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.