Endogenous endophthalmitis associated with pyogenic hepatic abscess.

BACKGROUND: Endogenous endophthalmitis has been associated with pyogenic hepatic abscess in several recent anecdotal reports. The purpose of this study was to determine the incidence of endophthalmitis associated with pyogenic hepatic abscess, identify the degree of association with Klebsiella pneumoniae as a causative organism, and determine the outcome of treatment. STUDY
DESIGN: A retrospective study was performed of 352 consecutive patients with a clinical diagnosis of pyogenic hepatic abscess who had been admitted to Chang Gung Memorial Hospital in Kaohsiung between 1986 and 1993. Findings from complete ophthalmologic evaluations and treatment results were recorded.
RESULTS: Eleven patients (3.1 percent) with endogenous endophthalmitis (monocular in eight and binocular in three) were found among the 352 cases of pyogenic hepatic abscess. Seven of the patients had diabetes mellitus and their blood glucose was poorly controlled. Only one patient had an intrahepatic stone as the cause of hepatic abscess, the other abscesses were of cryptogenic origin. The causative organism was mainly K. pneumoniae and the diagnosis was made by blood culture in ten patients, hepatic aspirate culture in seven, and vitreous contents culture in three. Systemic antibiotics were given in all patients with endogenous endophthalmitis. Percutaneous catheter drainage for hepatic abscess under echo guidance was performed in seven patients, medical treatment only was performed in three patients, and percutaneous tapping of abscess was done in one patient. All 11 patients were alive at the time of writing. Intravitreous culture followed by injection of antibiotics and steroids was immediately undertaken if septic endophthalmitis was suspected, except in two patients, who lost vision before any treatment was given. In five patients, cefamezin and gentamicin were given, and in four patients vancomycin, amikacin, and dexamethasone were given every three days if necessary. Finally, among the total of 14 eyes, there was blindness in ten, three of these had no light perception initially. In seven patients there had been a delay of treatment longer than one day. In one eye there was "counting fingers" vision and in three eyes there remained some vision.
CONCLUSIONS: Physicians should be alert to the development of endogenous endophthalmitis when a patient with pyogenic hepatic abscess or bacteremia complains of ocular symptoms. Prompt diagnosis and vigorous treatment with intravitreous injections of vancomycin, amikacin, and dexamethasone within 24 hours can save the patient's eyes and vision.