Endophthalmitis

Dr. Jannatul Ferdows

DO (Student),year-2
Dept of ophthalmology, DMCH
Definition
• Inflammation of the internal layers of the eye resulting from
intraocular colonization of infective agents &manifesting with an
exudation into vitreous cavity (&/or ant.chamber)
Pathogenesis
Bacterial entry into eye

Cascade of inflammatory products

Inflammatory cell recruitment

Release of digestive enzymes by the cells & toxins by bacteria

Tissue destruction
Classification
Endophthalmitis

Non
Infectious infectious

Exogenous Endogenous Intraocular

Post Post Phacoanap
(85%) (15%) tumour
operative traumatic hylytic
necrosis
Post Post
operative traumatic

Chronic or
Acute delayed
onset
Risk Factors
• Systemic
• Diabetes mellitus
• Immuno-suppression
• Steriod therapy
• Rheumatoid arthritis
• Septic foci in the body
Risk factors
• Local
• Infection of lids of normal pts
• Chronic NLD obstruction
• Blepharitis, canaliculitis
• Conjunctivitis
• Contact lens wear, ocular prosthesis in other eye
Risk factors
• Intra-operative
• Prolonged operating time
• Wound dehiscence
• Vitreous loss
• Retained lens matter
• Contaminated instruments and solutions
Continued…
• Traumatic cataract
• Donar cornea
• Prolene IOL haptics
• Contaminated IOL and viscoelastics
• Type of surgery
Infective endophthalmitis

• Mode of infection

• Exogenous - perforating injuries,

perforations of infected corneal ulcers,
postoperative infections ( intraocular operations)
Postoperative endophthalmitis

Acute onset (<6 weeks)

• Bacteria are most common causative organism,
• Occurs within 1-2 weeks,usually 3-5 days after surgery

Chronic or delayed onset (>6 weeks)

• Occurs several weeks or months after surgery
• Less virulent bacteria (p.acnes)& fungi are organisms

Bleb associated (months-years after surgery)

• Increased incidence with use of antifibrotic agents
• Thin,cystic,avascular conjunctiva
• Endogenous or metastatic
blood stream from some infected focus in the body :
caries teeth,
generalised septicaemia,
puerperal sepsis
• Secondary infections from surrounding structures
orbital cellulitis,
thrombophlebitis,
infected corneal ulcers
Causative organisms
• Bacterial
• Staphylococcus epidermidis
• staphylococcus aureus
• streptococci
• pseudomonas
• pneumococci
• corynebacterium
• propionibacterium acnes
• actinomyces
• Fungal
• Aspergillus
• fusarium
• candida
• Non-infective (sterile) endophthalmitis

• Inflammation of inner structures of eyeball caused by certain

toxins/toxic substances
• Postoperative sterile endophthalmitis
• Chemicals adherent to intraocular lens
• Chemicals adherent to instruments
• Severe reaction confined to anterior segment -> Toxic anterior
segment syndrome
• Post-traumatic sterile endophthalmitis
• Retained intraocular foreign body e.g. pure copper

• Phacoanaphylactic endophthalmitis
• Lens proteins in patients with Morgagnian cataract

• Intraocular tumour necrosis

• Masquerade syndrome
Clinical features
• Symptoms
• Severe ocular pain
• Redness
• Lacrimation
• Photophobia
• Loss of vision
• Signs
• Lids become red and swollen
• Conjunctival chemosis and circumcorneal congestion
• Cornea oedematous, cloudy, ring infiltration
• Edges of wound become yellow and necrotic
• Anterior chamber – cells,flare,hypopyon
• Iris - oedematous, muddy
• Pupil shows yellow reflex due to purulent vitreous exudation
• Intraocular pressure raised in early stage

• Fundus
• Vitreous exudates (hallmark)
• Retinal periphlebitis (earliest sign)
• Loss of red reflex
Differential diagnosis
• Ocular retention of lens cortex or nucleus
• Hypopyon uveitis (behcet’s)
• Inflammatory reaction to intravitreal drug
• Blebitis
• Toxic anterior segment syndrome (TASS).
Investigations
• USG B scan
must be done before any invasive,diagnostic,therapeautic
procedure to look for
retinal or choroidal detatchment
dislocated lens/nucleas
retained IOFB
parasitic infestation
B scan : vitreous opacity
Microbiological specimen
• Aqueous tap
By using 25/27 gauge needle
0.1 ml of aqueous material is aspirated
40% Gram (+)ve.
Vitreous tap
A trans pars plana aspiration with a 23
gauge needle
Site: pseudophakic eye
3.5 mm post.to limbus
phakic eye
4 mm post.to limbus
Amount: 0.2 ml of vitreous,
60% Gram (+) ve.
Culture media
Treatment goals
• Primary objectives
control & eradicate infection
manage complications
restore vision
• Secondary objectives
symptomatic relief
maintain globe integrity
Treatment modalities
• Antimicrobial treatment
• Corticosteroids
• Supportive treatment
• vitrectomy
Treatment
a) Antibiotic therapy
1) Intravitreal antibiotics
• First choice - Vancomycin 1 mg 0.1 ml plus ceftazidime 2.25 mg in
0.1 ml
• Second choice - Vancomycin 1 mg 0.1 ml plus amikacin 0.4 mg in
0.1 ml
• Topical concentrated antibiotics

• Vancomycin(50mg/ml) or cefazoline(50mg/ml) plus

• Amikacin(20mg/ml) or tobramycin(15mg/ml)
Systemic antibiotics
• Ciprofloxacin I/V 200mg BD for 3-4 days followed by orally 500mg
BD for 6-7 days

• Vancomycin 1gm I/V BD and ceftazidime 2gm I/V 8 hourly

• Cefazoline 1.5gm I/V 6 hourly and Amikacin 1gm I/V 8 hourly

• Steroid therapy

• Intravitreal injection of dexamethasone 0.4mg in 0.1ml with

antibiotics

• Topical dexamethasone(0.1%)

• Systemic steroid
• Supportive therapy

• Cycloplegics - 1% atropine or 2% homatropine eye drop

• Antiglaucoma drugs - oral acetazolamide(250mg tds) and

timolol(0.5% bd)
Vitrectomy
Indication
• Patient does not improve intensive therapy for 48 to 72 hours

• Severe infection with reduced visual acuity to hand movement close to face

Advantages
• Helps in removal of infecting organisms, toxins, enzymes present in the
infected vitreous mass
Fungal endophthalmitis
• Candida
• Bilateral

• Central fundus lesion or severe

vitritis(fluffy cottonball or string of pearls

• Anterior uveitis

• Chorioretinitis - 1 or more small creamy

white lesions
• Aspergillus

• Iridocyclitis and vitritis

• Yellowish retinal and sub retinal

infiltrates -> macular involvement

• Occlusive retinal vasculitis

• Coccidioidomycosis

• Severe granulomatous anterior uveitis

• Multifocal choroiditis
Treatment

• Antifungal treatment - I/V Amphotericin B combination with oral

Flucytocine

• Voriconazol oral or I/V

• Pars plana vitrectomy

Prevention

• Preoperative
topical antibiotic drops
povidone iodine drops
meticulous drapping
• Intra operative
thorough irrigation & aspiration of anterior chamber
• Post operative
intracameral antibiotic
subconjunctival steroid injection
topical antibiotic drop