1. Early recognition and treatment of endophthalmitis is critical to prevent further spread and vision loss. Diagnosis involves a thorough ocular exam, microbiological investigations including aqueous or vitreous taps and cultures, as well as systemic workup to identify the source of infection. 2. Treatment involves prompt administration of broad-spectrum intravitreal antibiotics targeting both gram-positive and gram-negative organisms. Vitrectomy may improve outcomes in cases with initial light perception vision or suspected fungal infection. Close monitoring is needed as repeat injections or surgery may be required if the infection persists or vision declines. 3. Risk factors like older age, diabetes, and poor initial vision portend worse visual outcomes,

1. Endophthalmitis
Management
Jagdish Dukre

2. Diagnosis of endophthalmitis
Early recognition is critical.
High index of suspicion to be maintained.
A complete ocular and medical history is
essential
Search for septic foci.
Thorough ophthalmic examination
performed.

3. Microbiological investigations
 Aqeous tap
 Vitreous tap
(culture positivity >than with aqeous-EVS)

4. Aqueous tap
An anterior chamber paracentesis is performed using a
25 or 27 gauge needle and 0.1 ml of aqeous material is
aspirated.

5. Vitreous tap
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.
Small gauge battery powered vitreous cutting
instruments(Visitec,Sarasota,USA)
(culture +ity of tap=culture +ity of mech.cutter
biopsy)
Three port vitrectomy
(culture +ity of tap=culture +ity of vitrectomy-EVS)

6. OCULAR INVESTIGATIONS contd…
Gram staining
Giemsa staining
KOH preparation
Cultures on
 Blood agar
 Chocolate agar
 Sabourad dextrose
agar
 Thyoglycollate agar
 Robertson’s cooked
meat broth

7. OCULAR INVESTIGATIONS contd…
Repeat cultures may be needed
When clinical response is not good inspite of using correct
antibiotic
Due to presence of contaminants in media.
Presence of fungus which is especially likely to be missed
initially.
Negative cultures may arise due to
Presence of fastidious organisms
Insufficient sampling
Sterile endophthalmitis

8. Polymerase chain reaction-
May provide a more rapid method of specific diagnosis
by allowing detection of DNA from infecting organisms.
It has a higher sensitivity and shorter detection time.
Especially useful for culture negative samples.
Nested PCR with universal eubacterial primers
complimentary to regions of 16S rDNA conserved
sequences detected 50 fg of bacterial DNA spike in
normal vitreous. Nested PCR with P. acnes primers
detected 10 fg of DNA.
universal primers to detect the presence of pathogen
DNA probe hybridization to determine the species of the
bacteria.

9. ULTRASOUND
Helpful in cases with significant anterior segment
media opacity.
Commonest feature is presence of variable
echoes in vitreous cavity.
Thickening of choroid
Choroidal and retinal detachment
To search for retained lens remnants in the
posterior segment.
Intraocular foreign body in post traumatic cases.

10.  Comments: OS- low echo
reflective inferior vit
opacities, retina on.
 high reflective spot seen
superior(mid) vit cavity
with severe reverberating
echos.
 ?Air bubble. ???IOFB.

12. INVESTIGATIONS….contd
SYSTEMIC
 Routine investigations
complete haemogram( raised TLC)
blood sugar( predisposition in diabetics)
 Conjunctival smear ( existing organisms in adenexae)
 Blood and urine cultures ( endogenous endophthalmitis)
 Cultures from other sites(catheter tips,cerebrospinal fluid,skin
wounds,abscesses and joints)
 Chest x-ray, ECG and echocardiography.
 Abdominal ultrasound

13. DIFFERENTIAL DIAGNOSIS
History of intraocular surgery or trauma
 Severe sterile postoperative inflammation
 Lens induced inflammation
-phacoanaphylactic endophthalmitis
-retained lens material
 History of or predisposition to uveitis
 Inadvertant toxic substance introduced into eye.

14.  Drug induced
-metipranolol(usually mild)
-latanoprost(usually mild)
-rifabutin (frequently with hypopyon)
 Rebound inflammation after rapid antiinflammatory taper
 No history of intraocular surgery or trauma
 Neoplastic infiltration
 Viral retinitis

15. Management
Once the clinical diagnosis is made ,to avoid
further spread and for better control –all
systemic source of infection should be
eliminated-
 All the indwelling catheters are removed
 Hyperglycemia,if present, is controlled
 If patient is on corticosteroids or other
immunosuppresives,the dose is monitored.

16. MEDICAL Rx- endophthalmitis
Acute infectious endophthalmitis is an
ophthalmic emergency.
It requires prompt therapy.
Rapid administration of antibiotics without
waiting for culture reports or even gram stain
reports.
Emperical broad spectrum coverage of both gm.
+ve & gm. –ve organisms. Antifungals- if strong
suspicion of fungus.

17. ROUTE OF ADMINISTRATION
TOPICAL-
frequent instillation of topical antibiotics and
steroids penetrate cornea and reach anterior segment
Fortified drug Percent. Conc. Mg/ml
Cephazolin 5% 50
Tobramycin 1.3% 13.6
Vancomycin 0.3% 3

18. INTRAVITREAL-
-this is the most accepted mode of
delivery of drugs to the posterior segment.
- drugs are administered via pars plana.
SYSTEMIC ADMINISTRATION-
- intravenous antibiotics are administered
in endogenous endophthalmitis
- systemic antibiotics are recommended
for posttraumatic endophthalmitis.
- role of systemic antibiotics has been
severely questioned by Endophthalmitis
Vitrectomy Study.

19. SUBCONJUNCTIVAL-
have no advantage over topical and is more
painful.
INTRACAMERAL-
is not indicated as frequent topical instillations
reach significant levels of drugs in anterior
chamber.(except in suspected P.acne
infections with little or no posterior segment
involvement.)

20. Intra vitreal injections are the most
preferred way to administer antibiotics
locally.
Broad spectrum antibiotics are chosen.

21. For gram positive organisms
(according to EVS)
Agent of choice-Vancomycin.
broad-spectrum activity against most gram
positive species
 1 mg in (0.1 ml) is given intravitreally
Non toxic in recommended clinical dosage.
Arch Ophth 1999; 117: 1023-1027

22. Single intravitreal vancomycin dose –provides
adequate antibiotic concentrations for over one
week
Time after intravitreal
administration of
vancomycin(hrs)
vitreal level (mg/ml)
48
72
137.85
182.36
Arch.ophth.1999; 117: 1023-27
B J O 2001; 85: 1289-93

23. For gram negative organisms
(according to EVS)
Gentamycin(0.4mg)-associated with retinal toxicity
Amikacin was used(4 times less retinal toxicity)
Amikacin covers large number of gram negative
organisms and those resistant to other aminoglycosides
A survey of retinal specialists suggested that amikacin
can also cause retinal toxicity
Thus, Ceftazidime has emerged as an alternative to
amikacin
More effective than aminoglycosides
Retinal toxicity studies in primates reveal concentration
of 2.25 mg/0.1 ml to be safe.

24. Vancomycin combined with
amikacin or ceftazidime appears to
be best .
Br. J Ophth 1997; 81: 1006-15

25. For fungal infections-
Fungal endophthalmitis is treated with intravitreal
amphotericin B(5microgm in 0.1 ml)
- after a positive culture is obtained or
- if there is a strong suspicion of fungal
infection.
 Intavitreal voriconazole is used for resistant fungal
endophthalmitis.
Systemic therapy should be given but renal toxicity must
be monitored closely.
Oral high dose fluconazole(400-600mg/day)is beneficial
in infections with candida.
Adjunctive corticosteroid therapy is not given.

26. Role of steroids
To control the inflammation mediated damage
while antibiotics take care of the infection.
Intravitreal steroids -along with antibiotics if
fungus is not suspected.
Alternately one can wait for 24hrs for antibiotics
to act and then administer intravitreal steroids or
start oral steroids.

27. contd…
Usually 360 to 400 micrograms of
dexamethasone is injected
.
Subconjunctival injection dexamethasone(12mg)
and topical steroids are used commonly.
Systemic glucocorticoids can be administered
orally(30 mg twice a day for 5 to 10 days)if there
is no contraindication.

28. OTHER MEDICATIONS
A topical cycloplegic is usually administered.
Raised pressure can be seen in fungal
endophthalmitis.
Oral acetazolamide or topical beta blockers may
be given.

29. EMPIRICAL MEDICAL THERAPY OF
ENDOPHTHALMITIS
ACUTE ONSET POST CATARACT
EXTRACTION
 INTRAVITREAL
 Vancomycin hydrochloride 1.0 mg in 0.1 ml (normal saline) and
 Ceftazidime 2.25mg in 0.1ml(normal saline) or amikacin 200-
400micrograms in 0.1(normal saline)
 Dexamethasone 400micrograms in 0.1ml(optional)
 SUBCONJUNCTIVAL
 Vancomycin hydrochloride 25mg in 0.5ml(normal salineand
 Ceftazidime 100mg in 0.5 ml(normal saline)or amikacin 25mg
in 0.5ml(normal saline)if B-lactam allergy exists and
 Dexamethasone 6mg in 0.25ml(normal saline)

30. TOPICAL
 Vancomycin hydrochloride 50mg/ml and
 Amikacin 20mg/ml and
 Atropine sulphate 1% or scopolamine hydrobromide 0.25%and
 Prednisolone acetate 1%
ORAL
 Prednisone 30mg twice daily for 5 to 10 days (optional)

31. POST TRAUMATIC
 Parallel to those listed for post cataract extraction,and
in addition:
 May also consider use of intravitreal clindamycin
phosphate(450 micrograms)
 Systemic antibiotics still considered standard of care.
Options include selections from the following:
Clindamycin 600-900mg intravenously every 8 hrs
Ceftazidime 2gm intravenously every 8 hrs
Amikacin 7.5mg/kg intravenously once,then 6mg/kg every
12hrs
Ciprofloxacin 750 mg po twice daily

32. BLEB ASSOCIATED ENDOPHTHALMITIS
 Similar to post cataract extraction,but consider
addition of systemic antibiotics as well.

33. SURGICAL TREATMENT
Surgical management of endophthalmitis begins
BEFORE the infection occurs.
 Careful operative technique to-
 Minimize wound abnormalities
 Avoidance of vitreous loss during cataract
surgery
 Careful microsurgical wound management
and closure in open globe injuries

34. VITRECTOMY
ADVANTAGES OF EARLY THERAPEUTIC
VITRECTOMY
 Clearing of ocular media
 Removal of potentially harmful bacterial products
 Reduction of bacterial load
 Removal of vitreous scaffolding by which tractional retinal
detachments may occur.

35. LIMITATIONS
Delay in treatment until operating room is available
Iatrogenic retinal holes and detachments
Choroidal haemorrhage
Problem of visualizing the posterior segment in an eye
that has had recent surgery
Retinal detachment is difficult to treat in eyes that have
undergone vitrectomy for endophthalmitis due to the
need for air-fluid exchange and injection of aqeous
antibiotic.
Concentration of antibiotic in the aqeous layer may lead
to an increased risk of toxicity.

36. INDICATIONS FOR VITRECTOMY
In acute-onset post cataract extraction endophthalmitis ,the
Endophthalmitis vitrectomy study showed that
 In patients with visual acuity hand motions or better
no difference in visual outcome with or without vitrectomy.
 In patients with initial light perception,
vitrectomy produced
-a threefold increase in the frequency of acheiving 20/40(6/12)vision or
better
-a twofold increased chance of achieving 20/100(6/30)vision or better,
- a 50% decrease in the frequency of severe visual loss

37. Contd...
Immediate vitrectomy - in suspected fungal endoph.
( Debulking allows relatively weak
antifungals to act better.)
-In retained intraocular foreign
body presenting with infection.
Immediate vitrectomy is done in infectious endophthalmitis because
of risk of rapid toxic damage from IOFB.
However it is performed 4-14 days after injury, to allow media to
clear and a PVD to occur.
Non magnetic FBs can be removed by vitrectomy and aid of a
forceps and electromagnet can be used for metallic FBs.

38. Vitrectomy is done in nonmagnetic,large,or subretinal
IOFBs,in eyes with opaque media(due to cataract or
vitreous haemorrhage.)
 Chronic infection due to sequestered organisms in the
capsular bag after cataract surgery with IOL implantation
can only be managed by surgery, which often involves
removal of the intraocular lens.

39. TIPS TO PERFORM VITRECTOMY
Six mm long cannula is used to clear the edematous
ciliary body so that accidental suprachoroidal infusion
may be avoided.
High cutting rate and low suction are used.
The peripheral vitreous is avoided for fear of inducing
peripheral retinal dialysis.

40. Surface retinal exudates are left alone.attempts to
remove them with flute needle suction can lead to retinal
breaks.
Corneal edema can affect visualisation
- visualisation improves on removing the exudates
from AC.
-corneal epithelium can be removed.
Use of viscoelastics in the anterior chamber can reduce
the descemet’s folds significantly.

41. Wound dehiscence – if the surgical wound gives
way,resuturing needs to be done with long bites of
interrupted sutures.
Areas of scleral necrosis are occasionally seen in cases
of bleb-induced endophthalmitis.which may need patch
scleral grafting to correct the tissue loss.

42. MANAGEMENT OF THE INTRAOCULAR LENS
In post cataract surgery endophthalmitis,in cases of
exudates on the IOL,visibility of the fundus can be
severely impaired.
Very often the fibrin can be removed using a needle or a
forceps under viscoelastic.
Sometimes exudates can be trapped between the
posterior capsule and the IOL.A posterior capsulotomy
can be done with a vitreous cutter and the trapped
exudates can be removed.

43. Removal of the IOL should not be restrained from in
severe cases.
Most cases of fungal endophthalmitis and eyes with
sequestered organisms in the capsular bag such as
propionibacterium endophthalmitis would need IOL
removal along with the capsular bag.

44. EVISCERATION
Evisceration as an end stage procedure may be
required in –
Uncontrolled infection and loss of light perception
In cases of panopthalmitis

45. COURSE AND OUTCOME
“if it isn’t worse, it’s better”
Media clarity and visual acuity may not improve initially.
An early response may be determined on the basis of
level of pain and lid injection.
Repeat intravitreal injections of antibiotics may be
required if the condition worsens and infection persists
as confirmed by a repeat culture.
Serial ultrasonography may be used to moniter clinical
response and detect retinal detachment.

46. BASELINE RISK FACTORS FOR
DECREASED VISUAL ACUITY OUTCOME
(AS DETERMINED BY EVS)
Older age
Diabetes
Corneal infiltrate or ring ulcer
Posterior capsule not intact
Intraocular pressure less than 5mm and more than 25mm Hg
Afferant pupillary defect
Rubeosis irides
Absent red reflex
Visual acuity of light perception,the most important risk factor,with a
twofold greater risk of poor visual outcome compared with those with
hand motion or better acuity during initial evaluation.

47. ROUTINE ANTISEPTIC MEASURES THAT
CAN REDUCE THE OCCURANCE OF
POSTOPERATIVE INFECTIONS
Improving the hygiene of the patients before and after
the surgery.
Use of povidine iodine(5%) in the conjunctival cul de sac
preoperatively
Strict adhesion to sterilisation precautions.Specifically
the phacoemulsification probe needs to be dismantled
and autoclaved between two cases.
Precaution in inspecting the irrigating fluid and
viscoelastics just before their use.
Careful draping of the patient to avoid the patient’s lid
margins and lashes from the wound.

48. GRADING A-BEST B-GOOD C-FAIR
Prophylactic intervention Clinical
recommendation
Preop lash trimming C
Preop saline irrigation C
Preop topical antibiotics C
Irrigating solutions with
antibiotics
C
Preop povidine iodine
antisepsis
B
Intraop heparin C
Post op subconj antibiotic C

49. Endophthalmitis vitrectomy study
Purpose-
To determine the role of initial pars plana vitrectomy in the
management of postoperative bacterial endophthalmitis.
To determine the role of intravenous antibiotics in the management
of bacterial endophthalmitis.
To determine which factors, other than treatment, predict outcome
in postoperative bacterial endophthalmitis

50. Description –
Two strategies for the Mx of endophthalmitis.
Eyes received either
(1) initial pars plana vitrectomy with intravitreal antibiotics, followed by
retap and reinjection at 36-60 hours or
(2) initial anterior chamber and vitreous tap/biopsy with injection of
intravitreal antibiotics, followed by vitrectomy and reinjection at 36-
60 hours .
In addition, all eyes were randomized to either treatment or no
treatment with intravenous antibiotics

51. Results:
There was no difference in final visual acuity or media clarity with or
without systemic antibiotics.
If patients presented with hand motions or better acuity, there was
no difference in visual outcome with or without an immediate 3 port
pars plana vitrectomy. ,
vitrectomy
-tripled the frequency of achieving 20/40 or better acuity;
- approximately doubled the chance of achieving 20/100 or better
acuity
- decreased by more than half the frequency of severe visual
loss in the subgroup of patients who presented with visual
acuity of light perception only.

52. BIBLIOGRAPHY
Retina,Vitreous and Macula
 Ophthalmology
Clinical practice in
ophthalmology
Parson’s diseases of the eye
British Journal of
Ophthalmology
Radiology
David
R.Guyer,L.A.Yanouzzi,S.Chan
g,W.R.Green
MyronYanoff,
J.S.Duker
 Dr.Sandeep Saxena
 Ramanjit Sihota
Radhika Tandon
 Sutton