Endophthalmitis in children

Endophthalmitis develops when the infectious process is localized in the cavity of the eyeball. The term panophthalmitis is used in the progressive spread of infection that affects all tissues of the eye. Diagnosis of endophthalmitis in children presents certain difficulties, which is associated with the complexity of research. Usually, if you have this disease, you can find:

1. such an etiological factor as trauma, surgical intervention, etc .;
2. swelling of the eyelids;
3. conjunctival injection and chemosis;
4. uveitis;
5. hypopion;
6. expansion of the vessels of the retina.

The severity and malignancy of the clinical course of endophthalmitis depends on the pathway of transmission of the infection and on the type of pathogen. For example, Streptococcus spp. or Pseudomonas cause rapidly progressive endophthalmitis with severe clinical course. Endophthalmitis caused by Staphylococcus spp., Especially Staph, epidermidis, are characterized by a late onset and relatively benign course. Fungal endophthalmitis, as a rule, proceeds relatively easily, but complications can not be ruled out.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]

The cause of endophthalmitis in children

1. Trauma: surgical intervention; penetrating wound.
2. Keratitis: a pathogenic microorganism penetrates the Descemet's membrane, causing an infectious anterior uveitis, which creates conditions for the development of endophthalmitis.
3. Metastatic endophthalmitis on the background of meningitis (especially meningococcal), infective endocarditis and otitis media, and general infection. In many cases, endophthalmitis is bilateral and often diagnosed late due to the extreme importance of the background disease.

Possible infectious agents

Bacterial flora

Most often endophthalmitis, especially post-operative, causes Streptococcus and Staphylococcus spp. Post-traumatic endophthalmitis, as a rule, provokes Proteus and Pseudomonas, often in combination with other bacterial flora. In the presence of  Pseudomonas, specific keratitis develops.

Hypopion accompanying endophthalmitis. The background was keratitis, caused by the inconsistency of the eye gap. Although the eye was preserved due to the timely appointment of antibiotic therapy, visual acuity after 5 years remained low, due to the development of amblyopia

Fungal flora

The infectious process caused by Candida spp., Usually accompanies immunodeficiency or, in other words, more often affects children with severe somatic pathology.

Research

1. Color of smears on Gram.
2. Color of smears on Giemsa, especially for the exclusion of fungal flora.
3. Sowing blood for sterility.
4. Diagnostic puncture of the anterior chamber and / or vitreous with subsequent bacteriological examination.

Samples should be immediately inoculated on a Petri dish with blood agar, thioglycolic medium and "chocolate" agar. For the detection of fungal flora, culturing in a Sabouraud nutrient medium and blood agar is used.

To clarify the degree of involvement in the pathological process of the posterior segment of the eye in the disease of the anterior segment, ultrasound is performed. A general examination helps to eliminate the metastatic nature of endophthalmitis.

Other forms of endophthalmitis

The course of toxocarosis and toxoplasmosis sometimes resembles the endophthalmitis clinic. With Behcet's disease (Behcet), uveitis is so severe that it mimics endophthalmitis.

Infectious conjunctivitis

The diagnosis of conjunctivitis is based on the following clinical signs:

1. mucopurulent discharge;
2. conjunctival injection, accompanied in some cases by hemorrhages and edema;
3. lacrimation;
4. a feeling of discomfort in the eye;
5. mild itching, which is not a pathognomonic symptom;
6. the vision does not decrease, although the patient may be disturbed by the "fog" before his eyes, which is associated with a large amount of mucous discharge;
7. a feeling of "sand" in the eyes, especially in cases of concomitant keratitis.

Diagnosis

1. The diagnosis is established based on the history of the disease, the study of the discharge from the conjunctival cavity, the presence of the corresponding general disorder (inflammatory process of the upper respiratory tract, etc.)
2. Research:
   • visual acuity check - vision loss is usually associated with the presence of abundant mucopurulent discharge or concomitant keratitis;
   • examination on the slit lamp reveals changes in the conjunctiva and in some cases combined keratitis;
   • assessment of the purity of the skin (to eliminate the rash) and the state of the mucous membranes.
3. Laboratory research.

Most pediatricians and ophthalmologists do not conduct laboratory diagnostics during the initial treatment. Since conjunctivitis
Occurs very often, and the viral or bacterial agents that cause it do not pose a serious threat and are easily susceptible to adequate antiviral and antibacterial therapy, there is no need for sowing. Sowing is indicated in cases of severe clinical course, with chronic and recurrent (after antibiotic cancellation) processes, as well as with follicular and atypical forms of the disease.

Treatment of endophthalmitis in children

Antibiotic therapy

Bacterial endophthalmitis. Assign a specific antibacterial treatment, based on the individual sensitivity of the microbial flora, identified by sowing on different media. If the sensitivity of the microflora is unknown, the following regimens for the administration of medications are recommended:

1. Installations:
   • instillation solution of gentamicin (preferably containing no preservatives) every hour;
   • instillation of a 5% solution of cefuroxime (preferably containing no preservatives) every hour;
   • instillatsii 1% solution atropine (children under 6 months of age instilled 0.5% atropine) twice a day.
2. Subconjunctival injections (if necessary, vitreous body puncture, subconjunctival injections combine with surgical intervention):
   • gentamycin - 40 mg;
   • cefazolin 125 mg.
3. Intravitreal injections:
   • gentamycin (in 0.1 mg dilution in 0.1 ml);
   • ceftazidime (in dilution of 2.25 mg in 0.1 ml).
4. General use of antibiotics:
   • gentamycin - intravenously, in a daily dose of 2 mg / kg body weight;
   • cefuroxime - intravenously, in a daily dose of 60 mg / kg of body weight, in several doses.

Endophthalmitis of a flexible etiology. When isolating Candida fungi, ketoconazole or amphotericin B in combination with flucytosine is usually prescribed. Most other representatives of fungal flora are sensitive to amphotericin B, which is administered intravitreally (5 μg).

Vitrectomy

In some cases, early vitrectomy may play a role, with the aim of maximally sanitizing the infectious focus, as well as removing foreign bodies and necrotic tissue. Simultaneously with the implementation of vitrectomy, an antibiotic is administered intravitreal and subconjunctival.