Detailed description on endophthalmitis - Eitiology, Clinical features , management .

1. ENDOPHTHALMITIS
Endophthalmitis is defined as an inflammation of the inner structures of the eyeball( uveal tissue
and retina ) associated with pouring of exudates in the vitreous cavity, AC and PC
ETIOLOGY
Etiologically endophthalmitis may be Infectious or Non Infectious (Sterile)
INFECTIVE ENDOPHTHALMITIS
Modes of infection
1. Exogenous Infection :
Purulent inflammations are generally caused by exogenous infection following perforating
injuries, perforation of infected corneal ulcers or as post op infections following intraocular
surgeries.
2. Endogenous or metastatic Endophthalmitis :
It may occur rarely through bloodstream from some infected focus in the body such as caries
teeth, generalised septicaemia and puerperal sepsis.
3. Secondary infections from surrounding structures :
It is very rare. Cases of purulent intraocular inflammation have been reported following
extension of infection from orbital cellulitis, thrombophlebitis and infected corneal ulcer.
NON INFECTIVE ( STERILE) ENDOPHTHALMITIS
Sterile Endophthalmitis refers to inflammation of the inner structures of the eyeball caused
by certain toxins/ toxic substance. It occurs in following situation :
1. Post operative sterile endophthalmitis may occur as toxic reaction to
 Chemicals adherent to IOL
 Chemical adherent to instruments
 TASS
2. Post traumatic sterile endophthalmitis :
 May occur as toxic reaction to retained IOFB (Copper)
3. Phacoanphylactic endophthalmitis :
 Induced by lens proteins in pts with morgagnian cataract

2. 4. Intraocular tumour necrosis:
 May present as sterile endophthalmitis (Masquerade syndrome)
COMMON ORGANISMS CAUSING ENDOPHTHALMITIS :
Exogenous Endophthalmitis
1. Acute postoperative ( 1 to several days after surgery )
 Staphylococcus epidermidis
 Staph aureus , Strep spp.
 Gram –ve bacteria : Pseudomonas , proteus, H.
 Influenza, Klebsiella , E coli , Bacillus spp, Enterobacter spp. & anaerobes .
2. Delayed onset post operative endophthalmitis ( a week to a month or more after
surgery)
 Fungi : Aspergillus, Fusarium, Candida, Cephalosporium, Penicillum
 Bacteria : Propionibacterium acnes and any bacteria infecting a thin filtering bleb
(often streptococci), vitreous wick or after partial suppression with antibiotics during
or after surgery.
3. Post traumatic :
 Bacillus spp
 S. Epidermidis
 Fungi – Fusarium
Endogenous endophthalmitis
 Bacillus cereus ( especially in intravenous drug abusers)
 Streptococci
 Neisseria meningitides
 Staph aureus
 H. Influenza
 Fungi : Mucor and candidia

3. CLINICAL FEATURES OF ACUTE POST OP BACTERIAL ENDOPHTHALMITIS
Acute post op endophthalmitis – Incidence 0.1 %
RISK FACTORS : May include operative complication such as :
 PCR
 Prolonged procedure time
 Combined procedure (e.g vitrectomy)
 Clear corneal sutureless incision
 Temporal incision
 Wound leak on the 1st
post op day
 Delayed post op topical antibiotics
 Topical anaesthesia
 Adenexal disease
 DM
SYMPTOMS :
 Severe ocular pain
 Redness
 Photophobia
 Loss of vision
SIGNS :
LIDS : Become red and swollen
CONJUNCTIVA : shows chemosis and CCC
CORNEA : Odematous, cloudy and ring infiltration may be formed
EDGES OF THE WOUND : become yellow and necrotic and wound may gape in exogenous form.
ANTERIOR CHMABER : Hypopyon ; soon AC becomes full of pus
IRIS : when visible, will be odematous and muddy.
PUPIL : shows YELLOW REFLEX due to purulent exudation in vitreous. When AC becomes full of pus ,
iris and pupil details wont be visible.
VITREOUS EXUDATION : In metastatic forms and in cases with deep infections , VC will be filled with
exudation and pus. A yellowish white mass is seen through fixed dilated pupil. This sign is called
AMAUROTIC CAT’S EYE REFLEX.

4. IOP: Raised in early stages, but insevere cases, the ciliary process are destroyed, and a fall in IOP
may ultimately result in shrinkage og globe.
DIFFERENTIAL DIAGNOSIS :
If there is any doubt about the diagnosis, treatment should be that of infectious endophthalmitis, as
early recognition leads to better outcome.
 Retained lens material in the AC or vitreous
 Vitreous hemorrage – especially if the blood is depigmented
 Post op uveitis
 Toxic reaction : to use of contaminated or inappropriate fliud or visco
 Complicated or prolonged surgery may result in corneal odema and uveitis
INVESTIGATIONS FOR IDENTIFICATION PATHOGENS
Samples for culture should be obtained from aqueous and vitreous to confirm diagnosis.
Negative culture doesnot necessarily rule out infection and treatment should be continued.
B SCAN :
Should be performed prior to vitreous sampling if there is no clinical view, to exclude
RD
AQUEOUS SAMPLING :
0.1ml – 0.2ml of aqueous is aspirated via limbal paracentesis using a 25 gauge
needle on a tuberculin syringe. The syringe is then caped and labelled.
VITREOUS SAMPLING :
More reliable than aqueous sampling . 1 – 2ml of syringe and 23 gauge needle may
be used, or optimally a disposable vitrector. The vitreous cavity is entered 3.5mm
from the limbus (pesudophakic eye),. 0.2 – 0.4 ml is aspirated from the mid vitreous
cavity. If using a disposable vitrector, the tubing is capped and both the vitrector and
tubing is sent for analysis
CONJUNCTIVAL SWAB :

5. May be taken in addition , as significant culture may be helpful in the absence of a
positive result from intraocular samples.
MICROBIOLOGY :
Specimens should be sent to the microbiology lab immediately. The specimen will be
divided for microscopy and culture. PCR can be helpful in identifying unususal
organisms and if culture results have been negative.
TREATMENT
1. INTRAVITREAL ANTIBIOTICS
These are the key to management because levels above the minimal inhibitory
concentration of most pathogens are achieved and are maintained for days.
They should be administered immediately after culture specimens have been
obtained.
Antibiotics commonly used in combination are :
 Ceftazidime 2mg in 0.1ml and Vancomycin 2mg in 0.1ml
 Amikacin 0.4mg in 0.1ml is an alternative to ceftazidime in patients with penicillin
allergy . (amikacin is more toxic to retina)
SUBCONJUNCTIVAL ANTIBIOTIC INJECTIONS
Are often given but are of doubtful additional benefit if intravitreal antibiotics have
been used.
Vancomycin 50mg and ceftazidime 125mg (or amikacin 50 mg if penicillin
allergy)

6. TOPICAL ANTIBIOTICS :
 These are of limited benefit and are often used 4 – 6 times daily in order to protect
the fresh wounds from contamination.
 Vancomycin 5% (50mg/ml) or ceftazidime 5% (50mg/ml) applied intensively may
penetrate the cornea in therapeutic levels. 3rd
and 4th
generation fluoroquinolones
achieve effective level in the aqueous and vitreous, even in uninflamed eyes and
may be considered.
ORAL ANTIBIOTICS :
 Fluoroquinolones penetrate the eyes well.
 Moxifloxaxin 400mg daily for 10 days is recommended
 Clarithromycin 500mg twicw daily may be helpful for culture negative infection.
ORAL STEROIDS :
 The rationale for the use of steroids is to limit destructive complications of the
inflammatory process.
 Prednisolone 1mg/kg/day may be considered in severe cases after 12 – 24 hours ,
provided fungal infection has been excluded.
PERIOCULAR STEROIDS:
 Dexamethasone and triamcinolone should be considered if systemic therapy is
contraindicated.
TOPICAL DEXAMATHASONE :
 0.1% 2 hourly initially for anterior uveitis
TOPICAL MYDRIATIC :
 Atropine 1% twicw daily
INTRAVITREAL STEROIDS :
 May reduce inflammation in short term but do not influence the final visual
outcome;

7. PARS PLANA VITRECTOMY :
 The endophthalmitis vitrectomy study showed a benefit for immediate PPV in eyes
with a V/A of PL+ (not HM or better) at presentation, with 50% reduction in severe
visual loss.
Approach to management of a case of Endophthalmitis (based on the results of
EVS Group)
Management of Late problems:
Check the VISUAL ACUITY and then plan treatment
accordingly
If vision is >= HMCF, proceed for
vitreous sampling by tap for
microbiology and intracanthal
injection of antibiotics
If vision in only PL + , then
patient should be taken up for
vitrectomy with IV antibiotics
If No PL , then no surgical
intervention is required or
evisceration if developing
panophthalmitis
1st
STEP
2nd
STEP
After 48 hours check the vision and if there is no improvement, proceed for
rpt vitreous tap for infection
If there is no improvement after 2 intravitreal injections, proceed for
vitrectomy

8.  Persistent vitreous pacification : Aggressive and extended topical, periocular and if
necessary oral steroid treatment will often lead to resolution . vitrectomy can be
considered if the opacification is persistant
 Maculopathy in the form on ERM, CME and ishchaemia
 Hypotony . Wound leak should be excluded and persistant inflammation addressed.
Choroidal effusion should be identified and drained if necessary. RD and anterior
vitreous membrane may require vitrectomy.
 Chronic uveitis , secondary glaucoma , RD and pthisis bulbi should be managed
accordingly.
DELAYED ONSET POSTOPERATIVE ENDOPHTHALMITIS
PATHOGENESIS
Delayed onset endophthalmitis following cataract surgery develops when a low
virulence organism , such as P. acnes becomes trapped within the capsular bag .
Also called as saccular endophthalmitis.
Organisms can become sequestered within the macrophages, protected from
eradication but with continues expression of bacterial antigen.
Onset : 4 weeks to years postoperatively and typically follows uneventful cataract
surgery.
May be rarely precipitated by laser capsulotomy – due to release of organism.
DIAGNOSIS
 SYMPTOMS :
Painless mild progressive visual loss is typical.
Floaters may be present
 SIGNS :
Low grade anterior uveitis, sometimes with medium – large KPs.
Vitritis is common

9. An enlarging capsular capsular plaque composed of organisms sequestered in residual cortex within
the peripheral capsular bag is common
MANAGEMENT
INITIAL MANAGEMENT :
Later generation of fluroquinolones – moxifloxacin , penetrate the eye well and are concentrated
within macrophages.
10 – 14 day course of moxifloxacin may be prior to invasive options
Alternative drug : clarithromycin
INVESTIGATION
Sampling of aqueous and vitreous should be done / considered if oral antibiotics are ineffective.
Anerobic culture should be done if P. acnes infection is suspected and isolates may take 10 to 14
days to grow.
PCR – to rule out viral anterior uveitis
TREATMENT IF PERSISTANT
Intravitreal antibiotics alone are usually unsuccessful in resolving the infection
Removal of the capsular bag, residual cortex and IOL, requires PPV.
Secondary IOL implantation may be considered on a later date
Intravitreal antibiotic are combined with PPV – vancomycin (1-2mg in 0.1 ml ) can also be irrigated
into any capsular remanant