Panophthalmitis: Types, Causes, Symptoms and Management

Panophthalmitis

Panophthalmitis

Definition

Panophthalmitis is a severe, rapidly progressing, and sight-threatening inflammatory condition involving all the layers and structures of the eye, including the sclera, retina, choroid, and even the orbit. It is a serious ocular emergency that can lead to blindness and systemic complications if not managed promptly.

Types of Panophthalmitis

Panophthalmitis can be classified based on its cause and onset:

1. Infectious Panophthalmitis

Caused by bacterial, fungal, viral, or parasitic infections.

  • Bacterial: Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae
  • Fungal: Candida, Aspergillus
  • Viral: Herpes simplex virus (HSV), Cytomegalovirus (CMV)
  • Parasitic: Toxoplasma gondii

2. Non-infectious Panophthalmitis

Rare but can occur due to:

  • Autoimmune diseases (Sarcoidosis, Rheumatoid Arthritis)
  • Chemical or traumatic injury (e.g., alkali burns, gunshot wounds)

Causes of Panophthalmitis

Panophthalmitis is often caused by infections spreading from:

  • Post-Surgical Infections – After cataract surgery, corneal transplants, or glaucoma surgery.
  • Penetrating Ocular Trauma – Foreign body injury, sharp objects, or road accidents.
  • Endogenous Infections – Spread of bacteria or fungi from systemic infections (sepsis, endocarditis).
  • Contaminated Injections – Intravitreal injections or contaminated eye drops.
  • Uncontrolled Orbital Cellulitis – Infection spreading from adjacent sinus infections.

Signs and Symptoms

Panophthalmitis presents with:

  • Ocular Symptoms:
  • Severe eye pain
  • Redness and swelling of the eyelids
  • Purulent discharge
  • Proptosis (bulging of the eye)
  • Loss of vision (partial or complete)
  • Corneal opacity
  • Hypopyon (pus in the anterior chamber)
  • Chemosis (swelling of the conjunctiva)

Systemic Symptoms:

  • Fever
  • Headache
  • Nausea
  • Malaise (general discomfort)
  • Signs of sepsis in severe cases

Diagnosis of Panophthalmitis

Early diagnosis is crucial for vision and life preservation.

1. Clinical Examination:

  • Slit-lamp examination
  • Fundoscopy
  • Ocular ultrasound (B-scan) to check vitreous involvement

2. Microbiological Tests:

Aqueous and Vitreous Tap Culture & Gram Stain: Identifies bacterial or fungal pathogens.

Blood Culture: Helps identify systemic infections causing endogenous panophthalmitis.

3. Imaging Studies:

  • B-scan Ultrasound: To detect retinal detachment or intraocular abscess.
  • CT Scan/MRI: To assess orbital extension and rule out brain involvement.

Investigations Required

  • Complete Blood Count (CBC) – Checks for infection (increased WBCs).
  • Erythrocyte Sedimentation Rate (ESR) & C-Reactive Protein (CRP) – Elevated in inflammatory and infectious conditions.
  • Blood Culture – Helps detect systemic infections.
  • Ocular Fluid Analysis – Microscopy, Gram stain, culture, and sensitivity.
  • Polymerase Chain Reaction (PCR) – Identifies viral or fungal DNA.
  • Imaging – B-scan ultrasound, CT scan, MRI.

Treatment of Panophthalmitis

Treatment is aggressive and requires systemic and local therapies.

1. Medical Treatment:

Empirical Broad-Spectrum Antibiotics (IV):

  • Vancomycin (1g IV twice daily) – Covers Gram-positive bacteria.
  • Ceftazidime (2g IV twice daily) – Covers Gram-negative bacteria.

Intravitreal Antibiotics:

  • Vancomycin (1 mg/0.1 ml) + Ceftazidime (2.25 mg/0.1 ml)

Systemic Antifungal Therapy (if fungal infection suspected):

  • Amphotericin B (0.3-0.5 mg/kg/day IV)
  • Voriconazole (200 mg twice daily orally or IV)

2. Surgical Treatment:

  • Pars Plana Vitrectomy (PPV): If the infection is confined to the vitreous.
  • Enucleation (Eye Removal): In severe, non-responsive cases to prevent systemic spread.

3. Supportive Therapy:

  • Steroids: Intravenous dexamethasone (used cautiously).
  • Analgesics: Paracetamol or Ibuprofen for pain relief.

Medications That Should Not Be Given

Topical Steroids – Contraindicated in fungal or bacterial infections as they worsen the condition.

NSAIDs (e.g., Diclofenac, Aspirin in high doses) – May increase bleeding risks.

Immunosuppressants (e.g., Methotrexate, Cyclosporine) – Should be avoided in active infections.

Role of Vitamins 

Vitamins help in recovery and immune response:

Vitamin A – Essential for ocular health and epithelial healing.

Vitamin C & E – Antioxidants that reduce oxidative stress and aid healing.

Vitamin D – Boosts immunity and reduces inflammation.

Vitamin B12 & B6 – Aid nerve regeneration and prevent optic nerve damage.

Lifestyle Effects of Panophthalmitis

Vision Loss: May cause permanent blindness in the affected eye.

Psychological Impact: Anxiety, depression, and reduced quality of life.

Mobility Challenges: Vision impairment may limit daily activities.

Systemic Complications: If untreated, it may lead to septicemia and death.

Complications of Panophthalmitis

  • Complete Blindness – Due to optic nerve damage.
  • Endophthalmitis Progression – Leads to total eye destruction.
  • Orbital Cellulitis – Infection spread to orbital tissues.
  • Cavernous Sinus Thrombosis – Life-threatening complication.
  • Meningitis – Bacterial spread to the brain.
  • Sepsis – Infection spreads systemically, causing multi-organ failure.

Management and Prevention

1. Immediate Management

  • Hospitalization and IV antibiotics.
  • Early vitrectomy if needed.
  • Eye enucleation in severe, non-responsive cases.

2. Preventive Measures

  • Proper hygiene during eye surgeries.
  • Early treatment of ocular trauma.
  • Regular monitoring for systemic infections in immunocompromised patients.
  • Avoidance of contaminated eye medications.

Conclusion

Panophthalmitis is a medical emergency requiring prompt diagnosis and aggressive treatment. The prognosis depends on early intervention, the causative agent, and the patient's overall health. Preventive measures, proper post-surgical care, and early treatment of eye infections can significantly reduce the risk of developing panophthalmitis.

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