When sepsis hits the eye: The hidden danger of endogenous endophthalmitis

Introduction:  Endogenous bacterial endophthalmitis results from ocular seeding during disseminated septicemia and remains a major diagnostic and therapeutic challenge. It is a severe infection that threatens both survival and vision. Diagnosis is frequently delayed, and treatment remains difficult and imperfectly standardized.

Methods: We conducted a retrospective, descriptive study at our institution between January 2023 and August 2026. All patients hospitalized for endogenous endophthalmitis with microbiological confirmation were included. Patients with exogenous endophthalmitis or without microbiological confirmation were excluded.

Results: Over the 4-year study period, 167 patients were admitted for endophthalmitis, of whom 6 (3,59%) had endogenous disease. Mean age was 63 years, with a sex ratio of 1.2. Among these 6 patients, the underlying source was infective endocarditis in two, recent visceral surgery in two, 
erysipelas in one, deep abscess (prostatic and hepatic) in two, and staphylococcal septicemia in one. Diabetes was present in 91% of patients, and 42% had underlying cardiac disease. 
Four patients presented with severe, sleep-disrupting ocular pain, and all patients had systemic asthenia and fever. On examination, visual acuity was worse than counting fingers in every patient; ocular hypertension was present in 48% of cases, conjunctival hyperemia in 98%, corneal edema in 35%, and anterior chamber reaction in 78%. Ocular ultrasound consistently revealed intravitreal organization. Vitreous sampling was positive in 78% of cases, with Gram-positive organisms predominating — Staphylococcus aureus accounted for 65% of isolates. 
All patients underwent a full inflammatory and infectious work-up. Transthoracic echocardiography was performed in 5 patients, and abdominopelvic ultrasound and CT in 3. Treatment consisted of intravitreal antibiotic injections (vancomycin 1 mg/0.1 mL and ceftazidime 2 mg/0.1 mL), with dexamethasone (400 µg) added at the third injection, combined with systemic dual antibiotic therapy and treatment of the underlying source.

Discussion: Endogenous bacterial endophthalmitis arises from hematogenous seeding of the eye and is considerably less common than exogenous endophthalmitis. It typically develops in patients with predisposing conditions — immunosuppression, diabetes, cardiac disease, or malignancy — or in the setting of overt systemic infection. Because ocular symptoms are often overshadowed by the underlying systemic illness, diagnosis is delayed, contributing to its poor anatomical and functional prognosis.

Conclusion: Endogenous endophthalmitis poses a diagnostic challenge with both ocular and systemic implications, and it can be life-threatening. Prompt recognition and early, tailored treatment are essential to prevent both ocular and systemic complications.