Panophthalmitis

What panophthalmitis is

The eye has three main layers: the outer sclera and cornea, the middle uvea, and the inner retina, enclosing the vitreous gel. In endophthalmitis, infection is confined to the inside of the eye. In panophthalmitis, it spreads through all layers, including the sclera, into the surrounding orbit (Tenon's capsule and orbital tissues). The infection destroys eye tissues rapidly and can spread further to the brain.

Causes

Penetrating eye injury

Sharp objects, metal fragments from hammering or grinding, and contaminated plant material can carry bacteria into the eye. Bacillus cereus is a notorious cause after trauma, capable of destroying the eye within 24 to 48 hours. Retained foreign bodies increase the risk. See eye trauma.

After eye surgery or injections

Endophthalmitis after cataract surgery or eye injections is rare, but severe cases with virulent organisms can progress to panophthalmitis.

Corneal ulcer perforation

A severe corneal ulcer, often from contact lens misuse or fungal infection, can perforate and let germs into the eye.

Endogenous (bloodstream) infection

Bacteria or fungi carried in the blood from elsewhere in the body, such as a Klebsiella liver abscess, endocarditis, urinary infection, or contaminated injections in people who inject drugs. Risk is higher with diabetes, weakened immunity, cancer and intravenous lines. Candida is a common fungal cause.

Symptoms

• severe, deep eye pain
• rapid loss of vision, often to no light perception
• marked eyelid swelling and redness
• swollen, red conjunctiva (chemosis)
• a bulging eye (proptosis)
• painful or restricted eye movements
• pus visible in the front of the eye (hypopyon)
• fever, headache and feeling unwell

Diagnosis

Diagnosis is clinical, based on the appearance and history, confirmed by:

• examination by an ophthalmologist
• B-scan ultrasound of the eye when the view is blocked
• CT scan of the orbits and brain to assess spread, abscesses and foreign bodies
• samples of fluid from inside the eye for culture and identification of the germ
• blood cultures and a search for a source of infection in endogenous cases

Treatment

Treatment is urgent and usually in hospital:

• intravitreal antibiotics: injected directly into the eye
• intravenous antibiotics (and antifungals if needed), especially for endogenous infection and orbital spread
• vitrectomy: surgery to remove infected vitreous, in selected cases
• evisceration or enucleation: removing the contents of the eye or the whole eye is often necessary to control the infection, relieve pain and prevent spread to the brain
• treatment of the source: removal of foreign bodies, drainage of abscesses elsewhere
• tetanus vaccination after injuries

After eye removal, a prosthetic (artificial) eye can be fitted for appearance.

Complications

• permanent blindness in the affected eye
• orbital abscess
• cavernous sinus thrombosis
• meningitis and brain abscess
• sepsis
• sympathetic ophthalmia (a rare inflammatory attack on the other eye after injury)

Prevention

• wear protective eyewear when hammering, grinding, using power tools or doing yard work
• seek emergency care for any penetrating eye injury
• follow contact lens hygiene: never sleep or swim in lenses
• follow post-surgery eye drop instructions and report pain or worsening vision promptly
• control diabetes and seek treatment for systemic infections

Frequently asked questions

What is panophthalmitis?

Panophthalmitis is a severe infection involving every layer of the eye and spreading into the eye socket. It usually develops from endophthalmitis after an eye injury, surgery, a perforated corneal ulcer or a bloodstream infection, and threatens both the eye and, rarely, life.

What is the difference between endophthalmitis and panophthalmitis?

Endophthalmitis is infection inside the eye. Panophthalmitis is more extensive, involving all layers of the eye including the sclera and spreading into the orbit, causing swelling, a bulging eye and painful eye movement. It has a worse outcome.

What are the symptoms of panophthalmitis?

Symptoms include severe eye pain, rapid loss of vision, swollen eyelids, a red swollen eye surface, a bulging eye, painful or limited eye movement, pus inside the eye and often fever.

Can panophthalmitis be cured?

The infection can usually be controlled with antibiotics and surgery, but useful vision is rarely saved. Many patients need the contents of the eye or the eye removed to stop the infection and prevent spread to the brain.

How can I prevent serious eye infections after an injury?

Wear safety glasses for risky work, and seek emergency eye care immediately after any injury that may have penetrated the eye. Early removal of foreign bodies and prompt antibiotics greatly reduce the risk of severe infection.