Dr. Prabin Kumar Bam, MBBS Endophthalmitis: Definition, Etiology, Pathogenesis, Clinical Features, Complications, Treatment, Modern Technology.. Endophtalmitis power point presentation for MBBS and MD Endophthalmitis for MD ophthalmology Prabin Kumar Bam Chitwan Medical College

1. ENDOPHTHALMITIS
By: Prabin Kumar Bam

2. Definition
• Endophthalmitis is defined as an inflammation of
inner structures of the eye ball i.e; uveal tissue and
retina associated with pouring of exudates in the
vitreous cavity, anterior chamber and posterior
chamber
where as intense purulent inflammation of the
whole eyeball including the Tenon’s capsule is
called: Panophalmitis

3. Etiology
Modes of infection
1. Exogeneous infection: following perforating
injuries of infected corneal ulcer or as post-op
infections following intraocular operations
2. Endogeneous / metastatic endophthalmitis:
occurs through bloodstream from infected foci like
dental caries & septicaemia
3. Secondary infection: very rare. occurs from
infected surrounding structure like orbital cellulitis
& thrombophlebitis
A. Infective Endophthalmitis

4. …..cont
Causative organisms
•Bacteria: m/c are gram positive cocci i.e.
staphylococcus epidermidis & staphylococus aureus.
Other organisms include streptococci ,pseudomonas
,pneumococii and cornebacterium acnes
•Fungal: comparatively rare. Aspergillus, Fusarium,
Candida etc.

5. B. Non infective (sterile) endophthalmitis
1.Postoperative sterile endophthalmitis: can occur as
a toxic reaction to
• Chemical adherent to intraocular lens
• Chemical adherent to instruments
• Severe reaction mainly confined to the anterior
segment is also called toxic anterior segment
syndrome “TASS”

6. .....(cont) Non infective endophthalmitis
2.Post traumatic sterile endophthalmitis: as a toxic
reaction to retained intraocular F.B. Like pure
copper
3.Phacoanaphylactic : induced by lens protein in
people with Morgagnian cataract
4.Intraocular tumour necrosis may present as a
sterile endophthalmitis (masquerade syndrome)

7. Risk Factors For Development Of
Endophthalmitis

8. Systemic factors
• DM
• Immuno suppressive states
• Steroid therapy
• Rheumatoid arthritis

9. Local factors
• Chronic NLD obstruction
• Blepharitis, canaliculitis
• Conjunctivitis
• Contact lens wearer
• ocular prosthesis in the eye

10. Intra-operative factors
• Prolonged operative time
• Wound dehiscence
• Vitreous loss
• Retained lens mattter
• Contaminated instrument and solution

11. Acute post-operative Bacterial
Endophthalmitis
•Acute posoperative endophthalmitis is
catastrophic complication of intraocular surgery
• Incidence - 0.1%
•Source of infection: periocular bacterial flora of
the eyelid, conjunctiva & lacrimal sac
•Onset may be acute or delayed
-Acute:1-7 days of operation
-Delayed onset ophthalmitis: week to month after
surgery. Fungi are most common organism and
propionibacterium acne is the second m/c cause

12. Symptoms
• Severe ocular pain
• Redness
• Lacrimation
• Photophobia and Diminision of vision after
initial improvement

13. Signs
• Lids become red and swollen
• Conjunctiva shows cheimosis and marked
circumcorneal congestion
• Cornea is edematous ,cloudy and ring
infiltration may be present
• Edge of wound becomes yellow and necrotic
and wound may gape in exogeneous form

14. • Anterior chamber shows hypopyon; soon it
becomes full of pus.
• Iris, when visible is edematous and muddy
• Pupil shows yellow reflex due to purulent
exudate in vitreous
• Vitreous exudation. In metastatic form and
cases with deep infections, vitreous cavity
filled with exudation and pus. Soon a
yellowish white mass is seen through fixed
dilated pupi.This sign is called Amaurotic cat’s
eye reflex.

15. • IOP raised in early stages but in severe cases ,
the cilliary process are destroyed and a fall in
IOP may ultimately result in shrinkage of the
globe
Note: We should check ocular motility (to rule
out panophthalmitis )

16. Acute Post-operative Bacterial
Endophthalmitis

17. Ddx of Endophthalmitis
• Retained intraocular foreign body
(iron/copper)
• Severe pars planitis
• Old vitreous haemorrhage
• Toxocara/ Toxoplasma infestation –leucokoria
• Necrotic retinoblastoma

18. Diagnosis and Investigations
A detail history & ocular examinations are required.
1.USG-B scan: to look for retinal or choroid
detachment, Dislocated lens/nucleus, Retained
intra ocular foreign body , parasite infestation
2.Vitreous tap: should be made as early as
possible. It is performed trans-conjunctivally
under topical anesthesia from the area of pars
plana(4-5mm from limbus). The vitreous tap is
made using 23 gauge needle .The aspirate
examined by Gram and Giemsa staining and
specimen sent for bacterial and fungal culture .

19. (…cont) Diagnosis and Investigations
• if vitreous aspirate is collected in an
emergency when immediate facilities for
culture is not available, it should be stored
promptly in refrigerator at 4 degree C.
3.Complete and differential blood count
4.Fasting blood glucose
5.Serum electrolyte

20. Dictums (help in diagnosis of Endophthalmitis)
• Consider all unexpected post operative
reaction as infective unless proven otherwise
• Keep high level of suspicion
• Do not ignore any post operative symptom
(overdiagnosis >>>underdianosis)
TASS-due to inadequate cleaning of instrument

21. Treatment

22. Treatment
Need early diagnosis and vigorous treatment
1. Antibiotic therapy
2. Steroid therapy
3. Supportive therapy
4. Vitrectomy

23. 1.Antibiotic therapy
1. Intravitreal antibiotic and diagnostic tap
should be made as early as possible
Performed under topical anesthesia from area of
pars plana. vitreous tap is made using 23G
needle followed by the intravitreal injection
using a disposable tuberculin syringe and 30G
needle.
Intravitreal injection of antibiotics is main stay
of treatment.
•Combination of two antibiotics: one against
gram-positive coagulase negative staphylococci
and other against gram-negative bacilli

24. .....Antibiotic therapy
• First choice: Vancomycin 1 mg in 0.1 ml plus
Ceftazidime 2.25 mg in 0.1 ml
• Second choice: Vancomycin 1mg in 0.1 ml plus
Amikacin 0.4mg in 0.1 ml
Note:
If there is no improvement a repeat intravitreal
injection should be given after 48 hours taking
into consideration the report of bacteriological
examination.

25. .....Antibiotic therapy
2.Topical concentrated antibiotics
•Should be started immediately and used
frequently ( every 30 minute to 1 hourly)
•Both gram-positive and gram-negative
organisms should be covered :
Vancomycin (50mg/ml) or Cefazoline(50mg/ml)
plus Amikacin (20mg/ml) or Tobramycin
(15mg%)

26. .....Antibiotic therapy
3.Systemic antibiotics: limited role
•Ciprofloxacin intravenous infusion 200 mg BD
for 3-4 days followed by orally 500 mg for 6-7
days or,
•Vanconycin 1g IV BD & CeftazIdime 2g iv 8 hrly
or,
•Cefazoline 1.5 g IV 6 hourly and Amikacin 1 g IV
TDS

27. B.Steroid therapy
• Limits tissue damage caused by inflammation.
• Most surgeons recommended their use after 24 to 48
hours of control of infection by intensive antibiotic
therapy. However some surgeons recommended their
immediate use (controversial)
Routes & Doses:
Intravitreal: Dexamethasone 0.4mg in 0.1 ml along with
antibiotic
Topical: Dexamethasone 0.1% or predacetate1%
Systemic: daily 60 mg Prednisolone followed by by
50,40,30,20 mg for 2 days each may be adopted
Lansoprazole 30mg OD should be given before steroid for
gastric protection.

28. C. Supportive therapy
1.Cycloplegic: 1% Atropine or 2%Homatropine
eye drops TDS or QDS
• Control of inflammation and relief of cilliary
spasm
• Prevent synechie formation in miosis
• Dilated pupil helps in assesement during
vitrectomy
2.Antiglaucoma drugs : in patient with raised
IOP. oral Acetazolamide (250mg tds)and
Timolol (0.5%)

29. D. Vitrectomy
Advantages:
• Reduces the infection and inflammation load
• Increases the efficacy of intravitreal antibiotics
• Provide adequate specimen for culture
• Remove the media opacity
Indications:
• If above intensive therapy does not work for
48-72 hours .
• Patient present with severe infection with
visual acuity reduced to hand movement close
to face.

30. Endophthalmitis Vitrectomy study
Multicenter randomied trial at 24 center in us
(1990-94)
Purpose:
• Role of immediate vitrectomy
• Role of iv antibiotic
Results:
• No role of systemic antibiotics
• No role of immediate vitrectomy for HM or better
vision
• Immediate vitrectomy beneficial for only PL
• Acuity at presentation is an important prognostic
factor for vitrectomy
• Vitreous is the best source for culture.

31. ..
• EVS recommendation do not apply to
endogeneous, traumatic & bleb associated
endophthalmitis
• Systemic antibiotics are useful adjuncts in
these cases.

32. Complication of Endophthalmitis
• Loss of central vision
• Phthisis bulbi
• Surgical complications
• Iatrogenic retinal holes
• Posoperative rd
• Posoperative PVR
• Phthisis bublbi

33. Prophylaxis
• Topical 5% Povidine-iodine
• Draping of eyelashes and lid margin