1. Endophthalmitis is an intraocular inflammation that predominantly affects the inner spaces of the eye. 2. It can be classified as infectious (exogenous or endogenous) or non-infectious. The most common type is exogenous endophthalmitis, which accounts for over 85% of cases. 3. Treatment depends on the type and severity of endophthalmitis. For acute postoperative endophthalmitis with vision of light perception or worse, immediate pars plana vitrectomy and intravitreal antibiotics is recommended. For vision of hand motions or better, a tap and inject of intravitreal antibiotics is recommended initially.

1. Endophthalmitis
3rd year resident, MNUMS
B.Bulganchimeg MD

2. Endophthalmitis
• Endophthalmitis is defined as an intra-ocular inflammation which
predominantly affects the inner spaces of the eye (vitreous and/or
the anterior chamber)
Urgent Vision loss
Loss of the
eye

3. Classification
Infectious
Exogenous
Post
operative
Acute
Chronic
Traumatic
Bleb
associated
After IV
injection
Endogenous
Noninfectious

4. Types of endophthalmitis
Exogenous (>85%)
• Acute Postoperative
• Chronic Postoperative
• Traumatic
• Filtering Bleb-Associated
• After Intravitreal
Injections
Endogenous (<15%)
• Originates from sources
within the body
• 2-8% of endophthalmitis
cases
• Recent intravenous
infusion, DM, HIV, IV drug
abuse, renal failure on
dialysis, cardiac disease,
malignancy,
immunosuppressive
therapy, or indwelling
catheters
• Liver abscess

5. Postoperative endophtalmitis
Acute onset (6wk>)
• Coagulase (-) staphylococcus species
Chronic -delayed onset (6wk<)
• Coagulase (-) staphylococcus species
• Fungi, propioni bacterium acnes
Bleb-associated (months,years after)
• Streptococcus species
• Haemophilus species
• Gram (+) organisms

6. Bacterial Fungal
Viral Parasitic

7. Common organism causing endophthalmitis
A. Exogenous
Acute onset Postsurgical Gram positive : S. epidermidis, S. aureus , Streptococcus spp.
Gram negative : Pseudomonas, Proteus, H. influenzae, Klebsiella, E. coli,
Enterobacter
Delayed onset Postsurgical Fungi : aspergillus, fusarium, candid, penicillum
Bacteria : P. acnes S. epidermidis
Post-traumatic Bacillus spp. S. epidermidis Streptococcus spp.
fungi (fusarium)
B. Endogenous Bacteria : B. cereus ( IV abusers), Streptococcus spp.,
S. aureus, Meningococci , H. influenzae
Fungi : mucor, candida

8. Bacterial entry into eye
Cascade of inflammatory products
Inflammatory cell recruitment
Tissue destruction
Release of digestive enzymes by the cells&
toxins by bacteria
PATHOGENESIS

9. Post operative endophthalmitis
• Cataract surgery 0.08-0.7%
Intravitreal injections
Penetrating keratoplasty 0.11-0.18%
 Trabeculectomy and glaucoma drainage device implantation 0.2%–9.6%
 Pars Plana Vitrectomy 0.03-0.05%

10. Postoperative endophthalmitis
Acute • (<6 weeks)
Chronic • (>6 weeks)

11. Acute Postoperative Endophthalmitis
• Shortly after ocular surgery /within 1-2wk, usually 3-5 days/
Epidemiology:
• APE most common form of endophthalmitis
• Following cataract surgery 0.08% - 0.68%
• Rates increasing since clear corneal incisions
• Highest risk after 2ndary IOL (0.2-0.367%),
• Lowest risk after PPV (0.03-0.046%).

12. 10
0.12
0.3-0.5
0
2
4
6
8
10
12
ICCE ECCE Phaco (CCI)
The incidence of endophthalmitis after cataract surgery

13. Acute endophthalmitis with hypopyon

14. Source of infection

15. Risk factors
Preoperative
Blepharitis
Active conjunctivitis
LD infection, obstruction
Operative
Wound abnormalities
Vitreous loss
Prolonged surgery

16. Endophthalmitis Vitrectomy Study (EVS)
94.3% 82.1% 74%
34.5% Photophobia Purulent discharge

17. Symptoms
85% hypopyon 79% hazy media 26 % LP

18. Clinical signs
• Decreased visual acuity
• Lids- edema
• Conjunctiva- congestion and
chemosis
• Cornea edema, ring
abscess(Pseudomonas and
Bacillus)
• Anterior chambercells and flare
• Hypopyon (in 86%patients in
EVS)

19. • Iris muddy and boggy
• Pupil-fibrinous exudate
• IOL-may be covered by fibrin
• Fundus-
 vitreous exudates,
scattered retinal haemorrhages
Periphlebitis
 loss of red reflex

20. Presenting Visual Acuity
• HM vs LP - Important
• Pars plana vitrectomy recommended in patients with visual acuity of
light perception (LP).
• Hand motion (HM) or better, tap and inject intravitreal antibiotics
• When measuring VA, the technique of differentiating LP vs. HM vision
is most important

21. Differential Diagnosis of Acute
Endophthalmitis
• Occult retention of lens cortex or nucleus
• Hypopyon uveitis (Behcet’s or rifabutin)
• Inflammatory reaction to intravitreal drug
• Blebitis
• Keratitis
• Toxic anterior segment syndrome (TASS)

22. Toxic anterior segment syndrome (TASS)
Sterile postoperative
endophthalmitis
• Rapid onset ( 12-24 hours,
limbus to limbus corneal
edema)
• Noninfectious substance the
enters AS
• Increased intraocular pressure
• Absent vitreous inflammation
• Iris damage
• Response to steroid

24. Diagnosis
• Clicinal signs, symptoms
,evaluation
• Ultrasound
• Microbiological testing
• Aqueous and Vitreous Specimen
• PCR

25. Ultrasound
• Should be performed if significant media opacification prevents
adequate view of the fundus
• Findings c/w endophthalmitis:
• Dispersed vitreous opacities with vitritis
• Chorioretinal thickening
• Rule out: RD or choroidals, dislocated lens material, retained foreign
bodies
• Retinal or choroidal detachment are poor prognostic factors

26. Aqueous tap (40% Gr +)
• An anterior
chamber
paracentesis is
performed using a
25 or 27 gauge
needle and 0.1 ml
of aqeous material
is aspirated.

27. Vitreous tap (60% Gr +)
• A trans pars plana aspiration
with a 23 gauge needle
• 3mm posterior to limbus in
pseudophakic and aphakic
eyes.
• 4mm posterior to limbus in
phakic eyes
• 0.2 ml of vitreous aspirated.

28. Microbiological Characteristics (EVS)
CNS (Staph.epi)
70%
Staph.aureus
10%
Streptococcus
9%
Enterococcus
2%
Other gr +
3%
Gr -
6%
CNS (Staph.epi)
Staph.aureus
Streptococcus
Enterococcus
Other gr +
Gr -

29. Treatment goals
1. Retention of useful vision
2. Minimize the infection with antimicrobial agents.
3. Limit the inflammation.
4. Symptomatic relief.

30. Treatment
• PPV
• Intravitreal AB
• Systemic
antibiotics
• Cotricosteroids
• Supportive
treatment

31. Endophthalmitis
Is there good reflex ?
Yes
No
Initiate medical therapy and observe
patient closely for the 1st 24 hours
Vitrectomy
Is there improvement?
Yes No
Continue the medical
therapy and close
observation
Treatment algorithm of CEVE for
acute postoperative endohthalmitis

32. TREATMENT
For VA that is "hand motions" or better:
 Tap and inject. First tap the eye for samples:
o Anterior chamber aqueous tap with 30g needle on a tuberculin syringe
sent for cultures
o Vitreous sample obtained through the pars plana with a 25 gauge, 1
inch needle directed toward the mid-vitreous cavity and then sent for
cultures
 Inject the vitreous cavity with antibiotics (ie. Vancomycin and amikacin
were used in the EVS. Ceftazidine is often used in clinical practice in the
place of amikacin, primarily due to the risk of aminoglycoside toxicity with
amikacin)
For VA that is worse than "hand motions":
 Pars plana vitrectomy. Send aqueous and vitrectomy cultures taken during
surgery.
 Inject intravitreal antibiotics at the time of surgery
Follow cultures and adjust antibiotics accordingly, if necessary

33. The EVS
Conducted between 1990 and January
1994, the EVS was a prospective, randomized,
multicenter trial on 420 eyes to determine
whether it is necessary in acute postoperative
endophthalmitis to use systemic antibiotics
or perform routine immediate vitrectomy

34. Materials and method
• 24 centers across the US
• 1990.02-1994.01
Patient selection
• Patients had clinical signs and symptoms of bacterial endophthalmitis
within 6 weeks after cataract surgery or secondary intraocular lens
implantation.

35. Inclusion criteria
• ETDRS- VA=LP↑ or
20/50↓
• Cornea, AC-clear
• Cornea clear to perform
VIT
• Hypopyon or sufficient
clouding of the AC or
vitreous to obscure a
view of second-order
retinal arterioles.
Exclusion criteria
• VA<0.2 before cataract
• Intraocular surgery
• Penetrating trauma
• Injection of IV AB
• Prior PPV
• RD, CD
• strong suspicion of
fungal endophthalmitis
• 18 age ↓

36. Screened 1283
patients
855 patients /6wk-
endoph diagnosed/
510 met eligibilty criteria
420 agreed to
participate

37. Study groups
Initial
VIT+IV
antibiotics
Initial VIT
without IV
antibiotics
Initial TAP
with IV
antibiotics
Initial TAP
without IV
antibiotics

38. Initial procedure (Eyelid culture, 0.1ml AC sample)
VIT group
• 3 port pars plana VIT
• When necessary
vizualization, AC was
cleared
TAP group
• Vitreous spicemen collected
either PP vitreous needle
aspiration or vitreous biopsy
• Vitreous sample 0.1-0.3mL

39. Study medication
• After initial VIT or TAP procedure all patients: intravitreal inj of
amikacin 0.4mg/0.1ml, vancomycin 1.0mg/0.1ml
• Vanco 25mg/0.5ml+ceftazidime 100mg/0.5ml+dexa
6mg/0.25ml→subconj
• Topical AB 1d/4h
• Topical cycloplegics, corticosteroids
• Systemic CS (prednisoloni 30mg*2→5-10days)

40. Results
• Systemic antibiotics do not improve the
outcome
• Vitrectomy is indicated only in eyes with
light perception vision.
1. There was no difference in final visual acuity
or media clarity with or without the use of
systemic antibiotics.
2. HM ↑ - immediate VIT not influenced
3. LP – VIT increase VA.
a. Three times more likely to achieve ≥20/40
(33% vs 11%)
b. Two times more likely to achieve ≥20/100
(56% vs 30%)
c. Less likely to incur <5/200 (20% vs 47%)

41. Prevention
1. Pre-operative
oPovidone iodine drops
oTopical AB
oMeticulous draping
2. Intra-operative
oIrrigation of A/C with vancomycin
3. Post-operative
• Intra cameral cefuroxime
• Post op subconj AB injection
• Post op AB drops

42. Chronic Postoperative Endophthalmitis
(> 6 weeks)
• Usually manifest several weeks
or months after surgery
• Less common than acute variety
• Organisms isolated are less
virulent bacteria and fungal
66%
17%
17%
Pathogens
Pro.acnes
Staph.epidermidis
Candida parapsilosis

43. Chronic saccular endophthalmitis (Note
whitish plaque)

44. SYMPTOMS-
• Photophobia
• Blurred vision
• Mild pain
SIGNS-
• KPs in AC
• Vitreous flare and cells
• Capsular plaque(in
Propionibacterium
acnesendophthalmitis after
Nd:Yagcapsulotomy)
• Granuloma formation in the
pupillaryarea or near the section(in
fungalendophthalmitis)

45. DDx of postoperative endophthalmitis
• Noninfectious uveitis
• Retained lens material
• Triamcinolone acetonide particles
• Longstanding (dehemoglobinized) vitreous hemorrhage

46. Diagnosis
• Clinical diagnosis
• B scan (RD, SCH, retained lens fragment)
• Cultures (VS>AS)
Commonly used cuture media
5% blood agar
Chocolate agar
Sabouraud agar
Anaerobic blood agar

47. Treatment for Chronic Cases
• Obtain A/C and vitreous samples
• Identification of infectious organism is key in management of these
infections Intravitreal antibiotics
• However, Vanco is often inadequate for P acnes
• Often need PPV and removal of capsule with IOL

48. Bleb related endophthalmitis
• Occurs as a result of pathogenic organisms gaining entry to intraocular
tissue through the conjunctival filtering bleb
• Mean time b/w surgery and endophthalmitis is 19.1 months (range 3-9
years)
• 0.2 – 9.6% of glaucoma filtering procedures
• Increased incidence with use of antifibrotic agents
• Early PPV
• Thin, cystic, avascular conjunctiva
• Clinical signs infected
 White bleb
 Vitritis
 Hypopyon

49. Endophthalmitis after Intravitreal Injection
• Increasing use of these agents, therefore concern for risk of
endophthalmitis
• Like acute postop endophthalmitis, CNS is the most common cause
• No infectious agent is identified in many cases
• Triamcinolone acetonide crystals can migrate into A/C and mimic
hypopyon
• 1.4%/injection for IVK
• 0.2%/injection for ranibizumab
• Intravitreal triamcinolone may play a role in endophthalmitis
potentiation

50. Non-infectious Endophthalmitis after
Triamcinolone Injection or intravitreal anti-VEGF
(aflibercept)
• Crystals in A/C or vitreous cavity can be difficult to distinguish from
inflammatory reaction
• Use gravity-induced shifting of layered material and absence of A/C
flare or fibrin as a sign of a non-inflammatory cause
• Triamcinolone crystals may shift from the inferior anterior chamber
angle when the pt is placed on his or her side, a phenomenon that
does not occur with sticky, fibrin-laden material in a true
inflammatory hypopyon
• Management options
• Close observation, topical steroids alone, oral levofloxacin alone

51. Post traumatic endophthalmitis
• Approximately 25% of
endophthalmitis cases
• After open globe injury, chance
of developing endophthalmitis
is approx 7%
• Injuries including IOFB have
higher rates

52. Risk factors
• Dirty wound
• Lens capsule rupture
• older age(>50)
• Initial presentation with a delay of more than 24 hours
• The presence of intraocular foreign bodies.
The incidence of endophthalmitis in cases of
• penetrating ocular trauma: 3.3% to 30% and
• after intraocular foreign body: 1.3% to 61%.

53. Managemant
• Primary repair and removal of IOFB as soon as possible
• Exclude the possibility of occult, retained IOFB
• CT scan with thin 1mm cuts
• Obtain cultures
• Intravitreal Vanco and Ceftaz
• Some advocate Gent + Clinda for synergistic effect against Bacillus and
Staph
Post-traumatic endophthalmitis has worst visual prognosis than other
categories

54. Endogenous endophthalmitis (2-8%)
• Hematogenous spread of organism from distant source
• It occurs when microorganisms in the bloodstream get into the eye, cross
the blood–retinal barrier, and infect the ocular tissue.
• Retina and choroid primarily involved due to high vascularity.
• Predisposing factors
 Diabetes - immunosuppresion(AIDS,malignancies medications)
 recent major abdominal surgery –
 prolong indwelling catheter ( intravenous , TPN)
 intravenous drug abuser
 distant infection ( endocarditis, meningitis, septicemia etc)
no structural defect in globe

55. Management of Endogenous Endophthalmitis
• Cultures are essential and may be lifesaving
• Vitreous sample should be obtained in all cases
• ID of causatic organism is made by systemic culture of blood, urine or
CSF in 75-80% of cases
• In contrast to postoperative endophthalmitis, systemic antibiotics are
central to the treatment of endogenous endophthalmitis
• Focal chorioretinitis and associated mild vitritis can respond to
systemic therapy alone

56. Symptoms
• Decreased or blurred vision
• ( sudden / severe – acute)
• ( slowly / mild—chronic)
• Pain
• Photophobia
• Redness of eyes
• Swollen eyelids Discharge
• White lesion in black part of the eye
• Floaters Fever

57. Fungal endophthalmitis
• Chronic infection (Rarely acute)
• Late onset (Redness + floaters)
• Fixed cheesy hypopyon
• Fibrinous mesh like exudation
• Snowball and fluffy opacities in the vitreous

58. Candidal endophthalmitis
• The two most characteristic
1. creamy white, well
circumscribed chorioretinal
lesions , most common in the
posterior pole
2. yellow or white fluffy vitreous
opacities.
“string of pearls”

59. Aspergillus endophthalmitis
• Most patients with endogenous Aspergillus
• Acute or subacute ocular symptoms.
• AS inflammatory signs: AC cells , KPs, hypopyon
• In most cases the organism initially affects the posterior segment,
forming a yellowish macular infiltrate .
• It frequently involves the macula, and this probably accounts for the
rapid onset of visual loss in many cases.

60. • A frequent clinical feature is the
pseudohypopyon in either the
preretinal (subhyaloid) or
subretinalspace .
• Vitritis
• Other features include occlusive
vasculitis and retinal hemorrhages.
• After treatment the area of
chorioretinitis progresses to
formation of a subretinal scar.
• The visual outcome is generally poor