Muda et al.

Journal of Ophthalmic Inflammation and Infection (2018) 8:14

https://doi.org/10.1186/s12348-018-0158-3
Journal of Ophthalmic
Inflammation and Infection

ORIGINAL RESEARCH Open Access

Endogenous endophthalmitis: a 9-year

retrospective study at a tertiary referral
hospital in Malaysia
Rosiah Muda1, Valarmathy Vayavari2, Deivanai Subbiah3, Hamisah Ishak4, Azian Adnan3
and Shelina Oli Mohamed5*

Abstract
Background: The objective of this study was to determine the clinical presentation, systemic risk factors, source of
infective microorganism, treatment outcomes, and prognostic indicators of endogenous endophthalmitis at a main
tertiary referral hospital for uveitis in Malaysia. A retrospective review of medical records of 120 patients (143 eyes)
with endogenous endophthalmitis over a period of 9 years between January 2007 and December 2015 was
undertaken.
Results: Identifiable systemic risk factors were present in 79.2%, with the majority related to diabetes mellitus (60.
0%). The most common source of bacteremia was urinary tract infection (17.5%). A positive culture from ocular fluid
or other body fluids was obtained in 82 patients (68.9%), and the blood was the highest source among all culture-
positive results (42.0%). Gram-negative organisms accounted 42 cases (50.6%) of which Klebsiella pneumonia was
the most common organism isolated (32.5%). Sixty-nine eyes (48.6%) were managed medically, and 73 eyes (51.4%)
underwent vitrectomy. Final visual acuity of counting fingers (CF) or better was achieved in 100 eyes (73.0%).
Presenting visual acuity of CF or better was significantly associated with a better final acuity of CF or better (p = 0.001).
Conclusions: The visual prognosis of endogenous endophthalmitis is often poor, leading to blindness. As expected,
gram-negative organisms specifically Klebsiella pneumonia were the most common organisms isolated. Urinary tract
infection was the main source of infection. Poor presenting visual acuity was significantly associated with grave visual
outcomes. A high index of suspicion, early diagnosis, and treatment are crucial to salvage useful vision.
Keywords: Endogenous, Endophthalmitis, Diabetes mellitus, Bacteria, Fungal, Intravitreal injections, Vitrectomy, Visual
acuity

Background endophthalmitis cases and gram-negative isolates are

Endogenous endophthalmitis (EE) occurs when infec- found in only 32% of cases [3, 4]. In contrast, most cases
tious agents are hematogenously disseminated into the of EE in East Asia are caused by gram-negative organ-
eye from a remote focus of infection. Even though this isms especially Klebsiella species accounting for 80 to
entity is relatively rare and accounts for approximately 90% of positive cultures [4, 5].
2–15% of all cases of endophthalmitis [1–3], it is an ocu- The outcome of endogenous endophthalmitis is often
lar emergency and is potentially life-threatening. The dismal. Sharma et al. reported that 60% of the eyes had a
causative organisms may vary depending on the geo- final visual acuity of hand motions or worse and as many
graphical location. In Europe and the USA, Streptococcus as 29% required removals [6]. Hence, prompt diagnosis
species, Staphylococcus aureus, and other gram-positive and management are essential if useful vision is to be
bacteria account for two thirds of bacterial endogenous preserved.
To the best of our knowledge, there is no large case
* Correspondence: [email protected]
series on endogenous endophthalmitis being reported
5
Department of Opthalmology, Hospital Shah Alam, Shah Alam, Malaysia yet from Malaysia. The current study was performed to
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 2 of 17

determine the clinical profile of EE at a tertiary hospital our country with 72 Malays (60.0%), 33 Chinese (27.5%),
while focusing on the clinical presentation, predisposing 13 Indian (10.8%), and 2 others (1.7%). There was a slight
risk factors, source of infective microorganism, treat- female predominance (61, 50.8%) compared to males
ment outcomes and prognostic indicators. (59, 49.2%).

Methods Systemic features

A retrospective observational study was conducted in Systemic risk factors
Selayang Hospital which was the main national tertiary At least one underlying medical illness was identified in
referral center for uveitis in Malaysia. We reviewed the 95 patients (79.2%). Diabetes mellitus was the most
medical records of patients with endogenous endoph- common medical illness (72, 60.0%), followed by renal
thalmitis who were seen or referred to our hospital over failure (20, 16.7%), and 15 patients (12.5%) had solid
a period of 9 years between January 2007 and December organ tumor or hematologic malignancy. Six patients
2015. The diagnosis of endogenous endophthalmitis was (5.0%) had liver disease and 3 patients (2.5%) were preg-
defined as the presence of iritis and vitritis on ophthal- nant. Five patients (4.2%) were on systemic corticoste-
mic examination and one or more of the following: (1) roids for underlying autoimmune diseases, and 1 was on
constitutional symptoms and systemic infection; (2) systemic immunosuppressants.
positive cultures of vitreous, blood, or other body fluids;
(3) presence of loculation, vitreous debris, or membran-
ous debris on ultrasound; (4) lack of ocular trauma or Source of infection
ocular surgery within 1 year from onset of infection or A primary source of infection was identified in 90 patients
evidence of primary external ocular infection such as in- (75.0%). Urinary tract infection (21, 17.5%) was the most
fectious keratitis or filtering bleb infection. common source of bacteremia followed by pulmonary
Demographic details such as age, gender and race, pre- infection (19, 15.8%), skin or soft tissue infection (17,
senting complaints, preexisting medical illnesses, predis- 14.2%), and hepatobiliary infection (12, 10.0%). However,
posing risk factors, source of infection, laterality, visual the source of infection could not be identified in 30
acuity, ophthalmologic examination, ultrasound findings, patients (25.0%), despite extensive systemic work-up and
microbiologic profiles, treatment modalities, and final investigations (Table 1).
visual outcomes were collected from medical records.
The study was done according to Malaysian Good Clin- Ocular features
ical Practice (MGCP) 2nd edition January 2004 and regis-
tered in National Medical Research Register (NMRR). Ocular symptoms Majority of patients had unilateral
Data was analyzed using the Statistical Package for So- disease, 97 (80.8%), and involvement of the left eye (78,
cial Science (SPSS) version 22.0. Descriptive data was 54.5%) was more common. Blurring of vision (106,
expressed as mean ± standard deviation (SD) for numer- 74.1%), eye redness (52, 36.4%), eye pain or discomfort
ical data, and categorical variables were presented in fre- (42, 29.4%), and floaters (16, 11.2%) were ocular symp-
quencies and percentages. Logistic regression analysis toms at presentation. The blurring of vision (85, 68.5%)
was used to determine the factors associated with good was the most common presenting complaint, followed
visual outcomes. The association between presenting
Table 1 Identifiable source of infection
and final visual acuity was also analyzed using the Pear-
Source of infection No. of patients Percent
son correlation coefficient, and visual acuities were con-
verted to logarithm of the minimal angle of resolution Infected catheter 11 9.2
(logMAR) scale. For visual acuity less than counting fin- Urinary tract infection 21 17.5
ger (CF), the following scales were used: CF = 2.00 Log- Hepatobiliary infection 12 10.0
MAR units, hand motion = 2.30 LogMAR units, light Lung infection 19 15.8
perception = 2.60 LogMAR units, and no light percep- Meningitis 2 1.7
tion = 2.90 LogMAR units. A P value of < 0.05 was con-
Infective endocarditis 1 0.8
sidered to be significant.
Gastrointestinal infection 1 0.8
Results Genital infection 2 1.7
Demographic data Skin or soft tissue infection 17 14.2
A total of 143 eyes of 120 patients were included in this Septic arthritis 1 0.8
study. The age of patients ranged from 7 to 81 years, and Diabetic foot ulcer 3 2.5
the mean age at presentation was 52.6 ± 15.1 years. The
Nil 30 25.0
racial distribution reflected the multiracial population in
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 3 of 17

by eye redness (20, 16.1%) and eye pain or discomfort Microbiology

(14, 11.3%). A positive culture from ocular fluid or other body fluids
The interval between the onset of ocular symptoms was obtained in 82 patients (68.9%). The culture result of
and the first presentation to an ophthalmologist was less 1 patient was not available as he had it done elsewhere.
than 1 week in 62 eyes (47.3%), 1 to 2 weeks in 40 eyes The blood was the highest source among all culture-
(30.5%), more than 2 weeks to 1 month in 10 eyes positive results (50, 42.0%). Gram-negative organisms were
(14.5%), and more than 1 month in 10 eyes (7.6%). The more common (26 patients, 52.0%) than gram-positive or-
interval was not available in 12 eyes which were from ganisms (20 patients, 40.0%). Four patients (8.0%) had a
patients with no recorded ocular symptoms due to poor positive fungal culture from the blood (Fig. 2).
general medical condition or no documentation obtained Forty-six patients (38.7%) had at least one positive culture
from the medical records (Fig. 1). from other body fluids. Other body fluid cultures yielded
Systemic symptoms were identified in 84 patients gram-positive organisms in 11 patients (23.9%), gram-
(70.0%). This data was not available in 36 patients negative in 28 patients (23.3%), and fungal in 7 patients
(30.0%). The interval between the onset of systemic (15.2%). Nineteen patients (41.3%) had a positive urine cul-
symptoms and the onset of ocular symptoms was identi- ture; 14 (30.4%) had positive cultures from infected cath-
fied in 101 eyes. The interval was less than 1 week in 26 eter, skin, soft tissue, or joint; 8 (17.4%) had positive
eyes (25.7%), between 1 and 2 weeks in 25 eyes (24.8%), sputum cultures; 5 (10.9%) had positive culture from liver
more than 2 weeks to 1 month in 12 eyes (11.9%), and abscess; 3 (6.5%) had positive high vaginal swab; and 1 pa-
more than 1 month in 38 eyes (37.6%) (Fig. 1). tient (2.1%) had positive cerebrospinal fluid (Figs. 2 and 3).
Vitreous samples were obtained from 125 eyes. Vitreous
Ocular findings At presentation, based on the culture was positive in 27 eyes (22.3%). Of these, 22 eyes
Standardization of Uveitis Nomenclature (SUN), the (81.4%) had bacterial and 5 eyes (18.5%) had fungal
proportion of the eyes with anterior chamber cells better isolates. Among bacterial isolates, 10 (37.0%) were gram-
than grade 3 and grade 3 or worse was similar with 67 positive and 12 (44.4%) were gram-negative (Fig. 2).
eyes (49.6%) and 68 eyes (50.4%) respectively. Twenty- The causative organisms cultured from the blood, vit-
seven eyes (19.0%) had hypopyon, and 42 eyes (29.6%) reous, and other body fluids are summarized in Table 2.
had fibrin. The fundal view was present in 64 out of 143 The microbiology of causative organisms is summa-
eyes (44.8%). Among this, 32 eyes (50.0%) had choroidi- rized in Table 3.
tis or choroidal abscess, 11 eyes (17.2%) had retinitis, 6
(9.4%) had vasculitis, and 4 (6.3%) had optic disc swell- Treatment
ing. Six eyes had a combination of choroiditis or chor- All patients were treated with systemic antibiotics or
oidal abscess and retinitis and 2 eyes had choroiditis or antifungal agents aimed at the source of infection and
choroidal abscess, vasculitis, and optic disc swelling. presumed causative organism. One hundred nineteen
Ultrasound findings were documented in 97 eyes. cases (85.6%) were on systemic antibiotics, and more
Fifty-five eyes (56.7%) had vitreous loculation, whereas than half (55.1%) were treated with ciprofloxacin either
subretinal or vitreous abscess and retinal detachment as monotherapy or in combination with other antibi-
were found in 6 (6.2%) and 8 (8.2%) eyes respectively. otics. There was no statistically significant correlation

Fig. 1 The interval between the onset of ocular symptom and first presentation and the duration between systemic and ocular symptom
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 4 of 17

Fig. 2 Blood, other body fluids, and vitreous culture organism

between systemic ciprofloxacin and final visual out- by hand motion (38, 27.0%) and perception of light (22
comes (p = 0.68). Systemic steroids were not used in any eyes, 15.6%). Only 16 eyes (11.3%) and 14 eyes (9.9%)
of the patients. In addition, 126 eyes (88.7%) received in- had presented visual acuity between 6/6 to 6/18 and 6/
travitreal antibiotics (vancomycin and ceftazidime or 24 to 6/36 respectively. Overall, 56% had vision of CF or
amikacin) or antifungal (amphotericin B) injections or better at presentation. Vision was not available in 2 pa-
both. The injections were repeated in 75 eyes (59.5%). tients (1.4%) who could not cooperate during a vision
Intravitreal injection was not given in 16 cases (11.3%), test. Final visual acuity was available in 138 eyes (96.5%).
and 10 of them (62.5%) had relatively good presenting Three patients were transferred to their original hospi-
visual acuity of 6/24 or better and mild vitritis. They tals for the continuation of treatment and follow-up.
were treated with systemic antibiotics or antifungals with One patient defaulted follow-up, and another patient
close monitoring. No intravitreal injection of steroids passed away due to sepsis and multiorgan failure.
was given to any eye. Overall, 69 eyes (48.6%) were man- After treatment, 100 eyes (73.0%) achieved final visual
aged medically either with systemic or intravitreal antibi- acuity of CF or better. Ten eyes developed panophthal-
otics or antifungals or both. mitis, and 6 eyes required evisceration. Table 4 summa-
Out of 143 eyes, 73 (51.4%) underwent vitrectomy. rizes the logistic regression analysis results of patient
Early vitrectomy was performed within 2 weeks from characteristics that may predict a good visual outcome
diagnosis in 38 eyes (52.1%). Silicone oil was injected in (CF or better).
35 eyes (47.9%), gas in 3 eyes (4.1%), air in 19 eyes In univariate logistic regression analysis, factors found
(26.0%), and no intraocular tamponade was used in 16 to be statistically significant with good visual outcome
eyes (21.9%). were good presenting visual acuity (crude odd ratio 0.1;
95% CI 0.021, 0.384) and presence of fundus view at
Outcomes presentation (crude odd ratio 0.337; 95% CI 0.068,1.675).
The most common presenting visual acuity was between In the multivariate logistic regression analysis, elevated
6/60 and counting finger (CF) (48 eyes, 34.0%), followed risk for good visual outcome was observed only in good

Fig. 3 Other body fluid culture

Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 5 of 17

Table 2 Microbial isolates from blood, other body fluids, and vitreous
Species Blood (n = patient) Other body fluids (n = patient) Vitreous (n = eyes)
Culture positive 50 (42.0%) 46 (38.7%) 27 (22.3%)
Culture negative 69 (58.0%) 73 (61.3%) 94 (77.7%)
Gram-positive organism 20 (40.0%) 11 (23.9%) 10 (37.0%)
Staphylococcus aureas 13 (26.0%) 7 (15.2%) 5 (18.5%)
MRSA 3 (6.0%) 2 (4.3%) 2 (7.4%)
Staphylococcus coagulase -ve 2 (4.0%) 0 (0.0%) 2 (7.4%)
Streptococcus sp. 2 (4.0%) 2 (4.3%) 1 (3.7%)
Gram-negative organism 26 (52.0%) 28 (60.9%) 12 (44.4%)
Klebsiella pneumonia 17 (34.0%) 19 (41.3%) 8 (29.6%)
Pseudomonas aeruginosa 2 (4.0%) 4 (8.7%) 3 (11.1%)
Escherichia coli 1 (2.0%) 3 (6.5%) 0 (0.0%)
Acinebacter sp. 1 (2.0%) 2 (4.3%) 0 (0.0%)
Enterobacter intermedius 1 (2.0%) 0 (0.0%) 0 (0.0%)
Bukholderia cepacia 1 (2.0%) 0 (0.0%) 1 (3.7%)
Bukholderia pseudomallei 1 (2.0%) 0 (0.0%) 0 (0.0%)
Elizabethkingia meningosepticum 1 (2.0%) 0 (0.0%) 0 (0.0%)
Mycoplasma pneumonia 1 (2.0%) 0 (0.0%) 0 (0.0%)
Fungal 4 (8.0%) 7 (15.2%) 5 (18.5%)
Candida albicans 1 (2.0%) 5 (10.9%) 1 (3.7%)
Candida tropicalis 2 (4.0%) 1 (2.2%) 0 (0.0%)
Penicillium sp. 0 (0.0%) 0 (0.0%) 2 (7.4%)
Phanerochaeta chrysosporium 0 (0.0%) 0 (0.0%) 1 (3.7%)
Xylariaceae sp. 0 (0.0%) 0 (0.0%) 1 (3.7%)
Fungal (species not available) 1 (2.0%) 1 (2.2%) 0 (0.0%)

presenting visual acuity (adjusted odd ratio 0.09; 95% CI conditions predisposing to ocular infection in 56 to 68%
0.021, 0.384). We also found a moderate correlation be- of cases [4]. Another study conducted by Wu and col-
tween presenting visual acuity and final visual acuity leagues revealed the identification of preexisting predis-
(Pearson r = 0.564, p < 0.001 (Fig. 4). posing condition in 90.9% of patients, and the most
Gender, age group, presence of underlying medical ill- common systemic condition found was diabetes mellitus
ness, existing DM, source of infection, culture positivity, (50%) [11]. In contrast, Connell et al. reported that intra-
types of organism, intravitreal antibiotics, vitrectomy, or venous drug abuse was the most common risk factor [1].
early vitrectomy were not significantly associated with Several East Asian studies reported that diabetes melli-
good final visual outcomes. tus was the most common, and hepatobiliary disease
was the second most frequent underlying disease [5, 12–
Discussion 14]. In a review of 57 cases of endogenous endophthal-
In this study, we wanted to determine whether the clin- mitis in Korea, diabetes mellitus (46.5%) was the most
ical profiles of EE at a tertiary hospital in Malaysia were common underlying disease followed by liver cirrhosis
similar to those reported from other countries. (20.9%) [15]. In a recent study in which all patients had
Previous studies had reported a male preponderance one or more preexisting medical conditions, the most
with unilateral involvement [7–10]. In contrast, our re- common was also diabetes mellitus (61.9%) [16]. Our
sults showed no difference between male and females. series revealed similar results, in which diabetes mellitus
Predisposing conditions are important in determining was the most common systemic disease (60.0%) followed
a patient’s risk for endogenous endophthalmitis. Okada by renal failure and malignancy. However, liver diseases
et al. reported 90% of patients had a positive history of were identified only in 6 patients.
underlying medical conditions such as diabetes, cardiac In a review of cases by Wong et al., it was reported that
disease, and malignancy [2]. A major review of endogen- hepatobiliary tract infection was the most common source
ous endophthalmitis demonstrated underlying medical of bacteremia (13 patients, 48%) [5]. Similar results were
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 6 of 17

Table 3 Microbiology of causative organism in endogenous Ratra et al. in their case series demonstrated that all
endophthalmitis eyes had severe diffuse endophthalmitis involving the
Number Percent posterior pole. Diffuse vitreous exudates were seen in 47
Gram-positive bacteria 27 32.5 eyes (77%). Retina could be visualized in 13 eyes (21.3%),
Staphylococcus aureas 17 20.5 and 3 (4.9%) had retinal detachment. None had panoph-
thalmitis [8]. In another case series in 18-year review of
MRSA 3 3.6
culture-positive cases in 34 affected eyes, the most com-
Staphylococcus coagulase -ve 4 4.8
mon findings were decreased visual acuity (91.1%), vitritis
Streptococcus sp. 3 3.6 (79.4%), conjunctival injection (67.6%), iritis or retinitis
Gram-negative bacteria 42 50.6 (61.7%), hypopyon (35.2%), and retinal detachment (5.8%)
Klebsiella pneumonia 27 32.5 [18]. In our study, 27 eyes (19%) had hypopyon, 64 eyes
Pseudomonas aeruginosa 5 6.0 (44.8%) had fundus view, and 8 eyes (8.2%) were noted to
have retinal detachment on ultrasound. Lower percentage
Escherichia coli 3 3.6
of hypopyon in our patients could be due to the applica-
Acinebacter sp. 2 2.4
tion of topical steroids and antibiotics by the referring
Enterobacter intermedius 1 1.2 ophthalmologist.
Bukholderia cepacia 1 1.2 The diagnosis of endogenous endophthamitis is typic-
Bukholderia pseudomallei 1 1.2 ally made following microbiologic evidence of infection
Elizabethkingia meningosepticum 1 1.2 from intraocular samples (aqueous or vitreous). Positive
cultures from the blood, cerebrospinal fluid, or any
Mycoplasma pneumonia 1 1.2
extraocular site can be highly suggestive. In our series,
Fungal 14 16.9
the organism causing endophthalmitis was identified by
Candida albicans 5 6.0 a positive culture from at least one body fluid source in
Candida tropicalis 3 3.6 82 patients (68.9%). Blood culture positivity rate varies
Penicillium sp. 2 2.4 widely, from 33 to 94% [4, 19]. Previous large case series
Phanerochaeta chrysosporium 1 1.2 have shown higher rates of positivity following blood
cultures as compared to vitreous aspirates possibly due
Xylariaceae sp. 1 1.2
to a larger volume sampled [2, 4, 11]. In contrast, Ratra
Fungal (species not available) 2 2.4
et al. had reported that ocular fluid samples tended to
give positive culture results more than blood (58.6% vs
found in other Korean case series [12, 15, 17]. Interest- 3.4%). This is because all the patients with suspected
ingly, our case series did not show similar findings with endogenous endophthalmitis immediately underwent an
other East Asian reports. We found that urinary tract in- aqueous tap in the outpatient department before any in-
fection (21, 17.5%) was the most common source of travitreal therapy [8]. High rate of positive cultures from
bacteremia followed by pulmonary infection (19, 15.8%). intraocular specimens was also demonstrated by Okada
Hepatobiliary tract infection was only identified in 12 pa- et al. (86%), Binder et al. (70%), and Ness et al. (81%) [2,
tients (10.0%). We also found that among patients who 20, 21]. Vitrectomy has a higher diagnostic yield for cul-
were younger than 40 years old, and older than 60 years ture (92%) compared to a vitreous aspirate (44%) [22].
old, the most common systemic infection was urinary Vitreous samples during vitrectomy were taken near the
tract infection at 17.4% and 30.0% respectively. In con- retinal surface, which can potentially explain the lower
trast, lung infection (17.5%) followed by hepatobiliary in- yield of needle biopsy. This is because early or localized
fection (14.0%) was the commonest infections among infection located near the retinal surface might be
those aged from 40 to 60 years old. missed by a needle biopsy [23]. We noted low vitreous
In a case series by Lim et al., the most common present- yield of organisms in our study. This could be because
ing complaint was decreased vision (68.8%) followed by some of our patients with systemic infection were ini-
ocular discomfort (44%), red eye (20.8%), and ocular pain tially managed by physicians depending on the source of
(17.4%) [15]. Ratra et al. also reported that reduced vision infection. During the time of referral, most of them were
(60, 98.4%), redness (47, 77%), and pain (42, 68.8%) were already on systemic antibiotics or partially treated. Fur-
the three most common presenting symptoms [8]. Similar thermore, the diagnosis may have been delayed in some
to these studies, our study too revealed blurring of vision, while others were generally not stable for early vitreous
eye redness, and eye pain or discomfort as the main pre- tapping. Thirty-six patients (30.0%) in our series were
senting ocular symptoms. However in a case series by culture negative.
Nishida et al., floaters was the second most common ocu- Causative organisms vary geographically. Studies from
lar symptom after blurring of vision [16]. the western population revealed that fungal infection was
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 7 of 17

Table 4 Prognostic factors associated with good visual outcomes

Prognostic factor (referent) Crude odds ratio (95% CI) p valuea Adjusted odds ratio (95% CI) p valueb
Gender (male)
Female 2 (0.92, 4.37) 0.079
Age (0–50 years)
> 50 years 0.85 (0.39, 1.86) 0.679
Medical illness (yes)
No 1.60 (0.55, 4.63) 0.383
DM (yes)
No 2.12 (0.93, 4.85) 0.071
Presenting VA (≥ CF)
< CF 0.10 (0.04, 0.25) 0.000 0.09 (0.021, 0.384) 0.001
Fundus view (yes)
No 0.15 (0.06, 0.38) 0.000 0.337 (0.068, 1.675) 0.184
Source of infection (yes)
No 2.61 (0.93, 7.37) 0.062
Culture (positive)
Negative 1.29 (0.54, 3.07) 0.566
Organism (gram+)
Gram− 0.965 (0.275–3.386) 0.956
Fungal 0.185 (0.019, 1.848) 0.151
Intravitreal antibiotic (yes)
No 2.85 (0.62, 13.2) 0.234
Vitrectomy (yes)
No 1.13 (0.53–2.41) 0.751
Early vitrectomy (≤ 2 weeks)
> 2 weeks 1.69 (0.59–4.82) 0.327
The clinical summary of patients were summarized in Table 5
a
Univariate logistic regression
b
Only factors associated with good visual outcome in multivariate logistic regression model

the main source in predisposed states, such as intravenous (42 patients, 50.6%) in which K. pneumonia was the most
drug abusers and immunocompromised patients [1, 19, common organism isolated (27 patients, 32.5%). Interest-
21]. In contrast, gram-negative microbes as the causative ingly, in contrast to several East Asian studies, urinary
organisms were overwhelming in the East Asian experi- tract infection including renal abscess (9 patients, 33.3%)
ence. In these Asian populations, Klebsiella was found to was the most common source of infection caused by K.
be responsible for approximately 90% of all endogenous pneumonia followed by lung infection (8 patients, 29.6%)
bacteria endophthalmitis cases [5]. Studies that were con- in our series. Liver abscess was identified in 7 patients
ducted in Korea showed that liver abscess was the most (25.9%). Necrotizing fasciitis, infected wound breakdown,
common infection source and Klebsiella was the most and acute gastroenteritis (AGE) were noted in one patient
common causative agent [15, 17]. A study from Japan in each. Apart from that, there was a relatively higher fre-
2015, however, demonstrated that gram-positive organ- quency of gram-positive cocci and fungal infection in our
isms were more common (76.2%) than gram-negative study, 32.5% and 16.9% respectively.
(19.0%), contrasted to the findings from other East Asian Most systemically administered antimicrobials that have
studies [16]. K. pneumonia which is predominant in East been used in the therapy of endophthalmitis do not pene-
Asia may be due to the high incidence of cholangiohepati- trate well into the non-inflamed vitreous humor. However,
tis. Therefore, the East Asian population is more prone to the penetration of several antibiotics into the eye may be
have liver abscess than Caucasians [24]. We found that increased by inflammation which occurs following sur-
gram-negative organisms were responsible for half of the gery, trauma, or infection. Kowalski and colleagues com-
cases of endogenous endophthalmitis in our case series pared the minimum inhibitory concentration (MIC) of
Table 5 Clinical summary of endogenous endophthalmitis in the current study
Case Age/ Systemic risk factors Initial Culture Organism Source of Systemic antibiotics/antifungal IVT abk/ Vitrectomy Final
sex/eye VA infection antifungal VA
Blood Other body Vitreous
fluids
1 49/M/R – CF + + Sputum − Acinetobacter sp. Skin Ciprofloxacin Yes Yes 6/18
infection
2 76/F/R – PL − + Skin − Candida albicans Skin Fluconazole Yes Yes NPL
infection
3 49/M/L DM 4/60 − + Skin − Staphylococcus Skin Unasyn Yes No 6/36
aureus infection
4 46/F/L – NAV − + Sputum − Acinetobacter sp. Lung Ceftriaxone, sulperazone Yes No NAV
infection
5 39/F/L Leukemia 6/36 − − − – – Amphotericin, fluconazole Yes yes 6/9
6 71/M/L – CF + − − Klebsiella UTI Cefuroxime Yes No 6/24
pneumonia
7 56/F/R DM NPL − − − – Lung Ciprofloxacin Yes No NPL
infection
8 56/M/L Leukemia 6/60 + − − Enterobacter – Vancomycin, moxifloxacin Yes No HM
intermedius
9 26/M/R – 6/36 + − Not Staphylococcus IE Cloxacillin, gentamicin No No 6/36
done aureus
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14

10 26/M/L – 6/9 + − Not Staphylococcus IE Cloxacillin, gentamicin No No 6/6

done aureus
11 61/M/R DM CF + + Urine − Candida albicans UTI Fluconazole, voriconazole Yes Yes 6/9
12 61/M/L DM 6/36 + + Urine − Candida albicans UTI Fluconazole, voriconazole Yes Yes 6/9
13 60/M/R DM PL − + Liver, + − Klebsiella HPB Ciprofloxacin, cefuroxime, Yes Yes PL
sputum pneumonia infection metronidazole
14 60/M/L DM PL − + Liver, + − Klebsiella HPB Ciprofloxacin, cefuroxime, Yes No NPL
sputum pneumonia infection metronidazole
15 49/M/R DM HM − + Urine − Staphylococcus DFU Ciprofloxacin Yes Yes CF
aureus
16 49/M/L DM HM − + Urine − Staphylococcus DFU Ciprofloxacin Yes Yes NPL
aureus
17 52/F/L DM CF − − − – – Ciprofloxacin, vancomycin Yes No CF
18 57/M/L DM, renal failure CF − + Infected + Pseudomonas DFU Ciprofloxacin, ceftazidime, Yes Yes NPL
catheter aeruginosa meropenem
19 38/F/L DM HM − − − – HPB Ciprofloxacin Yes Yes HM
infection
20 71/F/R DM CF + − − Staphylococcus Lung Cefuroxime Yes No 6/60
coagulase -ve infection
21 49/F/L Renal failure on steroid CF − − − – – Fluconazole Yes Yes 6/12
Page 8 of 17
Table 5 Clinical summary of endogenous endophthalmitis in the current study (Continued)
Case Age/ Systemic risk factors Initial Culture Organism Source of Systemic antibiotics/antifungal IVT abk/ Vitrectomy Final
sex/eye VA infection antifungal VA
Blood Other body Vitreous
fluids
22 68/M/L DM, malignancy 6/12 − + Sputum Not Pseudomonas Lung Ceftriaxone, cefuroxime No No 6/9
done aeruginosa infection
23 56/M/L DM, renal failure, hydronephrosis 4/60 + − − Staphylococcus Infected Cloxacillin Yes No 4/60
aureus catheter
24 30/F/R DM PL − + Urine + Klebsiella UTI Vancomycin, ceftazidime Yes Yes PL
pneumonia
25 65/F/R – 6/60 − − − – UTI NAV Yes Yes 6/24
26 19/F/R SLE with lupus nephritis, on steroid 6/6 + − − Staphylococcus Infected Vancomycin Yes No 6/18
aureus catheter
27 75/F/R DM 6/18 − + Sputum Not Klebsiella Lung Ciprofloxacin No No 6/24
done pneumonia infection
28 75/F/L DM CF − + Sputum − Klebsiella Lung Ciprofloxacin Yes Yes PL
pneumonia infection
29 51/F/R DM HM − + HVS − Candida albicans – Fluconazole Yes Yes 6/9
30 53/F/L – HM + − − Staphylococcus – Ciprofloxacin Yes Yes CF
aureus
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14

31 49/M/L DM HM NAV NAV − NAV HPB NAV Yes Yes CF

infection
32 19/M/R – HM − − Not – Meningitis Ciprofloxacin Yes No NAV
done
33 65/F/L CNS lymphoma CF − − − – – Ciprofloxacin Yes Yes CF
34 77/M/R – CF − − − – – Ciprofloxacin, fluconazole Yes Yes 6/36
35 27/F/R – 6/24 − − Not – Lung NAV No No 6/9
done infection
36 27/F/L – 6/24 − − Not – Lung NAV No No 6/9
done infection
37 56/F/R – 3/60 + − Not Staphylococcus UTI C-penicillin, unasyn No No 6/9
done aureus
38 62/M/R DM 6/12 + + Urine Not Streptococcus sp. UTI Piperacillin-tazobactam Yes No 6/9
done
39 62/M/L DM PL + + Urine − Streptococcus sp. UTI Piperacillin-tazobactam Yes No 6/18
40 34/M/R Renal failure HM − + Urine NAV Klebsiella UTI Sulperazone Yes No 3/60
pneumonia
41 63/M/L DM CF − + Sputum Not Klebsiella Lung Trimethoprime, No No CF
done pneumonia infection sulphamethoxazole
42 30/F/R – 6/60 − − − – Skin Cloxacillin Yes No 6/6
infection
Page 9 of 17
Table 5 Clinical summary of endogenous endophthalmitis in the current study (Continued)
Case Age/ Systemic risk factors Initial Culture Organism Source of Systemic antibiotics/antifungal IVT abk/ Vitrectomy Final
sex/eye VA infection antifungal VA
Blood Other body Vitreous
fluids
43 30/F/L – 6/24 − − Not – Skin Cloxacillin Yes No 6/6
done infection
44 61/F/R DM, sigmoid colon carcinoma CF − − − – Infected Ciprofloxacin, fluconazole Yes Yes 6/36
catheter
45 40/M/L – HM − − − – HPB Ciprofloxacin, meropenem Yes Yes NPL
infection
46 53/M/R DM HM − − − – Lung Cefoperazone Yes No 6/60
infection
47 53/M/L DM HM − − − – Lung Ceftriaxone Yes No HM
infection
48 57/M/R DM HM − − + Staphylococcus UTI Vancomycin Yes Yes HM
aureus
49 57/M/L DM 3/60 − − + Staphylococcus UTI Vancomycin Yes Yes NPL
aureus
50 70/M/R DM, hydronephrosis HM + − − Staphylococcus Infected Cloxacillin, gentamicin Yes No 6/18
aureus catheter
51 70/M/L DM, hydronephrosis HM + − − Staphylococcus Infected Cloxacillin, gentamicin Yes No CF
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14

aureus catheter
52 19/M/L Takayashu arteritis, renal failure 2/60 − − − – – Ciprofoxacin, ceftazidime Yes No 6/18
on steroid
53 56/F/R DM 6/18 + + Liver − Klebsiella HPB Cefuroxime Yes No 6/18
pneumonia infection
54 56/M/R DM HM + − − MRSA Infected Ciprofloxacin Yes No CF
catheter
55 56/M/L DM CF + − − Klebsiella Lung Ceftazidime Yes No NPL
pneumonia infection
56 57/M/R – CF − − − – – Ciprofloxacin Yes No 6/12
57 57/M/L – 6/12 − − Not – – Ciprofloxacin Yes No 6/12
done
58 38/F/L – 6/9 − + Urine − Escherichia coli UTI Ceftazidime No No 6/9
59 55/M/R DM CF − + Infected − Staphylococcus Skin Ceftriaxone Yes No CF
catheter aureus infection
60 7/M/R Leukemia 6/36 − + Infected − Fungal* Septic Itraconazole Yes Yes 6/9
catheter arthritis
61 42/F/R – CF + − − Bukholderia – Ciprofloxacin Yes No 6/24
pseudomallei
62 63/F/R DM NAV + + Urine/infected Not Klebsiella Skin Ciprofloxacin No No NPL
Page 10 of 17
Table 5 Clinical summary of endogenous endophthalmitis in the current study (Continued)
Case Age/ Systemic risk factors Initial Culture Organism Source of Systemic antibiotics/antifungal IVT abk/ Vitrectomy Final
sex/eye VA infection antifungal VA
Blood Other body Vitreous
fluids
catheter done pneumonia infection
63 71/F/L – HM − − NAV – Lung Ciprofloxacin NAV NAV NAV
infection
64 22/F/L Leukemia 6/24 + − Not Fungal* – Voriconazole No No 6/18
done
65 45/M/L DM, renal failure NPL + + Infected − Staphylococcus Infected Cloxacillin Yes No NPL
catheter aureus catheter
66 48/M/R DM CF + − − Klebsiella Lung Ceftriaxone, amoxicillin- Yes Yes 6/60
pneumonia infection clavulanic acid
67 31/M/L – CF − − − – – Ciprofloxacin Yes Yes 6/6
68 54/M/L – 6/60 + + Sputum, CSF + Klebsiella Lung Ceftriaxone, imipenem Yes No NPL
pneumonia infection
69 55/M/R DM, renal failure HM + + Infected − Staphylococcus Skin Ciprofloxacin Yes Yes 6/60
catheter aureus infection
70 55/M/L DM, renal failure HM + + Infected − Staphylococcus Skin Ciprofloxacin Yes Yes 6/36
catheter aureus infection
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14

71 14/F/L – 6/36 − − Not – – Ceftazidime, trimethoprime, No No 6/18

done sulphamethoxazole
72 42/F/L – 6/60 − − − – HPB Ciprofloxacin, Ceftazidime Yes Yes CF
infection
73 30/F/R – 6/12 − + HVS − Steroptococcus sp. Genital c-penicillin Yes No 6/12
infection
74 67/F/L DM HM − − − – Lung Ceftazidime Yes No NAV
infection
75 65/M/L – CF − + Liver − Klebsiella HPB Ciprofloxacin, imipenem Yes Yes CF
pneumonia infection
76 34/F/R Leukemia PL + − − Candida tropicalis – Voriconazole Yes No NPL
77 34/F/L Leukemia CF + − − Candida tropicalis – Voriconazole Yes Yes 6/60
78 58/M/R DM, renal failure NPL + + Urine + Pseudomonas UTI Ciprofloxacin, metronidazole No No NPL
aeruginosa
79 55/F/R DM 6/60 + − + Bukholderia cepacia Meningitis Ceftazidime Yes No 6/36
80 25/M/L – PL + − + Steroptococcus sp. – Cloxacillin Yes Yes NPL
81 48/F/L – 6/60 − − − – – Ceftazidime Yes No 6/18
82 52/F/L DM CF + + Urine − Pseudomonas UTI Ciprofloxacin Yes Yes CF
aeruginosa
83 55/F/L DM HM + − − Klebsiella Lung Amoxicillin-clavulanic acid, Yes Yes CF
Page 11 of 17
Table 5 Clinical summary of endogenous endophthalmitis in the current study (Continued)
Case Age/ Systemic risk factors Initial Culture Organism Source of Systemic antibiotics/antifungal IVT abk/ Vitrectomy Final
sex/eye VA infection antifungal VA
Blood Other body Vitreous
fluids
pneumonia infection azithromycin
84 74/M/L DM, renal carcinoma CF − − − – Skin Ciprofloxacin, fluconazole Yes Yes 6/24
infection
85 37/F/R DM HM + − − – Lung Ciprofloxacin Yes Yes 5/60
infection
86 66/F/R DM PL − + Infected + Klebsiella Skin Ciprofloxacin Yes Yes CF
catheter pneumonia infection
87 66/F/L DM PL − + Infected + Klebsiella Skin Ciprofloxacin Yes No CF
catheter pneumonia infection
88 50/F/R DM HM + − − Staphylococcus UTI Ciprofloxacin Yes No 6/9
coagulase -ve
89 65/M/R DM, alcoholic liver disease CF − + Urine − Candida albicans HPB Fluconazole Yes Yes CF
infection
90 65/M/L DM, alcoholic liver disease CF − + Urine − Candida albicans HPB Fluconazole Yes Yes 3/60
infection
91 49/F/L DM 6/9 − − − – Skin Ciprofloxacin, fluconazole Yes Yes HM
infection
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14

92 41/F/R Leukemia 6/7.5 + − Not Candida tropicalis – Voriconazole Yes No 6/9

done
93 41/F/L Leukemia 6/60 + − − Candida tropicalis – Voriconazole Yes No 6/18
94 58/M/R DM, liver disease 6/36 − − − – – Ceftazidime Yes No 6/9
95 55/F/R Auto-immune hepatitis on steroid and CF − − − – – Ciprofloxacin Yes No 6/12
immunosuppressant
96 81/M/R – HM − − − – – Ciprofloxacin Yes Yes 6/12
97 32/F/R Leukemia 6/24 − − + Xylariaceae sp. – Voriconazole Yes Yes CF
98 32/F/L Leukemia 6/12 − − − – – Voriconazole Yes Yes 6/12
99 63/F/R – HM − − + Staphylococcus Skin Ciprofloxacin Yes Yes 6/9
coagulase -ve infection
100 54/M/L DM, renal failure PL + + Infected + Staphylococcus Infected Ciprofloxacin, amoxicillin- Yes No NPL
catheter aureus catheter clavulanic acid
101 46/F/R DM HM − − + Penicillium sp. – Amphotericin, fluconazole Yes Yes CF
102 64/M/L DM, rectal carcinoma PL − − − – – Ciprofloxacin Yes Yes HM
103 66/M/L DM 6/24 + − + Mycoplasma Lung Ciprofloxacin, azithromycin Yes Yes 6/9
pneumonia infection
104 59/F/L DM, renal failure HM − − − – – Ciprofloxacin Yes Yes CF
105 70/M/R DM PL + Penicillium sp. Itraconazole Yes Yes 6/36
Page 12 of 17

− − –
Table 5 Clinical summary of endogenous endophthalmitis in the current study (Continued)
Case Age/ Systemic risk factors Initial Culture Organism Source of Systemic antibiotics/antifungal IVT abk/ Vitrectomy Final
sex/eye VA infection antifungal VA
Blood Other body Vitreous
fluids
106 41/F/R DM HM − − − – Lung Ciprofloxacin Yes Yes PL
infection
107 67/M/L DM 6/9 + + Urine + Escherichia coli UTI Ciprofloxacin Yes Yes CF
108 63/M/R – 1/60 + + Infected + MRSA Skin Vancomycin, ciprofloxacin Yes Yes 6/9
catheter infection
109 63/M/L – 6/24 + + Infected Not MRSA Skin Vancomycin, ciprofloxacin No No 6/12
catheter done infection
110 52/M/L DM, renal failure HM − − + Phanerochaete Skin Voriconazole Yes No CF
chrysosporium infection
111 45/M/R DM, renal failure PL + − − Staphylococcus Infected Cloxacillin Yes Yes NPL
aureus catheter
112 47/M/R Alcoholic liver disease on steroid 6/12 + − Not Staphylococcus Skin Cloxacillin No No 6/9
done aureus infection
113 47/M/L Alcoholic liver disease on steroid 6/12 + − Not Staphylococcus Skin Cloxacillin No No 6/9
done aureus infection
114 58/M/L DM PL + + Infected + MRSA Genital Ciprofloxacin Yes Yes HM
catheter infection
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14

115 67/F/R – 6/36 − + Urine + Klebsiella UTI Cefuroxime Yes Yes CF

pneumonia
116 48/M/L DM HM − − Not – Skin Ciprofloxacin Yes Yes 6/18
done infection
117 78/F/L – CF − − + Staphylococcus – Ciprofloxacin, ceftazidime Yes Yes 3/60
coagulase -ve
118 61/F/L DM PL − + Urine − Klebsiella UTI Ciprofloxacin, meropenem Yes Yes CF
pneumonia
119 55/F/L DM 3/60 + + Sputum − Klebsiella Lung Ceftazidime Yes Yes 6/12
pneumonia infection
120 55/M/L – PL + − + Klebsiella HPB Ceftriaxone, ciprofloxacin, Yes No NPL
pneumonia infection metronidazole
121 60/M/R DM PL + + Infected + Staphylococcus Skin Cloxacillin, ceftazidime Yes No HM
catheter aureus infection
122 60/M/L DM PL + + Infected + Staphylococcus Skin Cloxacillin, ceftazidime Yes Yes HM
catheter aureus infection
123 40/F/R DM/liver cirrhosis, myelodysplastic 6/18 + + Infected − Klebsiella Lung Cefuroxime, piperacillin- Yes Yes CF
syndrome catheter pneumonia infection tazobactam
124 32/F/L DM 6/60 + − − Klebsiella UTI Cefuroxime Yes No 6/12
pneumonia
Page 13 of 17
Table 5 Clinical summary of endogenous endophthalmitis in the current study (Continued)
Case Age/ Systemic risk factors Initial Culture Organism Source of Systemic antibiotics/antifungal IVT abk/ Vitrectomy Final
sex/eye VA infection antifungal VA
Blood Other body Vitreous
fluids
125 34/F/L DM HM − + Urine + Candida albicans – Amphoterin Yes Yes 6/18
126 57/F/R DM PL + − − Klebsiella AGE Ciprofloxacin Yes Yes NAV
pneumonia
127 48/M/R DM PL − − − – DFU Ciprofloxacin, Ceftazidime Yes No NPL
128 65/F/R DM 1/60 − + Urine − Klebsiella UTI Ciprofloxacin Yes No 6/60
pneumonia
129 65/F/R DM, renal failure HM − − − – – Ciprofloxacin Yes Yes CF
130 72/F/L DM HM − + Urine − Escherichia coli UTI Ciprofloxacin, trimethoprime, Yes No NPL
sulphamethoxazole
131 55/F/R DM HM + − − Klebsiella HPB Ceftriaxone Yes Yes HM
pneumonia infection
132 67/M/R Adenocarcinoma of lung and colon HM − − − – Infected Fluconazole, voriconazole Yes Yes NPL
catheter
133 68/F/L DM, renal failure CF + − − Elizabethkingia Infected Ceftazidime, cefazolin, Yes No CF
meningocepticum catheter vancomycin
134 68/F/R DM, renal failure 6/24 + − − Elizabethkingia Infected Ceftazidime, cefazolin, Yes No 6/12
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14

meningocepticum catheter vancomycin

135 61/F/L DM, renal failure HM + − − Staphylococcus Infected Cloxacillin Yes No 6/36
aureus catheter
136 44/M/L DM PL + + Liver + Klebsiella HPB Ceftazidime, imipenem Yes No NPL
pneumonia infection
137 65/M/L DM, chronic cystitis CF − + Urine − Klebsiella UTI Ciprofloxacin Yes Yes CF
pneumonia
138 59/F/L DM, renal Failure HM − − − – Skin Ciprofloxacin Yes Yes 6/18
infection
139 67/F/L Hepatolithiasis PL + + Liver − Klebsiella HPB Ciprofloxacin, imipenem Yes No NPL
pneumonia infection
140 76/M/R DM CF − + Urine − Candida albicans UTI Fluconazole Yes Yes 6/9
141 76/M/L DM CF − + Urine − Candida albicans UTI Fluconazole Yes Yes 6/24
142 38/F/R – HM − − + Pseudomonas – Ceftriaxone, ciprofloxacin, Yes Yes HM
aeruginosa metronidazole
143 69/M/L DM HM + + Urine + Klebsiella UTI Cefepime, amoxicillin-clavulanic Yes Yes 1/60
pneumonia acid
Abbreviation: IVT intravitreal, abk antibiotic, DM diabetes mellitus, NAV not available, UTI urinary tract infection, IE infective endocarditis, HPB hepatobiliary, DFU diabetic foot ulcer, AGE acute gastroenteritis, MRSA
methicillin-resistant Staphylococcus aureus, CF counting finger, HM hand movement, PL perception of light, NPL non-perception of light
Page 14 of 17
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 15 of 17

Fig. 4 Correlation between presenting visual acuity (LogMAR) and final visual acuity (LogMAR)

bacterial isolates from 66 patients with endophthalmitis virulent organisms was associated with good overall out-
and found that all of the gram-negative isolates would come [14, 17]. In our case series, 73 eyes (51.4%) under-
have been inhibited by levels of ciprofloxacin achievable went vitrectomy. Vitrectomy was performed within
following systemic administration [25]. 2 weeks in 38 eyes (52.1%) and more than 2 weeks in 35
In endogenous endophthalmitis, the rationale for use eyes (47.9%). The most common indication for early
of intravitreal injections as an adjunct to intravenous vitrectomy was poor presenting visual acuity of CF or
therapy is also because of reduced permeability of the worse in 31 cases (81.6%). Persistent or increased vitre-
retinal-pigmented epithelium to systemically adminis- ous opacities or anterior chamber cells despite systemic
tered drugs [26]. Yonekawa et al. showed that early and intravitreal antibiotics were other indications for
administration, e.g., within 24 h, was associated with a early vitrectomy. There was no significant difference
favorable visual outcome [27]. Most of our patients between early vitrectomy (within 2 weeks) compared to
received intravitreal injections within 24 h of diagnosis. delayed vitrectomy (more than 2 weeks) for favorable
Vitrectomy serves as a diagnostic and therapeutic visual prognosis (p = 0.327).
option. It is indicated in cases with severe vitreous opac- Generally, the visual outcome of endogenous endoph-
ities, diffuse retinal infiltration, and poor presenting thalmitis is poor due to early and extensive retinal
visual acuity and when there is no clinical improvement involvement. Virulent causative organisms, poor host
with systemic and intravitreal therapy. However, the role defense, misdiagnosis leading to delayed treatment, inad-
and timing of vitrectomy remain unclear in patients with equate treatment, inappropriate therapy, and occurrence
endogenous endophthalmitis. Sheu et al. reported no of complications such as panophthalmitis are associated
significant relationship between vitrectomy and visual with poor prognosis. Wu et al. reported that the eyes
outcome in Klebsiella endophthalmitis. However, they with bacterial endogenous endophthalmitis had a worse
suggested early vitrectomy should be considered in outcome compared to patients with fungal endophthal-
patients whose anterior chamber inflammation did not mitis [11]. Lim et al. concluded that gram-negative bac-
respond well to intravitreal antibiotics [28]. On the other teria had worse visual outcomes compared to gram-
hand, Yoon et al. demonstrated that following early positive bacteria or fungus [15].
vitrectomy for Klebsiella endogenous endophthalmitis, Visual outcomes in Klebsiella endophthalmitis has
50% achieved a vision of CF or better after 6 months been poor despite treatment with a combination of sys-
[14]. Early vitrectomy performed within 10 days of the temic and intravitreal antibiotics [12, 13]. Case series
appearance of ocular symptoms or signs resulted in a and literature reviews involving infection with K. pneu-
better visual prognosis (CF or better) than without monia showed that visual acuity achieved was CF or bet-
vitrectomy [17]. In other studies, early vitrectomy within ter in 34.0% of eyes, and 16.0% had evisceration or
2 weeks of presentation in severe cases or suspected enucleation [5]. Sheu et al. reported 19 eyes (35.8%) had
Muda et al. Journal of Ophthalmic Inflammation and Infection (2018) 8:14 Page 16 of 17

final visual acuity of CF or better [28]. Connell et al. Ethics approval and consent to participate
found that all the patients in their study needing enucle- Ethics approval was obtained by the Medical Research and Ethics Committee
(MREC) prior to the initiation of the study.
ation were infected by Klebsiella [1]. In our series, 100
eyes (73.0%) achieved final visual acuity of CF or better. Consent for publication
However, in cases with Klebsiella endogenous endoph- Not applicable.
thalmitis, only 18 eyes (25.4%) achieved final visual acu-
Competing interests
ity of CF or better, which is comparable with other The authors declare that they have no competing interests.
studies. Ten eyes were complicated with panophthalmi-
tis, and 5 of them were due to Klebsiella pneumonia.
Publisher’s Note
In our series, a good presenting visual acuity was the Springer Nature remains neutral with regard to jurisdictional claims in
only prognostic factor associated with good visual out- published maps and institutional affiliations.
comes of CF or better. Lim et al., Nishida et al., and
Author details
Binder et al. in their case series also described that a good 1
Department of Opthalmology, Hospital Sultanah Nur Zahirah, Kuala
presenting visual acuity was significantly associated with Terengganu, Terengganu, Malaysia. 2Department of Opthalmology, Hospital
good final visual acuity [15, 16, 20]. We found that DM, Sungai Buloh, Sungai Buloh, Malaysia. 3Department of Opthalmology,
Hospital Selayang, Batu Caves, Malaysia. 4Department of Opthalmology,
presence of a source of infection, organism, and intravit- Hospital Kuala Lumpur, Kuala Lumpur, Malaysia. 5Department of
real antibiotics were not related to poor visual outcome. Opthalmology, Hospital Shah Alam, Shah Alam, Malaysia.

Received: 5 July 2018 Accepted: 27 September 2018

Study limitation
This study is limited by the retrospective design. As the
data was collected retrospectively, some of the informa- References
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