**5. Endophthalmitis**

Acanthamoeba infection may vary in presentation. The earliest clinical signs include multiple corneal epithelial cell swellings (as seen in adenoviral keratoconjunctivitis but here they are unilateral) and/or corneal edema. Late signs include perineural sheathing and stromal ring(s) (**Figure 10**). Acanthamoeba cysts may be identified by confocal microscopy. A history of contact lens wear and/or bathing in pools or sea is common and symptoms of pain are more striking than the clinical appearance. When diagnosis by cultures is impossible especially in recurrent

disease, polymerase chain reaction of the involved tissue may establish the diagnosis.

Corneal co‐infections as other co‐infections or mixed infections should be suspected when the course of the disease is atypical or when the condition deteriorates despite of treatment according to cultures and sensitivities. In such cases, repeated cultures should be obtained and

All corneal infections may result in either scarring (**Figure 10**) or melting and perforation.

**Figure 9.** Fungal keratitis with multiple foci and indistinct borders.

10 Advances in Common Eye Infections

**Figure 10.** Immune ring in Acanthamoeba keratitis.

broaden accordingly.

The hallmarks of endophthalmitis are flare and white cells both in the vitreous and the anterior chamber [11]. Additional findings may include fibrin in the anterior chamber, hypopyon and retinal periphlebitis. The vision is decreased and ocular pain is noted.

Endophthalmitis is divided to two categories: exogenous (postoperative, bleb‐associated and traumatic) and endogenous (source within another organ). Postoperative endophthalmitis may occur following any intraocular surgery including cataract, penetrating keratoplasty, glaucoma, vitrectomy and intraocular injections. Rarely, it may develop by spreading of keratitis or scleritis. In bleb‐associated endophthalmitis, the bleb is pale and necrotic. Endoph‐ thalmitis should be suspected in any eye after penetrating keratoplasty if epithelial defect or ulcer is present near the corneal‐graft interface even if there is corneal edema or signs sug‐ gesting corneal graft rejection (presence of flare and cells in the anterior chamber).

Prevention of endophthalmitis before any ocular surgery is by preparation with povidone iodide 5% that includes washing of the ocular periocular and surface. Prevention following penetrating ocular trauma injury is by intravenous broad‐spectrum antibiotics (e.g. ciproflox‐ acin 400 mg bid) for 3 days. The data about treatment of endophthalmitis are based mainly on postoperative (cataract extraction) endophthalmitis. When endophthalmitis is suspected, vitreous samples for smears, cultures and sensitivity should be obtained before commencing antibiotic treatment. Treatment includes intravenous broad‐spectrum antibiotics such as vancomycin 1 gr bid and ceftazidime 1 gr tid or moxifloxacin 400 mg/day IV as well as periocular injections and topical. Topical and/or systemic corticosteroids may be added only after the regression of the endophthalmitis.
