A Brief Review of Four Types of Ocular Infection

Educational Objectives

The goal of this program is to improve management of ocular infections. After hearing and assimilating this program, the clinician will be better able to:

1. Distinguish among various types of ocular infections.

Summary

Conjunctivitis: viral infection is more common among adults, while bacterial infection is more common among children; keratoconjunctivitis is rare; hyperacute conjunctivitis — caused by gonococcal (common) and meningococcal infections; may rapidly lead to perforation; epidemic keratoconjunctivitis — caused by adenovirus; monkeypox virus — rarely associated with conjunctivitis or keratoconjunctivitis

Infectious keratitis: infection of the cornea; often painful (painless following penetrating keratoplasty); viral keratitis is caused by herpes simplex virus or varicella-zoster virus; microbial keratitis (corneal ulceration) is caused by bacteria, fungi, or parasites (acanthamoeba is most common); the most common risk factor is contact lens wear, and cases of keratitis are usually related to poor contact lens hygiene; Cope et al (2015) found that ≈99% of individuals who wear contact lenses admitted to poor contact lens hygiene maneuvers

Endophthalmitis: exogenous or endogenous bacterial or fungal infection of the vitreous and/or aqueous humor; sampling the vitreous (through in-office aspiration or through vitrectomy in the operating room) establishes the diagnosis; acute bacterial endophthalmitis presents with increasing eye pain, decreasing vision, and hypopyon; fungal endophthalmitis is often indolent; candidemia can lead to ocular candidiasis (chorioretinitis or its extension into vitritis [endophthalmitis]); though the Infectious Diseases Society of America recommends screening for ocular candidiasis in all patients with a positive blood culture, the American Academy of Ophthalmology (AAO) recommends screening only in patients with eye symptoms (however, most patients are asymptomatic at diagnosis); AAO recommends intravitreal antifungals for endophthalmitis and systemic antibiotics for chorioretinitis; azole antifungal agents have better vitreal penetration than echinocandins, and prolonged therapy is recommended for end-organ candidal infection; candidemia can be transient in the outpatient setting, with negative blood cultures; candida endophthalmitis can occur with peripherally-inserted central catheters or opiate drug injection

Infectious uveitis: anterior uveitis (AU; iritis) involves the iris; posterior uveitis (PU) includes retinitis, choroiditis, and chorioretinitis; panuveitis involves the entire uveal tract; ≈80% of uveitis cases in the United States are rheumatologic or idiopathic in origin, while ≈20% are infectious; ≈10% of AU cases are caused by infection; intermediate uveitis is noninfectious in origin; ≈50% of PU cases are caused by infection (most commonly ocular toxoplasmosis); panuveitis is typically caused by syphilis; fungal endophthalmitis can mimic uveitis

Ocular syphilis: confirm rapid plasma reagin (RPR) testing result with Treponema pallidum particle agglutination assay; negative RPR does not exclude syphilis, as RPR levels spontaneously decrease over time in patients with late neurosyphilis; late syphilis can manifest as ocular syphilis; recent guidelines from the Centers for Disease Control and Prevention do not recommend lumbar puncture prior to administration of intravenous penicillin for patients with isolated ocular symptoms, reactive syphilis serology, and confirmed ocular abnormalities on examination

Ocular tuberculosis: Donahue et al (1967) found that ≈1.5% of patients with pulmonary tuberculosis also had ocular manifestations; vitreous cultures are negative; polymerase chain reaction is not helpful; most common findings include choroiditis, AU (typically granulomatous), and retinal vasculitis

Readings

Cash-Goldwasser S, Labuda SM, McCormick DW, et al. Ocular monkeypox - United States, July-September 2022. MMWR Morb Mortal Wkly Rep. 2022;71(42):1343-1347. doi:10.15585/mmwr.mm7142e1; Cope JR, Collier SA, Rao MM, et al. Contact lens wearer demographics and risk behaviors for contact lens-related eye infections--United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(32):865-70. doi:10.15585/mmwr.mm6432a2; Donahue HC. Ophthalmologic experience in a tuberculosis sanatorium. Am J Ophthalmol. 1967;64(4):742-748. doi:10.1016/0002-9394(67)92860-7; Durand ML. Bacterial and fungal endophthalmitis. Clin Microbiol Rev. 2017;30(3):597-613. doi:10.1128/CMR.00113-16; Durand ML, Barshak MB, Sobrin L. Eye infections. N Engl J Med. 2023;389(25):2363-2375. doi:10.1056/NEJMra2216081; Durand ML, Barshak MB, Chodosh J. Infectious keratitis in 2021. JAMA. 2021;326(13):1319-1320. doi:10.1001/jama.2021.0424.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Durand has been a stockholder/shareholder of Pfizer. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Durand was recorded at the 49th Annual Remington Winter Course in Infectious Diseases, held February 6-10, 2023, in Avon, CO, and presented by The Annenberg Center for Health Sciences at Eisenhower and the Winter Course in Infectious Diseases Foundation. For more information about upcoming CME activities from this presenter, please visit https://www.wintercourse.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

OP622304

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.