ENDOPHTHALMITIS

Dr Santosh Chaudhary
Department of Ophthalmology
BPKIHS, Dharan
08.04.2018
Definition
• End + ophthal + itis
(inner) (eye) (inflammation)

“Inflammation, often purulent, involving all

intraocular tissues except the sclera”
- Jack J Kanski
• Panophthalmitis
Purulent inflammation of entire globe, often with
orbital extension

• Uveitis
Inflammation of uveal tract

• Panuveitis
Inflammation of entire uveal tract without
predominant site of inflammation
• Severe and purulent intraocular inflammation
• Results in loss of vision, and sometimes loss of eye

Necessary to
• Recognize the condition early
• Execute the therapy in optimal fashion
Classification

TIS
EXOGENOUS
ENDOPTHTHALMI

ENDOGENOUS
ENDOPHTHALMITIS
Postoperative
• Acute
• Chronic
Filtering bleb associated
After intravitreal injection
Post traumatic

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EXOGENOUS ENDOPTHALMITIS:
POSTOPERATIVE
ENDOPHTHALMITIS

Postoperative
Endophthalmitis

Acute
Chronic
* 1-2 weeks, <6
* >6 weeks
weeks
* Indolent course
*Fulminant form
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ACUTE POST-OPERATIVE
ENDOPHTHALMITIS
• Most common form
• Occurs shortly after ocular surgery
• Within 6 weeks (mostly 1-2 weeks)

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Epidemiology
• Most common
• 90% of postoperative endophthalmitis, due to
cataract surgery

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Incidence of endophthalmitis after
ophthalmic procedure

Ophthalmic procedure Incidence (%)

Overall postsurgical 0.05-0.3
Postcataract surgery 0.08-0.68
Secondary IOL placement 0.2-0.367 (Highest)
Postintravitreal injection 0.03-0.87
Postvitrectomy 0.018-0.076 (Lowest)
Post-Trabeculectomy 0.06-0.18
Post PK 0.2-04

Expert Rev. 46 Ophthalmol. 8(1), (2013)

Causative Agents
Organism
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus sps
Gram-negative rods (Proteus,
Pseudomonas, Serratia)
Bacillus species
• Patients own flora is a common source
Relatively nonvirulent; 40-70%,
especially in diabetics
Virulent; 10-20%
Virulent; 6-9%
Virulent; relatively rare
Very virulent; extremely rare
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Risk factors
Preoperative Intraoperative Postoperative
• Blepharitis, • Complicated • Wound leakage
Conjunctivitis, surgery (Capsular • Wound
Dacryocystitis rupture, vitreous dehiscence
• Contact lens loss) • Vitreous
wear, ocular • Wound incarceration
prosthesis in abnormalities
fellow orbit • Secondary IOL
• Host implantation
immunosuppressi • Scleral fixation
on • IOL
• Diabetes Mellitus characteristics

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Symptoms Signs

Rapidly progressive • Decreased VA

• Pain • Lid swelling
• Red eye • Ciliary congestion,
• Ocular discharge Conjunctival and corneal
edema
• Blurring
• AC cells and fibrin, hypopyon
• RAPD
• Vitreous inflammation and
retinitis
• Blunting of red reflex
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Eyelid edema with ciliary congestion
Corneal edema, infiltrate Hypopyon

Severe vitritis Retinal vasculitis

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Endophthalmitis caused by Bacillus cereus

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Prophylaxis
• 5% povidine-iodine
• Scrupulous preparation
• Treatment of pre-existing infections
• Prophylactic antibiotics
• Early resuturing of leaking wounds

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Diagnosis
• Early recognition is critical
• Any eye with inflammation greater than the usual
postoperative clinical course should be suspected

• Once possibility of infectious endophthalmitis

considered
• Diagnostic and therapeutic management should
begin promptly

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• Certain lesions associated with endophthalmitis
should be recognized

Vitreous incarceration
Wound leak

• Would dehiscence
• Suture abscess
• Eroding scleral sutures
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Obtaining Specimens

Aqueous samples
• 0.1-0.2ml
• Aspirated via a limbal paracentesis using 30G needle
(tuberculin syringe)
If no fluid is obtained with a needle tap, a vitreous biopsy must be performed instead to avoid
aspirating formed vitreous Conjunctival swabs

Vitreous tap Vitreous biopsy

• 0.2ml of vitreous • 0.2-0.5ml
• 23G needle • Automated vitrector
• Pars plana route • Single port or 3 port
USG B-Scan

• Helpful in cases of media

opacities
• To confirm the presence
of vitreous exudates
• Associated
retinal/choroidal
detachment
• Dislocated lens material
or FB

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USG B-Scan of Normal Eye
Differential diagnosis
• Toxic anterior segment syndrome (TASS)
• Retained lens cortex or nucleus
• Hypopyon uveitis (Behcet’s disease or rifabutin
toxicity)

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Treatment
• Intervene as soon as possible
“Endophthalmitis is an emergency and must be
treated as one”

• Intravitreal antimicrobial
• Pars plana vitrectomy

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Antibiotic t/t (SEE NOTES BELOW)
Route Drug Dose
Intravitreal Ceftazidime 2.25mg/0.1ml
Vancomycin 1mg/0.1ml
Dexamethasone 400µg/0.1ml

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Subconjunctival Vancomycin 25mg/0.5ml
Ceftazidime 100mg/0.5ml
Dexamethasone 6mg
Topical Vancomycin 5% every hour
Ceftazidime 10% every hour
Systemic Ceftazidime 1g IV TID
Vancomycin 1g IV BD
Prednisone 1mg/kg (5-10 days)

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Vitrectomy
Advantages
• Increases retinal oxygenation
• Removes infecting organism and associated toxins
• Removes inflammatory debris
• Improves intraocular distribution of antibiotics
• Reduces duration of disease

Indication (EVS)
• Patient with VA of light perception

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CHRONIC POST-OPERATIVE
ENDOPHTHALMITIS
• Presents >6weeks after surgery
• Insidious inflammation occurring after intraocular
surgery
• Usually manifest several weeks to months after surgery

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Organisms
• Less virulent bacteria and fungal pathogens

Causative agents
Propionibacterium spss. 63%
S. Epidermidis 16%
Candida parasilosis 16%
Corynebacterium spss. 5%
Others:
• Actinomyces, Nocardia, Achromobacter,
Cephalosporium, Acremonium and
Aspergillus
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Clinical features
• Pain or discomfort (may or may not)
• Inflammation (initially steroid responsive, recurrent
after steroid taper)
(with fungal infections, inflammation worsened by
steroid)
• Microhypopyon (visible by gonioscopy)
• Granulomatous uveitis with large precipitates on
cornea or lens

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Delayed-onset pseudophakic endophthalmitis
caused by P. acnes
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 Fluff balls
or
Pearls-on-a-
string

white string of vitreous infiltrates,

which is characteristic of
endophthalmitis caused by Candida
species

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Management
• Identification of infectious organism
• Aqueous and vitreous samples
• If capsular plaque is present, should be harvested
during vitrectomy

Special considerations
• Slow growing, days to weeks
• PCR in culture negative cases

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• All areas of involved lens capsule and lens cortex
should be excised requiring PPV
• Vancomycin (1mg/0.1ml)
• Effective against P. acenes
• Better coverage against other causes (coagulase negative
staphylococcus)

• Amphotericin B (5-10µg/0.1ml)
• Effective against most fungi
• Voriconazole or miconazole if resistant
• Needed to be repeated

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• Systemic therapy
• 10-14 day course of new generation fluoroquinolones
(Moxifloxacin)
• Fluconazole 200mg BD or Ketoconazole 400-600mg/day

Fluconazole > Ketoconazole > Itraconazole

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SUMMARY
• Purulent inflammation of inner eye
• Early diagnosis and treatment with antimicrobial
therapy are critical to optimize visual outcome
• Intravitreal antimicrobial therapy remains the mainstay
of treatment

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Thank You

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