Panophthalmitis: A Ready Reckoner for Postgraduates

Dr. Namrata Adulkar
Published Online: April 1st, 2021 | Read Time: 11 minutes, 32 seconds


Panophthalmitis is a severe ocular and orbital condition which can lead to phthisis bulbi or may necessitate evisceration. Severe inflammation of the anterior and posterior segments is frequently accompanied by microbial keratitis, necrotizing scleritis, and perforation or rupture following trauma. The disease develops rapidly and the prognosis is poor. The management of patients with intractable panophthalmitis remains challenging with eye salvage almost impossible in most cases.

Etiology and Pathogenesis

Panophthalmitisis a purulent inflammation of all coats of the eyeball includingintraocular structures. Although post-traumatic endophthalmitis is the most common preceding event, the infection can result after postoperative endophthalmitis following cataract surgery, keratoplasty, or rarely after posterior segment procedures. It can also be caused by septicemia or can spread from a pus-producing infection in another part of the body. [Table 1] Organisms implicated include - Bacillus species (most common), Streptococcus pneumoniae, Pseudomonas aeruginosa,Staphylococcus epidermidis, Clostridiumspecies, Salmonella, E coli, Klebsiella, Tuberculous, and also fungi. [1-6] [Table 2]

Post cataract surgery


Post penetrating keratoplasty

Post microbial keratitis

Endogenous or Metastatic ocular infection in systemic immune compromise

Table 1 Etiology of Panophthalmitis



Bacillus cereus (most common)

Staphylococcus aureus, MRSA

Streptococcus pneumoniae


Pseudomonas aeruginosa (most common)

Clostridium species

E. coli








Table 2. Causative organisms of Panophthalmitis

Many theories have been postulated for the development of such overwhelming inflammation and necrosis in endophthalmitis which further progresses unabated to involve all the ocular coats. Endotoxins released by gram-positive cocci incite intense cellular and basement membrane inflammation which can cause a diffuse breakdown of various blood ocular barriers. This can lead to exuberant inflammation in cases where the infection does not get timely controlled and plays a significant role in the progression. [4]

Panopthalmitis is more commonly seen in immunocompromised patients or in patients with a debilitating illness, diabetes being a common association. The possibility of metastatic ocular infection may be suspected when patients with severe systemic illness, like pneumonia or sepsis, or poor immune status present with intraocular inflammation and severely impaired vision.

Panophthalmitis can have potentially serious complications like orbital cellulitis, cavernous sinus thrombosis, meningitis, or encephalitis and can be fatal if left untreated.

Clinical features

Figure 1: External photograph of the eye with panophthalmitis

The most common presentation includes pain and severe periorbital swelling, purulent discharge, proptosis, loss of vision, and complete external ophthalmoplegia. [Fig 1] Careful examination is required to look for signs pointing to the etiology like a postoperative wound, signs of trauma, sinus inflammation in case of fungal infections. [Table 3]



Swelling of the eye


Loss of vision

Watering and discharge

Malaise and fever


Light perception may not be present in most cases

Severe periorbital edema and erythema

Severe eyelid edema with complete mechanical ptosis

Purulent discharge

Conjunctival congestion and severe chemosis, hemorrhagic chemosis esp in trauma cases

Corneal signs – perforated corneal ulcer, opacification, graft failure

Anterior chamber – hypopyon, severe iritis, flat AC in case of corneal ulceration

Pupils: RAPD may be present

EOM: variable degree of limitation of movements in all gazes

IOP: variable, low in case of perforated corneal ulcers, high in cases of POE

B scan Ultrasonography: scleral thickening with ‘T’ sign

Table 3 Clinical features of panophthalmitis


Clinical presentation is almost always diagnostic. B scan ultrasonography of the eye shows thickening of the scleral coats and collection of fluid in the subtenon’s space giving rise to the classical ‘T’ sign [Fig 2]; confirms the clinical diagnosis.

Figure 2: USG Bscan showing vitreous echoes, thickening of the choroid and subtenon’s fluid collection

Diffuse thickening of ocular coats along with altered signal intensity in the vitreous cavity is a common finding on contrast-enhanced MRI of orbits and brain. Extraocular muscles and peri-ocular tissues show abnormal enhancement along with variable distortion of the globes.

Laboratory investigations reveal anemia, leukocytosis along with neutropenia, and raised ESR. In patients with suspected septicemia, blood cultures are sent. Cultures from anterior chamber tap and vitreous tap samples may help isolate the causative organism.


Panophthalmitis is a very serious infection and has usually an explosive course with rapid deterioration if untreated. Even with treatment, eye salvage remains a challenge more often than expected. The patient is hospitalized with close monitoring of ocular signs.


All patients are started empirically on broad-spectrum intravenous antibiotics (usually ceftriaxone 2 g/ cefotaxime 1g and gentamycin 80 mg twice daily) along with supportive therapy. In cases of trauma, metronidazole is added alongside either intravenously or oral. In patients with suspected fungal infections, especially in immunocompromised cases with suspected fungal sinus infections, amphotericin B infusions are prescribed. These patients often need aggressive sinus intervention by otolaryngologists. [6] Monitoring and control of blood sugars levels is crucial in patients with diabetes. Antibiotics may be reviewed depending on the findings of microbial culture and antibiotic sensitivity tests.

Pappuru et all have recommended the simultaneous administration of systemic corticosteroids to control the inflammation in cases of endophthalmitis progressing to panophthalmitis. They found the administration of systemic steroids to have very high odds of a favorable final outcome. [4] However this still remains controversial, especially in diabetic patients.


Treatment in the form of intravitreal antibiotics is advocated, but usually, the functional outcome is very poor. Vitrectomy is not possible, due either to poor media clarity or weak outer coats of the eye and severely congested choroidal tissues. In most reports in the literature on the management of panophthalmitis, the globe was lost requiring evisceration or enucleation. Although in some cases infection may be controlled with prolonged antibiotic therapy, functional outcomes remain poor with eyes going into phthisis bulbi. Factors predicting good outcome in endophthalmitis progressing to panophthalmitis have been hypothesized by some authors.[4] [Table 4]


Systemic steroid administration


Intravenous antibiotics administration


Presenting vision ≥ LP


Gram-positive cocci in smear


Culture positivity


Age < 40 years


Table 4 Factors predicting good outcome in endophthalmitis progressing to panophthalmitis.[4]

Because of a relatively high extrusion rate and the potential for sympathetic ophthalmia in the other eye, enucleation has been recommended [7,8]. In recent decades, evisceration with either delayed or immediate implant placement has been recommended in patients with endophthalmitis. Although delayed primary closure has certain theoretical advantages, primary implantation of orbital implants can prevent prolonged hospitalization and the need for additional surgeries [9-14].However, attempts at implant placement with evisceration are typically abandoned during surgery because the implant is considered unlikely to remain within the necrotic sclera. Melting of the scleral necrotic tissue causes a high extrusion rate of the orbital implant. [12] Frill evisceration is a technique popularised in these situations, wherein all the necrotic sclera is excised leaving a frill of healthy sclera around the optic nerve head. The conjunctiva may or may not be sutured.


Early diagnosis and prompt treatment is very important in the management of this condition. Outcomes are invariably poor and globe salvage still continues to remain a challenge.


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Dr. Namrata Adulkar
Consultant, Oculoplastic Surgeon, Sir H N Reliance foundation Hospital , Dr L H Hiranandani Hospital,Mumbai.
Dr. Namrata Adulkar graduated from Seth G S Medical College and King Edward Memorial Hospital, Mumbai. She completed her ophthalmology residency training from the prestigious Sankara Nethralaya, Chennai. After finishing residency, she followed her interest in oculoplastics by doing a longterm clinical fellowship at Aravind eye hospital, Madurai. Her quest for excellence took her to University of British Columbia, Vancouver Canada, where she pursued a year long clinical fellowship mastering orbital & endonasal surgery and nuances of thyroid eye disease under the mentorship of Dr Peter Dolman. She has trained with the pioneers of Facial aesthetics : Dr Jean Carruthers in Vancouver, Canada and Prof Bhupendra Patel at Moran Eye Center, Salt lake City, USA. She is the winner of the coveted Lachlan McNeil Scholarship in Ophthalmology of the Royal college of physicians and surgeons of Glasgow. She takes keen interest in academics and has a penchant for teaching postgraduate residents and fellows. She has a number of publications to her credit and has also presented her scientific work at numerous national and international conferences. She is currently affiliated as Consultant Oculoplastic Surgeon at Sir H N Reliance foundation hospital and Dr L H Hiranandani Hospital in Mumbai. She can be reached at
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