Endophthalmitis is defined as inflammation of the vitreous and inner eye coats, often classified as exogenous (common post-surgery) or endogenous due to hematogenous spread. The document outlines various risk factors, clinical features, diagnostic methods, and treatment modalities, emphasizing the importance of early intervention to prevent complications. It also discusses specific types of endophthalmitis, including post-operative and traumatic cases, along with differential diagnoses and management strategies.

1. EndophthalmitisEndophthalmitis
Dr.Shah-Noor HassanDr.Shah-Noor Hassan
Vitreo-Retina ConsultantVitreo-Retina Consultant
Bangladesh Eye Hospital & InstituteBangladesh Eye Hospital & Institute

2. Definition
 Inflammation of the vitreous and the inner
coats of the eye

3. Based on location in the eye
Involvement of sclera → Panophthalmitis

4. Classification
Endophthalmitis can be classified according
to the
Mode of entry Type of etiological agent

5. According to mode of entry
ExogenousExogenous
(> 85%)(> 85%)
EndogenousEndogenous
(<15%)(<15%)
Micro-org directly introducedMicro-org directly introduced
from environmentfrom environment
Haematogenous spread ofHaematogenous spread of
organisms as a metastaticorganisms as a metastatic
infectioninfection
Usually occurs following surgery:Usually occurs following surgery:
i.e.i.e. post-operativepost-operative
endophthalmitisendophthalmitis
or trauma i.e. post-traumatic oror trauma i.e. post-traumatic or
keratitiskeratitis
Structural defect of eye is notStructural defect of eye is not
necessarynecessary
Mainly bacterialMainly bacterial Common predisposing factors areCommon predisposing factors are
immunocompromised status,immunocompromised status,
septicemia or IV drug abusesepticemia or IV drug abuse
Mainly fungalMainly fungal

6. According to aetiological agents
Bacterial Fungal
viral Parasitic
Endophthalmitis

7. Exogenous
Endophthalmitis

8. Major categories of
endophthalmitis
Category Incidence (%)
Postoperative 62
Bleb-associated 25
Trauma-associated 10
Endogenous (Metastatic) <4
Post-intravitreal inj <1

9. Risk Factors
Systemic Local Intra-operative
Diabetes
mellitus
Immuno-
suppression
Steroid
therapy
Rheumatoid
arthritis
Septic foci in
the body

10. Risk Factors
Systemic Local Intra-operative
Diabetes
mellitus
Staph & strepto – lids of
normal pts
Immuno-
suppression
Chronic NLD obstruction
Steroid
therapy
Blepharitis, canaculitis
Rheumatoid
arthritis
Conjunctivitis
Septic foci in
the body
Contact lens wear,
Ocular prosthesis in other
eye

11. Risk Factors
Systemic Local Intra-operative
Diabetes
mellitus
Chronic NLD
obstruction
Prolonged
operating time
Immuno-
suppression
Blepharitis,
canaculitis
Wound
dehiscence
Steroid
therapy
Conjunctivitis Vitreous loss
Rheumatoid
arthritis
Contact lens wear Retained lens
matter
Septic foci in
the body
Ocular prosthesis
in other eye
Contaminated
instruments &
soln

12. Risk Factors
Systemic Local Intra-operative
Diabetes
mellitus
Chronic NLD
obstruction
Duration > 60
mins
Traumatic
cataract
Immuno-
suppression
Blepharitis,
canaculitis
Poor wound
integrity
Donor cornea
Steroid
therapy
Conjunctivitis Suture
dehiscence
Prolene IOL
haptics
Rheumatoid
arthritis
Contact lens wear Retained lens
matter
Contaminated
IOLs and
viscoelastics
Septic foci in
the body
Ocular prosthesis
in other eye
Use of many
instruments
Type of
surgery

13. Microbial
Spectrum

14. Organism Postoperativ
e
(n=63) (%)
Bleb
associated
(n=30) (%)
Trauma
(n=30)
(%)
Staph
epidermidis
38 0 20
S. Aureus 21 7 0
Strepto. Spp 11 57 13
Bacillus spp 0 0 27
Haemophilus
influenzae
3 23 0
Other Gram –ve 13 7 20
Fungi 8 3 17
Other 6 3 3
Mixed flora 2 0 11

15. In Post-operative Endophthalmitis
Fulminant
(< 4 days)
Acute
(5-7 days)
Chronic (>4 weeks)
Delayed
onset
Delayed
entry
Gram negative
bacteria
Coagulase negative
staphylococci
P. acnes Streptococci
Pseudo.
aeuruginosa
Staph.
epidermidis
Fungi H. influenza
Streptococcus
pneumoniae
Fungi (rare) Aspergillus
Staphylococcus
aureus
Candida

16. Day of presentation of infection
0
10
20
30
40
50
60
70
80
% infection
1-7 days 8-14 days >15 days >1 month
In most cases, infection occurs in immediate post-op period,

17. In Post-traumatic Endophthalmitis
Fulminant
(1-2 days)
Acute
(3-4 days)
Chronic
(5-7days)
In Children
Bacillus cereus Staph. epidermidis P. acnes Streptococci
Streptococci Gram negative
bacteria
Fungi Kingella
kingae
Clostridium Fusarium

18. In Endogenous Endophthalmitis
Fungal Bacterial In Children
Candida albicans Bacillus cereus Toxocara canis
Aspergillus
fumigatus
Klebsiella pneumoniae Cysticercus
cellulosae
Cryptococcus
neoformans
Listeria
monocytogenes

19. Clinical Features

20.  Ocular pain (74% cases)
 Blurring & diminished vision (94% cases)
 Headache
 Increased redness
 Discharge & watering
 Photophobia
 Blepharospasm
Symptoms

21. Signs
 Upper lid edema
 Marked conjunctival hyperaemia
 Intense chemosis
 Purulent discharge
 Corneal edema
 Endothelial precipitates
 Hypopyon
 Muddy iris resistant to dilatation
 Vitreous haze
 Yellowish / Absent red reflex
 Proptosis, periorbital swelling, low-
grade fever, leukocyotosis –
severe cases

22. -EVS grading on IO:
-Grade 1: All details seen
-Grade 2: 2nd
order branches seen
-Grade 3: Major vessels seen
-Grade 4: Disc faintly seen
-Grade 5: No glow seen
-Normal ocular motility (to r/o panophthalmitis)

23. Fungal Endophthalmitis
 Chronic infection (rarely acute)
 Late onset DOV with redness & floaters
 Fixed cheesy hypopyon
 Fibrinous mesh-like exudation
 Snowballs & fluffy opacities in vitreous

24. Fungal Endophthalmitis
 Candida chorioretinitis
Several small, creamy-
white, circumscribed
chorioretinal lesions with
overlying vitreous
inflammation
 Aspergillus endophthalmitis
Poor prognosis due to
preferred macular
involvement

25. Differential
Diagnosis

26. Differential Diagnosis
Post-Surgical
Non-Surgical
 Retained IOFB (iron / copper)
 Severe pars planitis
 Old vitreous hemorrhage
 Toxoplasma / Toxocara infestation
 Necrotic retinoblastoma

27. Sterile Endophthalmitis
 Non-infectious post-operative
inflammation
Retained lens matter
Residual chemicals from sterilization
Monomer toxicity (PMMA lenses)
Mechanical irritation
of iris & ciliary body
by IOL
Inadvertent intraocular
injection of xylocaine

28. Phaco Anaphylactic
Endophthalmitis
 Autoimmune process due to lens capsule
rupture
 Autosensitization due to release of
previously sequestered lens proteins
 Granulomatous inflammation which
surrounds the area of ruptured lens capsule
and cortical material

29. Infection Inflammation
History Severe pain & loss
of vision
Minimal pain &
decrease in acuity
Focal infiltrate Commonly present Rare
Fundus glow Poor / Absent Ok / Mildly poor
Vitreous cavity Haze seen Clear / Mild
Exudates Yellowish Whitish
IOP Low Normal
Steroid response Worsening Improves

30. Dictums
 Consider all unexpected post-operative
reactions as infectious unless proved
otherwise
 Keep a high level of suspicion
 Do not ignore any
post-operative
symptom

31. Investigations

32. USG B-scan
Must be done before
invasive, diagnostic or therapeutic intervention
To look for: Retinal or Choroidal detachment
Dislocated lens / nucleus
Retained Intra-Ocular Foreign Body (IOFB)
Parasite infestation

33. B SCAN ULTRASONOGRAPHY SHOWING
VITREOUS CAVITY FILLED WITH
EXUDATES AND MEMBRANES

34. Culture
Conjunctival
Swab
No longer used
Suture Must if sutural abscess or infected tract
Aqueous tap
(40% +ve)
-AC paracentesis with 27G needle
-0.1 ml aspirated in a tuberculin syringe
Vitreous tap
(60% +ve)
-0.2-0.3 ml (if fluid vitreous) with 25G
needle through pars plana
-Not adequate and danger of vitreous
traction leading to RD
-Through AC if aphakic without posterior
capsule

35. Culture
Aspirating
Needle
Needle itself put on media if dry tap
Vitreous
biopsy
(Diagnostic
Vitrectomy)
-Vitreous cutter placed in anterior vitreous
& 0.2-0.3ml manually aspirated
-With an infusion line: Dilutes sample &
need for additional sclerostomy
-Without infusion line: Lost volume
replaced by injecting saline
Vitrectomy
Cassette
-Vitreous admixed with irrigating fluid
-Passed over a 0.45µ millipore filter or
centrifuged for concentration
-Filter paper pieces placed in media

36.  Nested PCR – used to detect &
differentiate between species of Gram +ve
& -ve organisms
 Improved sensitivity
 PCR-RFLP has sensitivity of 1 organism

37. Vitreous Biopsy

38. Stains Cultures
(kept for at least 2 weeks)
Gram stain Blood agar Bacteria + Fungi
Giemsa stain Chocolate agar (with
CO2
)
Aerobic organisms
KOH mount Sabouraud’s agar Fungi
Air dried & fixed with
absolute methanol
Thioglycolate broth Anaerobic organisms
Centrifugal cytology is
superior but not a must
Brain-heart infusion
media
Fastidious fungi
Culture Media

39. STAPHYLOCOCCI
 Coagulase -ve cocci
Staph. epidermidis
 Coagulase +ve cocci
Staph. aureus

40. STREPTOCOCCI
 Toxin ⇒ tissue destruction
 Fulminant / Acute
 Poor prognosis
 In cases of blocked NLD

41. PROPIONIBACTERIUM
ACNES
 Gram positive anaerobic bacillus
 Cell wall resistant to break down by
macrophages and leukocytes
 Chronic infection
 Post-YAG capsulotomy

42. GRAM NEGATIVE
ORGANISMS
PSEUDOMONAS KLEBSIELLA

43. MIXED INFECTIONS

44. CHLAMYDOSPORES
CANDIDA ALBICANS
COLONIES

45. Laboratory confirmation of
diagnosis
Laboratory confirmed growth is defined as :
1. At least semi confluent growth on solid media
2. Any growth on more than or equal to 2 media
3. Growth on one media supported by a positive
gram stain
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No culture should be considered negative until two
weeks of observation

46. Treatment

47. Primary Objectives
1. Control and eradicate infection
2. Manage complications
3. Restore vision
Secondary Objectives
1. Symptomatic relief
2. Remove pupillary membrane in miosis
3. Maintain globe integrity

48. Determinants of Outcome
 Duration between onset & treatment
(Poor if >48hrs)
 Virulence & organism load
(Poor if Gram negative bacteria)
 Pharmacokinetics & Spectrum of activity of
antibiotics used

49. Treatment Modalities
 Antimicrobial treatment
 Corticosteroids
 Supportive treatment
 Vitrectomy

50. Intra-vitreal Injection
Gram-positive organisms:
Vancomycin 1 mg -Effective against MRSA
-Precipitates with ceftazidime
Gram-negative organisms:
Ceftazidime 2.25 mg -Effective against Pseudomonas
Amikacin 375µg -Least toxic & Most effective
aminoglycoside
Gentamicin 200µg -Macular toxicity and drug
resistance
Imipenem 25µg -Less toxic

51. Intra-vitreal Injection
Moxifloxacin
(Aydin et al)
150 µg -Single drug therapy
Antifungal:
Amphotericin B 5 µg -Slow release delivery needed
since fungi multiply slowly
Voriconazole 100µg -Aspergillus endophthalmitis

52. Intravitreal injection
 Immediately following diagnosis – bacterial colony
reproduaction occurs every 15 min
 Do not attempt to reattach syringe to vitreous biopsy
needle
 Re-enter the eye with new needle to deliver intravitreal
therapy
 Vitrectomized eyes – ¼ th dose
 Vitrectomized oil filled eyes – 1/10th
dose

53.  Direct injection of antibiotics into the
capsule may enhance clearing of the
infection and allow the IOL & capsule to
be retained
 Vancomycin + Dexamethsone in same
syringe – precipitate

54. Complications
 Retinal toxicity (aminoglycosides)
 Macular infarction

55. Systemic treatment
- Only an adjuvant (poor penetration into vitreous)
- High cost and systemic side-effects
- Antibacterial: Ceftazidime, Cefazolin, Imipenem,
Ciprofloxacin, Pefloxacin
- Antifungal: Amphotericin B (i.v.), Fluconazole or
Ketoconazole (oral)
- Important role in fungal and endogenous
endophthalmitis

56. Topical treatment
- Immediately following intravitreal inj, & on an hourly
basis
- 2-drug combinations (5% vancomycin with 2% amikacin
or 10% ceftazidime)
- Fortified drops in case of corneal involvement
- 0.3% Gatifloxacin, 0.5% Moxifloxacin: Dual action
- Frequency reduced after healing ensured
Sub-conjunctival injection
-Only if patient not compliant to topical instillation
-More discomfort, conjunctival tearing and SCH

57. Corticosteroids
- Prevent tissue damage by inhibiting release of
inflammatory mediators & endotoxins
- Contra-indicated in fungal infection
Intravitreal Dexamethasone 400µg in 0.1 ml
Systemic (oral) Prednisolone 1−2 mg/kg/day
Betamethasone 0.5-5mg/day
Sub-conjunctival Dexamethasone 1mg in 0.25ml
Topical Prednisolone 1%

58. Supportive treatment
 Cycloplegics:
Atropine 0.1%
Control of inflammation & relief of ciliary spasm
Prevent synechiae formation in miosis
Dilated pupil helps in assessment and during
vitrectomy
 Anti-glaucoma:
Oral Acetazolamide
Topical Timolol 0.5%

59. Response to Treatment
 Early diagnosis
 Prompt initiation
 Good compliance
Good response Recurrence on cessation of therapy

60. Response to Treatment
Chronic Post-operative Endophthalmitis

61. Vitrectomy
 Primary vitrectomy
Done for acute infection
 Secondary vitrectomy
Done in resolved phase to clear vitreous
opacification and membranes

62. Vitrectomy
Advantages Reduces the infectious & inflammatory load
Provides adequate specimen for culture
Increases the efficacy of intravit. antibiotics
Removes the media opacities
Indications Severe Endophthalmitis
Gram-negative organism or fungi identified
No response to intra-vitreal injections

63. Endophthalmitis Vitrectomy Study
 Multicenter randomized trial at 24 centres in
US (1990-94)
 Purpose:
Role of Immediate vitrectomy
Role of IV antibiotics

64. Endophthalmitis Vitrectomy Study
 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

65. Vitrectomy Considerations
 Obtain an undiluted vitreous sample
 Aggressive removal of all infiltrated vitreous
in the basal area is not necessary
 Discontinue if good visiblity cannot be
obtained
 GA is preferred

66. Beneficial effect of Silicone oil

67. Endophthalmitis in Silicone-filled
Eyes
 Anti-microbial activity
 AC & vitreous taps for culture
 Intravitreal injection of antibiotic dose
 Purulent exudate in vitreous cavity may be
removed with the oil using infusion fluid
 Silicone oil can be reinjected immediately or
following resolution of the inflammation

68. Combined vitrectomy + keratoplasty

69. Special Cases

70. P. acnes endophthalmitis
 Most common cause of chronic post-operative
endophthalmitis
 Propionibacterium acnes: Gram positive
anaerobic bacillus with intracellular habitat
 Commensal of conjunctival sac

71. P. acnes endophthalmitis
 White plaques on capsular bag (colonies + cells)
 Unexpected inflammation after Nd:YAG
posterior capsulotomy
 Relapse after initial response to steroids
 Treatment:
 Intravitreal
Vancomycin
(1mg in 0.1ml)
 Vitrectomy +
IOL explant +
Total capsulectomy

72. Bleb-related Endophthalmitis
 Delayed trans-conjunctival entry of virulent
organisms after AGS (with anti-mitotic agents)
 Streptococci (50%), H. influenza (25%):
Both penetrate intact conjunctiva
 Risk factors:
 Inferior or nasal or a high bleb
 Late-onset bleb leak
 Use of antimitotic agents
 Preceeded by conjunctivitis,
contact lens use or URTI
 Treatment: Early vitrectomy

73. Blebitis
 Definition:
 Isolated bleb infection
 Varying anterior segment inflammation
 Without vitreous involvement
 Symptoms:
 Redness,
 Photophobia
 Pain
 Discharge
 Lid swelling

74. Blebitis
 “White on Red” ⇒
Opalescent bleb against
a background of diffuse
conjunctival injection
 Seidel test is often
positive
 Responds to therapy
within 24 to 48 hours
 May represent an early
stage of endophthalmitis

75. Post-Traumatic
Endophthalmitis
 Disorganisation of normal anatomy
 Non-metallic IOFB
 Fulminant presentation with chemosis,
proptosis and corneal ring infiltrate
 Treatment:
Prophylactic systemic +/- intravitreal
antibiotics may be considered
Early vitrectomy with IOFB removal and
culture

76. Endogenous
endophthalmitis

77. Endogenous Endophthalmitis
 15% of endophthalmitis cases1
 Fungal > Bacterial
 2-8% are bacterial2
 10-40% cases of systemic fungal
infections develop endophthalmitis3
1. Rowsey JJ, Newsom DL, Sexton DJ, et al. Endophthalmitis: current approaches. Ophthalmology 1982;89(9):1055-66.
2. Okada AA, Johnson RP, Liles WC, et al. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective
study. Ophthalmology 1994;101:832-838
3. Donahue SP, Greven CM, Zuravleff JJ, et al. Intraocular candidiasis in patients with candidemia. Ophthalmology
1994;101:1302-1309.

78. Endogenous Endophthalmitis
 Organisms permeate the blood-ocular
barrier by:
Direct invasion (i.e. septic emboli) or
Changes in vascular endothelium caused by
substrates released during infection

79. Endogenous Endophthalmitis
 Fungal cases
Candida albicans: 75-80%
 Bacterial cases1
 Gram-positive organisms: 66%
 Streptococcal species: 32%
 Staphylococcus aureus: 25%
 Source identified in 93%1
 Endocarditis, Gastrointestinal tract
1. Okada AA, Johnson RP, Liles WC, et al. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective
study. Ophthalmology 1994;101:832-838

80. Diffuse scleral
thickening with
preseptal inflammation
and proptosis
Endogenous Endophthalmitis
 DM, decubitus ulcers & nephropathy
 MRSA endophthalmitis
Upper lid erythema &
swelling
Purulent discharge

81. Sources Risk Factors
- Hepatic abscess - Immunocompromised host
- Appendicitis - Indwelling catheters
- Endocarditis - Major surgery
- Pyoderma - Diabetes mellitus
- Suppurative otitis media - I.V. drug abusers
- Pulmonary infections - Organ transplant

82. Other Investigations
 CBC with differential
 ESR
 Blood urea nitrogen
 Sr. Creatinine
 Chest x-ray
 Cardiac ultrasound
 CT scan / MRI of orbit

83. Treatment
 Broad-spectrum IV antibiotics (vancomycin +
aminoglycoside or cephalosporin)
 Clindamycin in IV drug users until Bacillus
infection can be ruled out
 Intravitreal antibiotics are also indicated
 Vitrectomy may be needed for virulent
organisms
 Only 40% have >HM vision

84. Endophthalmitis in Children
 Etiology:
Post-traumatic (most common) or
Endogenous or
Contiguous spread
 Diagnostic problems (need to rule out
retinoblastoma)
 Important to try to at least maintain the
shape of the eyeball

85. Prophylaxis

86. Prophylaxis
Antibiotics in
irrigating fluid
Post-operative
antibiotic drops
Painting with
povidone-iodine
Draping of
eyelashes & lid
margin
Intracameral
antibiotics
Pre-operative
antibiotic drops
Topical 5%
povidone-iodine
Empirical / ControversialProven benefit

87. Prophylaxis
Antibiotics in
irrigating fluid
Post-operative
antibiotic drops
Painting with
povidone-iodine
Draping of
eyelashes & lid
margin
Intracameral
antibiotics
Pre-operative
antibiotic drops
Topical 5%
povidone-iodine
Empirical / ControversialProven benefit

96. Post operative Endophthalmitis (POE) is defined as a
severe inflammation involving both the anterior and
posterior segments of the eye after any surgical
intervention.
 It accounts for 25% of all endophthalmitis cases .
 70% are infective endophthalmitis.
Ophthalmol 1998; 105: 1004-1010

97. Post-Surgical Endophthalmitis
Fulminant(<4 days)
-gm negative bacteria
-streptococci
-staph. aureus
Acute(5-7 days)
-staph. Epidermidis
-Coagulase negative cocci
-fungi(rarely)
Delayed entry
(e.g.bleb related)
Delayed onset
-P. acnes
-fungi
-Staph. epidermidis
Chronic(>4 weeks)

98. Spectrum of Cases
*IJO-2000
 Gram-positive : 37.6%
S. epidermidis : 12.9%
S. aureus : 7.6%
P. acnes : 5.9%
Enterococcus : 2.3%
Streptococcus : 4.1%
Others : 4.8%

99. Spectrum of Cases
 Gram-negative : 41.7%
 P. aeruginosa : 7.1%
 Pseudomonas : 8.8%
 Non-fermenters : 10.6%
 Others : 5.8%
 Fungi : 21.8%
*IJO-2000

100. Other clinical features
Symptoms Signs
-Congestion, chemosis
-Corneal involvement
-Hypotony

101. Laboratory confirmation of
diagnosis
-Direct plating is better than sending the sample in
transportation media
-If direct plating is not possible, then the sample
should be sent at the earliest for plating in the
laboratory and immediate Gram and Giemsa
staining performed
-Lid margin and conjunctival swab cultures are no
longer recommended

102. Laboratory confirmation of
diagnosis
-Culture of suture removed in the presence of a
suture abscess or infected suture track is a must
-Samples from both aqueous and vitreous must be
cultured
-Aqueous and vitreous samples must be obtained
with sterile precautions
- Plating should be on all three culture media:
aerobic, anaerobic and fungal
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103. - The preferred culture media are :
1.Chocolate agar (37° C in C02)
2.Fresh enriched thioglycolate (37° C)
3.Fresh Sabourauds dextrose agar (25° C)
-
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Laboratory confirmation of
diagnosis

104. Toxoplasma retinochoroiditis
 A form of chronic recurrent
endophthalmitis
 T/t – repeated inj of 1 mg Clindamycin + 1
mg Dexamethasone