Endophthalmitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Moubarak, M.D. [2]

Overview

Endophthalmitis is an inflammation of the internal coats of the eye. It is a dreaded complication of all intraocular surgeries, particularly cataract surgery, with possible loss of vision and the eye itself. Infectious etiology is the most common and various bacteria and fungi have been isolated as the cause of the endophthalmitis. Other causes include penetrating trauma and retained intraocular foreign bodies.

Signs and symptoms

A history of recent intraocular surgery or penetrating ocular trauma is usually elicited. In some cases of metastatic endophthalmitis, the spread of infection may be hematogenous (via the blood-stream). That is more commonly seen in patients with immunocompromised states like AIDS and also in diabetes. The condition is usually accompanied by severe pain, loss of vision and redness of the conjunctiva and the underlying episclera. Alongside are present signs of inflammation of the various coats of the eye. Hypopyon can also be present in endophthalmitis and should be looked for on examination by a slit lamp. Progression to involve all the coats of the eye is called as panuveitis or panophthalmitis.

Treatment

Overview

The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retina specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics and also prepare for an urgent pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.

Bacterial Endophthalmitis

Bacterial Endophthalmitis
Preferred Regimen
▸ Vancomycin 1 mg intravitreal PLUS ▸ Ceftazidime 2.25 mg intravitreal
PLUS
▸ Vancomycin 1 gm IV q12h PLUS ▸Cefotaxime 1 gm IV q4h OR ▸Ceftriaxone 1 gm IV q4h OR ▸Ceftazidime 1 gm IV q8h

• Vitrectomy is very important in sever cases for better visual outcomes.
• Systemic antibiotics may shows a benefit as an adjunctive therapy to intravitreal antibiotics.
• Antibiotics are adjusted after sensitivity results.
• Clindamycin is added, in cases of intravenous drug users until Bacillus infection is ruled out.

Post-traumatic Endophthalmitis

Post-traumatic Endophthalmitis
Preferred Regimen
▸ Vancomycin 1 mg intravitreal PLUS ▸ Ceftazidime 2.25 mg intravitreal
PLUS
▸ Vancomycin 1 gm IV q12h PLUS ▸Ciprofloxacin 400 mg IV/po q12h OR ▸Ceftazidime 1 gm IV q8h

• Topical antibiotics, or subconjunctival antibiotics often used in conjunction with intravitreal antibiotics post-operatively.

Post Cataract Endophthalmitis

In early acute cases

• Immediate vitrectomy may be needed, and intravitreal injection of Vancomycin 1 mg, and Ceftazidime 2.25 mg.
• Intravitreal antibiotics may be repeated in 2–3 days.
• Lens can be left without removal.

In chronic cases:

• Intravitreal injection of Vancomycin 1 mg, and Ceftazidime 2.25 mg.
• Vitrectomy may or may not performed.
• Removal of the lens may be required.

Post Glaucoma Surgery Endophthalmitis

Post Glaucoma Surgery Endophthalmitis
Preferred Regimen
▸ Vancomycin 1 mg intravitreal PLUS ▸ Ceftazidime 2.25 mg intravitreal

• Topical ophthalmic antibiotics usually added to the above regimen.

Fungal Endophthalmitis

Fungal Endophthalmitis
Preferred Regimen
▸ Amphotericin B 5–10 μg in 0.1 mL sterile water intravitreal OR ▸ Voriconazole 100 μg in 0.1 mL sterile water intravitreal
PLUS
▸ Fluconazole 6-12 mg/kg daily OR ▸Flucytosine 25 mg/kg qid

• Duration of therapy is 4-6 weeks or longer based on the case improvement.

Contraindicated medications

Endophthalmitis is considered an absolute contraindication to the use of the following medications:

• Ranibizumab

External links

• Peters JR. "Endophthalmitis." eMedicine.com. Accessed September 28, 2006.
• Wu L. "Endophthalmitis, Fungal." eMedicine.com. Accessed September 28, 2006.