Post-traumatic endophthalmitis

Sir,

We read with interest the survey on post-traumatic endophthalmitis by Flynn and co-authors.¹ The authors have described the use of systemic or intravitreal antifungal agents in so-called ‘suspected fungal endophthalmitis’. Before instituting antifungal treatment, distinguishing fungal from bacterial post-traumatic endophthalmitis is important because the treatments are different and prophylactic antifungal treatment can be toxic both systemically or locally.^{2, 3, 4} A clinical feature that suggests fungal infection is a delayed onset of inflammation after injury.^{2, 3, 4} Literature search has reported that all post-traumatic cases of fungal endophthalmitis became symptomatic between the first and fifth weeks after injury, with minimal discomfort to the patient.^{3, 4} In the absence of microbiological diagnosis, clinical signs suggesting infection include slow indolent smouldering intraocular inflammation associated with a relatively quiet eye, which may or may not be associated with the presence of an inflammatory mass in the vitreous or anterior chamber that is described as a ‘fungal ball’, or white vitreous ‘snowball’, or ‘string of pearls’. More often than not, the patients with fungal endophthalmitis may have only minor discomfort.^{2, 3, 4}

Similarly, not all clinicians agree with the routine use of intravitreal antibiotics in prophylaxis.⁵ In patients with open globe injuries and traumatic endophthalmitis, there is always a risk of associated retinal detachment or choroidal detachment. Pre-operative B-scan is not routinely done in eyes with open globe injury and hence intravitreal injection can pose an additional risk of injection going inadvertently into subretinal or suprachoroidal space. On the other hand, it is important to realize that no large, randomized, prospective study has explicitly demonstrated a decrease in incidence of post-traumatic endophthalmitis with prophylactic antibiotics in eyes without IOFBs. For ruptured globes without IOFBs, until a prospective study shows a clear benefit from a prophylactic treatment protocol, one approach might be to treat all open globe injuries with systemic (oral/intravenous) and topical antibiotics for a few days. Intravitreal antibiotics prophylaxis can be used selectively in eyes with contaminated injuries, greater wound length, or delayed primary closure of the wound, and after ruling out retinal detachment or suprachoroidal haemorrhage, because such cases have an increased risk of endophthalmitis.⁶