今日の臨床サポート

感染性眼内炎

著者: 薄井紀夫 総合新川橋病院 眼科

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2021/12/08
参考ガイドライン:
改訂のポイント:
  1. 日本眼炎症学会ぶどう膜炎診療ガイドライン、日本眼科学会雑誌 123巻6号、p.635-696、2019年
患者向け説明資料

概要・推奨   

  1. 感染性眼内炎とは病原微生物の眼内感染により生じる虹彩毛様体炎、網脈絡膜炎の総称である。
  1. 感染性眼内炎の治療は、網膜のダメージを最小限に抑えることが目的である。
  1. 急性術後細菌性眼内炎に対しては、早期に硝子体手術および強力な抗炎症療法(ステロイド薬の全身・局所投与)を行う。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
薄井紀夫 : 特に申告事項無し[2022年]
監修:沖波聡 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、術後細菌性眼内炎の治療法ならびに急性網膜壊死の診断基準などについて加筆・修正した他、全体的にアップデートを行った。

病態・疫学・診察

疾患情報  
  1. 感染性眼内炎とは病原微生物の眼内感染により生じる虹彩毛様体炎、網脈絡膜炎の総称である。
  1. 発症に至る特有の背景や病原微生物による特徴的な所見、さらに臨床経過を見極めて診断する。
  1. 急性期に適切な治療が行われなければ病原微生物の侵襲および炎症の劇症化や遷延化により重篤化しやすい。感染性眼内炎とは病原微生物の眼内感染により生じる虹彩毛様体炎、網脈絡膜炎の総称である。
  1. 感染性眼内炎の種類は多岐にわたるが、病原微生物に関しては、細菌性、真菌性、ウイルス性、寄生虫性に大別される。
  1. 発症に至る特有の背景や病原微生物による特徴的な所見、さらに経過を見極めて診断する。
  1. 基本的な初期病態は、①病原微生物による眼組織への侵襲、②病原微生物に対する炎症反応、で形成される。したがって、初期治療に関しては常に①②を正しく認識して対処しなければならない。感染症の治療に重要なのは、常に感染と炎症のマネージメントである。
  1. 初期病態に続き、さまざまな組織障害の結果として二次的な合併症(例:続発緑内障、網膜剝離など)を生じることがある。その際には、機を逸せず手術などの対応が必要である。
  1. 細菌:白内障手術を代表とする内眼手術や抗VEGF薬の硝子体注射の際に眼内に持ち込まれた細菌によって引き起こされる細菌性眼内炎、免疫不全を背景に肝膿瘍などの化膿巣から血行性に感染を起こす内因性(転移性)眼内炎、穿孔性眼外傷による外傷性眼内炎、その他、全身感染症に合併する梅毒や結核による眼内炎が代表である。
  1. 真菌:中心静脈栄養(IVH)などの血管内留置針や尿管カテーテルなど体内留置物の使用歴のある患者では真菌血症から真菌性眼内炎を生じることがある。
  1. ウイルス:単純ヘルペスウイルス、水痘帯状疱疹ウイルス、サイトメガロウイルスなどヘルペス属ウイルスの眼内再活性化によって眼内炎が引き起こされる。また、ヒトT細胞白血病ウイルス1型(human T-cell leukemia virus type 1、HTLV-1)感染者にぶどう膜炎を発症する例がある。
  1. 寄生虫:トキソプラズマ原虫やイヌ蛔虫、ネコ蛔虫も眼内炎の原因となる。

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文献 

Abstract/Text OBJECTIVE: To determine the roles of immediate pars plana vitrectomy (VIT) and systemic antibiotic treatment in the management of postoperative endophthalmitis.
DESIGN: Investigator-initiated, multicenter, randomized clinical trial.
SETTING: Private and university-based retina-vitreous practices.
PATIENTS: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation.
INTERVENTIONS: Random assignment according to a 2 x 2 factorial design to treatment with VIT or vitreous tap or biopsy (TAP) and to treatment with or without systemic antibiotics (ceftazidime and amikacin).
MAIN OUTCOME MEASURES: A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically.
RESULTS: There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed. However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP. In this group of patients, the difference between VIT and TAP was statistically significant (P < .001, log rank test for cumulative visual acuity scores) over the entire range of vision.
CONCLUSIONS: Omission of systemic antibiotic treatment can reduce toxic effects, costs, and length of hospital stay. Routine immediate VIT is not necessary in patients with better than light perception vision at presentation but is of substantial benefit for those who have light perception-only vision.

PMID 7487614
Yusuke Oshima, Kazuaki Kadonosono, Hidetaka Yamaji, Makoto Inoue, Munenori Yoshida, Hideya Kimura, Masahito Ohji, Fumio Shiraga, Toshimitsu Hamasaki, Japan Microincision Vitrectomy Surgery Study Group
Multicenter survey with a systematic overview of acute-onset endophthalmitis after transconjunctival microincision vitrectomy surgery.
Am J Ophthalmol. 2010 Nov;150(5):716-725.e1. doi: 10.1016/j.ajo.2010.06.002. Epub 2010 Aug 16.
Abstract/Text PURPOSE: To explore the incidence and visual outcomes of acute-onset endophthalmitis after transconjunctival microincision vitrectomy surgery (MIVS).
DESIGN: Retrospective, interventional, multicenter survey with a systematic review.
METHODS: A clinical database search was performed at 27 institutions involving 43 868 consecutive patients who underwent vitrectomy between November 2003 and October 2008 to identify all patients with endophthalmitis after vitrectomy. A systematic review of studies reporting the endophthalmitis rates after MIVS versus 20-gauge vitrectomy was conducted to assess the pooled incidence rates of postvitrectomy endophthalmitis.
RESULTS: The endophthalmitis rates from the multicenter survey were 0.034% (10 cases per 29 030 eyes) after 20-gauge vitrectomy and 0.054% (8 cases per 14 838 eyes) after MIVS, with no significant (P = .603) differences between groups. Although the incidence in 25-gauge cases (6 per 8238 eyes; 0.073%) was greater than in 23-gauge cases (2 per 6600 eyes; 0.030%), the difference was not significant (P = 0.451). Of 8 eyes in which endophthalmitis developed after MIVS, 6 eyes (75%) had a final visual acuity of 0.5 or better, and none lost light perception. By combining the results of 7 studies, including the current multicenter survey, meta-analyses from a total of 77 956 cases at the baseline showed that the pooled endophthalmitis rates after MIVS (0.08%; 95% confidence interval, 0.030% to 0.164%) and after 20-gauge vitrectomy (0.030%; 95% confidence interval, 0.012% to 0.048%) did not differ significantly (P = .207, pooled risk difference; 0.0005 [95% confidence interval, -0.0002 to 0.0012]).
CONCLUSIONS: The incidence of postvitrectomy endophthalmitis was low with no significant differences between MIVS and 20-gauge vitrectomy.

Copyright © 2010 Elsevier Inc. All rights reserved.
PMID 20719299
David J Jacobs, Theodore Leng, Harry W Flynn, Wei Shi, Darlene Miller, Steven J Gedde
Delayed-onset bleb-associated endophthalmitis: presentation and outcome by culture result.
Clin Ophthalmol. 2011;5:739-44. doi: 10.2147/OPTH.S17975. Epub 2011 Jun 2.
Abstract/Text PURPOSE: To determine how culture results are associated with clinical presentations and outcomes in delayed-onset bleb-associated endophthalmitis (BAE).
METHODS: Retrospective consecutive case series of BAE at Bascom Palmer Eye Institute between January 1, 1996 and December 31, 2009. All patients had prior glaucoma filtering surgery. BAE was defined as intraocular infection with vitreous involvement receiving treatment with intravitreal antibiotics. Visual acuity (VA) outcomes and other clinical data were grouped by culture result and compared using the 2-sided Student's t-test.
MAIN OUTCOME MEASURE: Mean logMAR change at 3 months after treatment (3-month logMARΔ).
RESULTS: Eighty-six eyes of 85 patients were identified. Two eyes were primarily eviscerated. Fifty-three (63%) eyes were culture-positive with the following organisms: Streptococcus, 21 (25%); coagulase-negative Staphylococcus, 9 (11%); Enterococcus, 6 (7%); Gram-negative, 15 (18%); Moraxella, 8 (10%); Pseudomonas, 3 (4%); and Serratia, 3 (4%). Presenting logMAR VA: culture-positive worse than culture-negative cases (2.45 vs 2.19, P = 0.05). Presenting intraocular pressure (IOP): culture-positive higher than culture-negative cases (24 mmHg vs 14 mmHg, P = 0.002). Poor presenting view of the fundus: Streptococcus worse than coagulase-negative Staphylococcus cases (90% vs 44%, P = 0.006), Pseudomonas and Serratia worse than Moraxella cases (100% vs 50%, P = 0.04). Three month logMARΔ: culture-positive worse than culture-negative cases (1.03 vs 0.43, P = 0.02), Streptococcus worse than coagulase-negative Staphylococcus cases (1.44 vs 0.31, P = 0.004), Pseudomonas and Serratia worse than coagulase-negative Staphylococcus cases (2.41 vs 0.31, P = 0.001), Pseudomonas and Serratia worse than Moraxella cases (2.41 vs 0.04, P = 0.001). A culture result of Streptococcus or Serratia was present in 6 of 7 eyes that received an additional treatment of enucleation or evisceration (P = 0.01).
CONCLUSION: Culture-positive cases were associated with worse presenting VA, higher presenting IOP, and worse VA outcomes than culture-negative cases. Streptococcus, Pseudomonas, and Serratia cases were associated with poor presenting view of the fundus and worse VA outcomes than coagulase-negative Staphylococcus and Moraxella cases.

PMID 21691583
Andre J Witkin, David F Chang, J Michael Jumper, Steve Charles, Dean Eliott, Richard S Hoffman, Nick Mamalis, Kevin M Miller, Charles C Wykoff
Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes.
Ophthalmology. 2017 May;124(5):583-595. doi: 10.1016/j.ophtha.2016.11.042. Epub 2017 Jan 19.
Abstract/Text PURPOSE: To expand understanding of presentation, diagnosis, and outcomes of hemorrhagic occlusive retinal vasculitis (HORV).
DESIGN: Retrospective case series.
PARTICIPANTS: Thirty-six eyes of 23 patients.
METHODS: The American Society of Cataract and Refractive Surgery (ASCRS) and the American Society of Retina Specialists (ASRS) formed a joint task force to define clinical characteristics of HORV and to study its prevalence, cause, treatment, and outcomes. An online registry was established on both societies' web sites. Surveys were e-mailed to members of both societies soliciting cases of suspected HORV. A literature search was performed to uncover additional cases.
MAIN OUTCOME MEASURES: Historical data including intraoperative characteristics, images, treatment regimens, and visual and anatomic outcomes.
RESULTS: Characteristic findings of HORV included unremarkable postoperative day 1 undilated examination, delayed-onset painless vision loss, mild anterior chamber and vitreous inflammation, sectoral retinal hemorrhages in areas of ischemia, and predilection for venules and peripheral involvement. Based on predetermined diagnostic criteria, 36 eyes of 23 patients were diagnosed with HORV. All eyes received intraocular vancomycin via intracameral bolus (33/36), via intravitreal injection (1/36), or through the irrigation bottle (2/36). Patients sought treatment with HORV 1 to 21 days after surgery or intravitreal injection. Visual results usually were poor: 22 of 36 eyes (61%) had 20/200 or worse visual acuity and 8 of 36 eyes (22%) had no light perception (NLP). Neovascular glaucoma developed in 20 of 36 eyes (56%). Seven eyes received additional intravitreal vancomycin after surgery; 5 of these 7 eyes had NLP visual acuity at the most recent examination. Three eyes received intravitreal corticosteroids and had final visual acuities of 20/40, 20/70, and hand movements.
CONCLUSIONS: Hemorrhagic occlusive retinal vasculitis is a rare, potentially devastating condition that can develop after cataract surgery or intraocular injection. All cases in this series were associated with intraocular vancomycin. Disease course and findings suggest that HORV is caused by a delayed hypersensitivity reaction to vancomycin. Early treatment with corticosteroids likely is beneficial. Subsequently, anti-vascular endothelial growth factor injections and panretinal photocoagulation are important to prevent neovascular glaucoma, a common complication. Avoidance of additional intravitreal vancomycin is recommended if HORV is suspected.

Published by Elsevier Inc.
PMID 28110950
Chao-Chien Hu, Jau-Der Ho, Horng-Yuan Lou, Joseph J Keller, Herng-Ching Lin
A one-year follow-up study on the incidence and risk of endophthalmitis after pyogenic liver abscess.
Ophthalmology. 2012 Nov;119(11):2358-63. doi: 10.1016/j.ophtha.2012.05.022. Epub 2012 Jul 18.
Abstract/Text PURPOSE: Although endophthalmitis secondary to pyogenic liver abscess (PLA) is becoming a globally emerging infectious disease, population-based investigations evaluating the relationship between PLA and endogenous endophthalmitis remain scarce. This study aimed to investigate the incidence and risk of endogenous endophthalmitis in patients with PLA compared with unaffected individuals by using a nationwide, population-based dataset.
DESIGN: Retrospective, cohort study.
PARTICIPANTS AND CONTROLS: This study used data sourced from Taiwan's National Health Insurance Research Database. In total, 12 727 patients with PLA were included in the study group and 63 635 matched subjects were randomly extracted as a comparison group.
METHODS: Stratified Cox proportional hazards regressions were performed to assess the effect of PLA on the hazard of developing endogenous endophthalmitis.
MAIN OUTCOME MEASURES: The incidence and risk of endogenous endophthalmitis between the study group and comparison group.
RESULTS: Of the total sample, 148 subjects (0.10%) were diagnosed with endophthalmitis during the 1-year follow-up period. Endophthalmitis was found in 106 patients (0.84%) with PLA and 42 comparison patients (0.07%). After adjusting for patient monthly income, geographic location, and urbanization level, those suffering from PLA were found to have a greater likelihood of developing endophthalmitis during the 1-year follow-up period than comparison patients (hazard ratio [HR], 12.83; 95% confidence interval, 8.94-18.41). Stratification did not reveal any large differences in the adjusted HRs for endophthalmitis between PLA patients suffering from diabetes and those in whom diabetes was absent. We further analyzed the etiology of cases with endogenous endophthalmitis in this investigation and found Klebsiella pneumonia to be the causative organism among 75.5% of the cases but only 33.4% of the comparison group.
CONCLUSIONS: We found that the incidence and risk of developing endophthalmitis was significantly higher among patients with PLA compared with matched controls irrespective of diabetes status.

Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
PMID 22817832
Ahila Lingappan, Charles C Wykoff, Thomas A Albini, Darlene Miller, Avinash Pathengay, Janet L Davis, Harry W Flynn
Endogenous fungal endophthalmitis: causative organisms, management strategies, and visual acuity outcomes.
Am J Ophthalmol. 2012 Jan;153(1):162-6.e1. doi: 10.1016/j.ajo.2011.06.020. Epub 2011 Sep 13.
Abstract/Text PURPOSE: To report the causative organisms, management strategies, and visual outcomes in endogenous fungal endophthalmitis.
DESIGN: Observational case series.
METHODS: Microbiologic and medical records were reviewed retrospectively for all patients with culture-positive endogenous fungal endophthalmitis between January 1, 1990, and July 1, 2009.
RESULTS: Study criteria were met in 65 eyes of 51 patients with mean follow-up of 18 months. Yeasts were the most common causative organism in 38 (75%) patients compared with molds in 13 (25%) patients. Retinal detachment occurred in 17 eyes (26%). Visual acuity of 20/200 or better was present in 28 (56%) eyes with yeasts and in 5 (33%) eyes with molds at the last follow-up.
CONCLUSIONS: Yeasts were the most common cause of culture-proven unilateral or bilateral endogenous fungal endophthalmitis. Endogenous fungal endophthalmitis generally is associated with poor visual acuity outcomes, especially when caused by molds. Retinal detachment is a frequent occurrence during follow-up.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 21917234

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