background Endophthalmitis is an inflammatory condition of the intraocular cavities (ie, the aqueous and/or vitreous humor), usually caused by infection. Among hospitalized patients with hematogenous infections in the United States, infective endocarditis is one of the most common risks for the development of EE. Eye (Lond) 23(4):945956. PubMed Fluconazole or voriconazole are preferred over amphotericin for the systemic treatment of sensitive isolates because azoles are less toxic and produce higher levels in the vitreous [1]. This phenomenon is attributed to the peculiarities of the circulatory system, with more direct blood flow from the heart to the right carotid artery [2]. Urological interventions along with gastrointestinal are the most common predisposing factor to the occurrence of fungal EE, especially those of Candida etiology [42]. These can be detected as dome-shaped lesions arising from the choroid on B-scan. An analysis of the NIS databases from 2002 to 2014 showed that more than 600,000 patients were hospitalized for infections associated with injecting drug use, 0.1% of them had EE. EE is rarely the first symptom of endocarditis, as it usually indicates a developed infection that is difficult to overlook or ignore, but such cases have been reported [28,31]. Pasula S., Trivedi V., Loshe E., Chandrasekar P. Serratia marcescens infection-associated loss of vision: A case report in a patient with a history of intravenous drug use. Clin Experiment Ophthalmol 39(8):771778. The most probable cause is a dysfunction of the blood vessels leading to an increasing permeability of the bloodretinal barrier. Am J Ophthalmol 137(4):725731. doi:10.1097/ICB.0b013e3181cc2146, Ramakrishnan R, Bharathi MJ, Shivkumar C, Mittal S, Meenakshi R, Khadeer MA, Avasthi A (2009) Microbiological profile of culture-proven cases of exogenous and endogenous endophthalmitis: a 10-year retrospective study. As with infections associated with intravenous drug use, Rhodotorula infections are increasingly being observed in immunocompromised patients with CVADs. Carr J.M., Hagan G., Guest P., Gompertz S. A "not so superficial" skin infection in a patient with diabetes. HHS Vulnerability Disclosure, Help As patients are often in poor general condition, the prognosis is poor. The source of pathogens in endogenous endophthalmitis is located inside the body, and infection spreads hematogenously. reported that the eyes with bacterial EE had a worse outcome with more patients requiring enucleation or evisceration compared to patients with fungal EE [21]. Etiology and clinical manifestations of bacterial liver abscess: A study of 102 cases. Retina (Philadelphia, Pa) 21(3):203209, Shen X, Xu G (2009) Vitrectomy for endogenous fungal endophthalmitis. PubMed Clin Infect Dis 27(5):11341136, Martinez-Vazquez C, Fernandez-Ulloa J, Bordon J, Sopena B, de la Fuente J, Ocampo A, Rubianes M (1998) Candida albicans endophthalmitis in brown heroin addicts: response to early vitrectomy preceded and followed by antifungal therapy. All of the above circumstances make the assessment of the vitreous body and retina in an ophthalmoscopic examination often impossible. In addition, vitrectomy patients usually require further surgeries to remove the silicone oil. Asian studies have reported fungi as the causative organisms in approximately 11.1 to 17.54% of total cases of EE, with the rest being attributed to bacterial causes [14, 15]. An increased risk of developing infections, including EE, in injecting drug users is associated with the direct inoculation of pathogens into the bloodstream during injection. PPV has a diagnostic as well as therapeutic role in the management of EE. 3 The main symptoms of endophthalmitis are pain, red eye and progressive visual acuity loss, and the main signs are ciliary hyperemia associated with Tyndall, hypopyon and vitritis. In endophthalmitis, a bacterial or fungal infection triggers inflammation, an immune system response. PubMed Sugita et al. In the case of EE, an additional risk for the patient is the presence of a primary source of infection, which can be directly life-threatening. have previously proposed clinical classifications of fungal EE [47, 48]. In cases of bacterial EE, vitrectomy is generally performed when there is no response to intravitreal antibiotics within 48h or when the eye condition continues to decline or with a worse grade of RAPD [26]. A proposed management of patients with endogenous endophthalmitis. It occurs when infecting organisms enter the posterior segment of the eye. Moreover, some cases can be classified as soft tissue inflammation [62]. The genitourinary system is the common way by which pathogens gain access to the bloodstream. Lu X., Chen W., Xia H., Zheng K., Jin C., Ng D.S., Chen H. Atrophy of retinal inner layers is associated with poor vision after endophthalmitis: A spectral domain optical coherence tomography study. Patients with EE can present with abscesses in the choroid (Fig. Clin Microbiol Rev 15(1):111124, Lindstedt EW, Bennebroek CA, van der Werf DJ, Veckeneer M, Norel AO, Nielsen CC, Wubbels RJ, van Dissel JT, van Meurs JC (2014) A prospective multicenter randomized placebo-controlled trial of dexamethasone as an adjuvant in the treatment of postoperative bacterial endophthalmitis: interim safety analysis of the study drug and analysis of overall treatment results. Ocul Immunol Inflamm 18(2):133138. The pathogen responsible for the most cases of endocarditis is Staphylococcus aureus-up to 40%. The inflammatory process can affect the heart valves, resulting in their destruction and formation of abscesses. Surgery combined with antibiotics for the treatment of endogenous endophthalmitis caused by liver abscess. The organisms responsible for bacterial EE differ depending on the geographic location. The basic diagnostic tool in such cases is an ultrasound examination. Endogenous Endophthalmitis Caused by Infective Endocarditis in East Asia. The cornea opacification and Descemets membrane folding are common. Pharmacotherapy 27(12):17111721. Prolonged endotamponade can lead to oil emulsification and the resulting increase in intraocular pressure. Academic research paper on topic "Endogenous endophthalmitis: diagnosis, management, and prognosis" Sadiq et al. Ultrasound B scan with numerous hyperechoic densities in vitreous chamber. Yoshida M., Yokokura S., Nishida T., Mochizuki K., Suzuki T., Maruyama K., Otomo T., Nishiguchi K.M., Kunikata H., Nakazawa T. Endogenous endophthalmitis caused by group B streptococcus; Case reports and review of 35 reported cases. reported seven cases of EE caused by vancomycin-resistant bacteria [62]. Fundus photograph of a 78-year-old male (a) with a yellow white mass in the temporal paramacular region with some superficial hemorrhages suggestive of a choroidal abscess. The J Obstet Gynaecol Res 38(9):12201222. Retina 32(6):11291134. However, the lower intensity of the changes is noticeable. doi:10.1016/j.ophtha.2012.05.022, Sheu SJ, Kung YH, Wu TT, Chang FP, Horng YH (2011) Risk factors for endogenous endophthalmitis secondary to klebsiella pneumoniae liver abscess: 20-year experience in Southern Taiwan. Privacy Endogenous endophthalmitis: diagnosis, management, and prognosis. However, the study did report better final visual outcomes in patients with initial visual acuity better than counting fingers. Pyogenic liver abscess is currently most often a complication of inflammation of the bile ducts; less often the cause is seeding of the portal vein from an intra-abdominal infection (appendicitis, diverticulitis, inflammatory bowel disease), direct extension (from cholecystitis, perinephric abscess, and subphrenic abscess), hematogenous abscess spread, trauma, or postoperative complications. In a large systematic review of 342 cases of bacterial EE liver abscess was the most common source of infection worldwide (in 19%) [4]. Negative intraocular cultures do. However, it is an expensive method and still not widely used. doi:10.1097/01.iae.0000250011.68532.a2, Marangon FB, Miller D, Giaconi JA, Alfonso EC (2004) In vitro investigation of voriconazole susceptibility for keratitis and endophthalmitis fungal pathogens. Nearly two-thirds (63.9%) were male and the median age was 58 years (range 19-77 years). Tyndall can be found in the aqueous humor, often there is also hypopyon in the anterior chamber (Figure 3 and Figure 4). Endogenous endophthalmitis: diagnosis, management, and prognosis. Hatzenbuehler J., Pulling T.J. b Fundus photograph taken at 3weeks following intravenous trimethoprim-sulfamethoxazole therapy. Despite the enormous advances made in diagnostic and treatment modalities in recent years, EE remains a challenge. Optical coherence tomography (OCT) has also been used as an imaging modality in patients with EE where it helps in localizing the pathology within the retinal layers as well as sub-retinal space [58, 59]. Proper diagnosis is necessary for the choice of the most appropriate treatment. PubMedGoogle Scholar. Vaziri K., Schwartz S.G., Kishor K., Flunn H.W., Jr. Endophthalmitis: State of the art. Lin H.-H., Chien C.-C., Fang J.-T., Lai R.-H., Huang C.-C. Christensen S.R., Hansen A.B.E., la Cour M., Fledelius H.C. The actual incidence of EE in Klebsiella liver abscess ranges from 0.9 to 7.9% [25]. In this review, we focus primarily on the importance of the primary source of infection for the course of the disease and prognosis. EE can be a first symptom of bacterial meningitis and bilateral cases are reported quite frequently [32,34]. Over 72% declare that opioids are the most frequently used intravenous drug [64]. Uppuluri A., Zarbin M.A., Bhagat N. Endogenous endophthalmitis in patients with intravenous opioid use: Demographics and associated comorbidities. Wang W.J., Tao Z., Wu H.L. Degenhardt L., Peacock A., Colledge S., Leung J., Grebely J., Vickerman P., Stone J., Cunningham E.B., Trickey A., Dumchev K., et al.

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