Endophthalmitis is an intraocular inflammatory reaction caused by bacterial or fungal infection. It can be exogenous from direct inoculation through ocular procedures/trauma or endogenous from hematogenous spread. Treatment involves intravitreal antibiotic injections with or without vitrectomy depending on visual acuity. Prognosis depends on causative organism, time to treatment, and underlying patient health issues. Proper surgical technique and systemic infection control can help prevent this potentially vision-threatening condition.

1. Endophthalmitis
H44.0 - Purulent endophthalmitis
Dr. Rajeev Kumar Aadiwasi
Surgery is multiplication of all steps
so don’t put negative in any step.

2. Definition
• Endophthalmitis is a purulent intraocular inflammatory
reaction marked by inflammation of intraocular fluids and
tissues, usually caused by infection with either bacteria or
fungi.
1. Exogenous endophthalmitis results from direct inoculation of
an organism from the outside as a complication of ocular
procedures, foreign bodies, and/or penetrating ocular
trauma.
2. Endogenous (Metastatic) endophthalmitis results from the
hematogenous spread of organisms from a distant source of
infection (e.g. endocarditis).
Progressive vitritis is the hallmark of any form of endophthalmitis
• Panophthalmitis is inflammation of all coats of the eye,
including intraocular structures.
Endophthalmitis is defined as an intraocular inflammation which predominantly affects
inner spaces of the eye qnd their contents, i.e. the vitreous and/or the anterior chamber.

3. Classification of Endophthalmitis And Common Causative Organisms
A. Exogenous
1. Acute-onset postoperative
endophthalmitis
– Coagulase-negative staphylococci
– Staphylococcus aureus
– Streptococcus spp.
2. Delayed-onset > 6 weeks) postoperative
endophthalmitis
– Propionibacterium acnes (63% )
– Coagulase-negative staphylococci (16%)
– Candida parapsilosis (16%)
– Propionibacterium granulosum,
– Achromobacter,
– Corynebacterium, and fungi
3. Filtering bleb-associated
endophthalmitis
– Streptococcus spp. (56%)
– Haemophilus influenza (20%)
– Staphylococcus spp.
4. Endophthalmitis associated with
intravitreal injection
– Coagulase-negative staphylococci
– Streptococcus spp.
5. Post-traumatic endophthalmitis
– Staphylococcus spp.
– Bacillus cereus
6. Endophthalmitis associated with microbial
keratitis/PK
– Gram-negative organisms
– Staphylococcus aureus
– Fusarium spp.
B. Endogenous (Metastatic)
endophthalmitis
– Candida albicans
– Aspergillus spp.
– Staphylococcus aureus
– Gram-negative organisms
Adapted from Schwartz SG, Flynn HW Jr, Scott IU. Endophthalmitis: classification and current
management. Expert Rev Ophthalmol 2007;2:385–96
Mandelbaum S, Forster RK, Gelender H, et al. Late onset endophthalmitis associated with
filtering blebs. Ophthalmology 92:964-972, 1985.

4. Epidemiology
• Incidence
– Varies by cause: 62% occur after intraocular
surgery, 20% after penetrating trauma, 10% after
planned or inadvertent filtering blebs, and 8% as a
result of metastatic infection
– Postoperative endophthalmitis incidence ranges
from approximately 0.05-0.16% of cataract cases.
• Highest risk after secondary IOL (0.2-0.367%), and
lowest after pars plana vitrectomy (0.03-0.046%).

5. Pathophysiology
• Under normal circumstances, the blood-ocular barrier provides a natural
resistance against invading organisms.
• In endogenous endophthalmitis, blood-borne organisms (seen in patients
who are bacteraemia in situations such as endocarditis) permeate the
blood-ocular barrier either by direct invasion (e.g., septic emboli) or by
changes in vascular endothelium caused by substrates released during
infection.
– Initial infiltration (diffuse liquefactive necrosis) of vitreous by infectious
organism is followed by invasion of ocular tissue by polymorphonucleocytes
within 24 h.
– Significant photoreceptor damage by 48 h.
– Inflammation can spread to involve the orbital soft tissue.
– Experimental models of bacterial and fungal endophthalmitis have shown
tissue damage continues to occur after organisms are able to be isolated from
vitreous cavity; thus, implicating endotoxin in disease progression.
• Any surgical procedure that disrupts the integrity of the globe can lead to
exogenous endophthalmitis (e.g., cataract, glaucoma, retinal, radial
keratotomy, intravitreal injections).
• In unilateral cases of endogenous endophthalmitis, the right eye is twice
as likely to become infected

6. History
• History of ocular surgery, ocular trauma, hammering steel with steel, working with
baling wire, or working in an industrial setting may be elicited.
• History should be focused toward practices or procedures (e.g. intravenous drug
use, other risks for sepsis or endocarditis, recent invasive ophthalmologic
procedure) that would increase risk of endogenous or exogenous endophthalmitis.
• Bacterial endophthalmitis usually presents acutely with pain, redness, lid swelling,
and decreased visual acuity.
• Propionibacterium acnes may cause chronic inflammation with mild symptoms.
• Fungal endophthalmitis may present with an indolent course over days to weeks.
A history of penetrating injury with a vegetative substance or soil-contaminated
foreign body.
• Patients with candidal infection may present with high fever, followed several days
later by ocular symptoms including occult retinochoroidal fungal infiltrate.

7. Exogenous endophthalmitis
• Organisms that reside at the conjunctiva, eyelid, or
eyelashes and are introduced at the time of surgery usually
cause postoperative endophthalmitis.
• Gram-positive organisms account for almost 90% of cases,
of which the majority are coagulase-negative
Staphylococcus from the natural conjunctival flora.
• The most common gram-negative organisms associated
with postoperative endophthalmitis are P aeruginosa and
Proteus and Haemophilus species.
• Postoperatively, fungal endophthalmitis is most common
after keratoplasty with up to 31% of cases due to Candida.
• The use of intracameral antibiotics is associated with a
decreased occurrence of postoperative endophthalmitis.

8. Traumatic endophthalmitis
• Endophthalmitis can occur in up to 13% of cases of penetrating
injury to the globe.
• Trauma with pure corneal injuries, intraocular foreign bodies, lens
rupture, or needle-related injuries have a higher incidence of
endophthalmitis.
• Usual agent- Staphylococcal, streptococcal, and Bacillus species (B.
Cereus can cause serious infection). Most FB are contaminated
with multiple infectious agents.
• Prophylactic intravitreal/intracameral antibiotics .(in presence of
risk factors 2 of 3: dirty wound, lens breach, or delay in closure over
24 hours).
• Patients with larger lacerations, delay in time to repair of open
globe, and those with more virulent organisms tend to do worse.

9. Endogenous endophthalmitis
• Individuals at risk for developing endogenous endophthalmitis usually have
comorbidities that predispose them to infection. These include
– Conditions such as diabetes mellitus, chronic renal failure, cardiac valvular disorders, systemic
lupus erythematosus, AIDS, leukemia, gastrointestinal malignancies, neutropenia, lymphoma,
alcoholic hepatitis, and bone marrow transplantation.
– Invasive procedures, which may result in bacteremia, such as hemodialysis, bladder
catheterization, gastrointestinal endoscopy, total parenteral nutrition, chemotherapy, and
dental procedures, also can lead to endophthalmitis.
– Recent nonocular trauma or surgery, prosthetic heart valves, immunosuppression, and
intravenous drug abuse may predispose to endogenous endophthalmitis.
– Sources for endophthalmitis include meningitis, endocarditis, urinary tract infection, and
wound infection. Additionally, pharyngitis, pulmonary infection, septic arthritis,
pyelonephritis, and intra-abdominal abscess also have been implicated as sources of infection.
• Fungal organisms (50% of all cases of endogenous endophthalmitis).Candida
albicans is by far the most frequent cause (75-80% of fungal cases). Aspergillosis is
the second most common cause of fungal endophthalmitis, especially in IV drug
users.
• Most commonly involved gram positive organism is S. aureus,
• E coli is the most common among the gram-negative bacteria.
• Nocardia asteroides, Actinomyces species, and Mycobacterium tuberculosis are
acid-fast bacteria that may cause endogenous endophthalmitis.

10. Risk Factors
• Factors with Increased risk of Postoperative endophthalmitis.
– IOLs with polypropylene (Prolene) haptics
– Silicone IOLs
– The use of silk suture for wound closure.
– Prolonged and complicated surgery.
– Vitreous loss, Vitreous incarceration to wound.
– Posterior capsular tears, and
– ICCE.
– wound leak
• Post-traumatic: Dirty penetrating wound,Intraocular foreign body,
vegetable matter in wound, delayed presentation, lens breach.
• Endogenous: lmmunocompromised patients, Indwelling catheters,
Intravenous drug use.

11. Clinical Features
• History
– The earliest symptom of endophthalmitis is usually ocular discomfort or deep pain, now
improvement in postoperative visual acuity with IOL implantation has increased the
proportion of patients reporting decreased vision as the initial symptom.
– Other symptoms include complaints of lid swelling, a red eye, photophobia, and discharge.
– History of recent ocular surgery, trauma, hospitalization, IV drug use.
• Physical exam
– Exogenous cases are typically unilateral,
– Endogenous cases may be bilateral.
– Ocular findings may include the following:
• Adnexal swelling,
• Conjunctival chemosis and injection. Infiltrated conjunctival bleb
• Corneal edema,
• AC- Hypopyon, Anterior Chamber fibrin.
• Vitritis, loss of red reflex,
• Retinal perivasculitis (early retinal sign), scattered retinal haemorrhage may be masked by
opacification of the media.
• Note: Absence of pain and hypopyon do not rule out endophthalmitis, particularly in the
chronic indolent form of P acnes infection.
• The presence of a hypopyon or fluctuating inflammation on topical corticosteroids should
raise the index of suspicion for infection.

12. Vitreous Haze Grading
• The clarity of ocular media could be assessed by
indirect ophthalmoscopy as follows:
Grade I Media clarity 6/12 view of the retina.
Grade II Media clarity < 6/12; can visualise second
order retinal vessels.
Grade III Can see some retinal vessels.
Grade IV Vessels not seen; red reflex present.
Grade V Red reflex absent.

13. Complications
• Decreased vision and permanent loss of vision.
• Retinal detachment (5%).
• Loss of Ocular Architecture
• Phthisis.
• Patients may require enucleation to eradicate
septic focus in a blind and painful eye.
• Mortality is related to the patient's comorbidities
and the underlying medical problem, especially
when considering the etiology of hematogenous
spread in endogenous infections.

14. Prophylaxis And Early Detection
• Control of Systemic illness & Safe Surgical customs.
• Preop (3days) Topical Antibiotics ± single application of 5%
Povidone Iodine.
• Meticulous surgery and wound closure.
• Intracameral Cefuroxime.
• Post op close Follow up.
• Prophylactic Intravitreal Antibiotic in Penetrating globe injury in
presence of risk factors 2 of 3: dirty wound, lens breach, or delay in
closure over 24 hours.
• Use of appropriate protective eyewear can decrease risk of ocular
trauma or globe penetration in certain circumstances.
• As a physician be vigilant to patient expected to develop
bacteraemia – seek timely ophthalmological opinion and transfer.

15. Laboratory Studies & Interpretation
• Gram/KOH stain and culture of the aqueous(0.1cc) and
vitreous(0.2cc) aspirate.
– Approximately two-thirds of eyes with a clinical diagnosis of infectious
endophthalmitis will have a positive culture result.
– Negative culture results are associated with greatly improved visual
prognosis, with up to 94% of pseudophakic eyes achieving 20/400 or
better visual acuity.
• Pathological Findings
– Coagulase negative bacteria followed by S. aureus are the most
common cause of endophthalmitis.
– Endogenous cases may also be associated with fungal infection
(approx 50% of cases). Candida albicans and Aspergillus are the
predominant Species.
• Real-time polymerase chain reaction (RT-PCR).
• Prompt procurement of microbiologic specimens in all suspected
cases of endophthalmitis is an essential part of management.

16. Diagnostic Tests & Interpretation
• Lab test for endogenous endophthalmitis include the following:
– Complete blood count (CBC)
– Erythrocyte sedimentation rate (ESR)
– Blood urea nitrogen (BUN)
– Serum Creatinine
– Blood and urine culture.
• Follow-up and special considerations
– Careful history and physical examination important for identifying
source in endogenous cases.
– Consider echocardiogram to rule out endocarditis in patients with
endogenous endophthalmitis.
• Imaging
– B-scan ultrasound to evaluate vitreous cavity for vitritis, chorioretinal
thickening, Localisation of Foreign body, Retained lens fragments.
– However, sensitivity is not high enough to rule out the diagnosis with a
negative ultrasound.
– Retinal or choroidal detachment are poor prognostic factors.

17. Differential Diagnosis
• Sterile endophthalmitis.
• Non-infectious posterior uveitis: Sarcoidosis,
pars planitis.
• Infectious posterior uveitis: Toxoplasmosis,
Toxocara, syphilis.
• Other causes of postoperative inflammation:
Sympathetic ophthalmia, Phacoanaphylactic
uveitis , TASS

18. Treatment
• VA>HM
– lntravitreal antibiotic injections to empirically treat Gram-positive and Gram-
negative bacteria ± lntravitreal steroid injections to reduce inflammatory
response.
– lntravitreal antifungal medications in patients with endogenous disease.
• Vancomycin 1.0 mg in 0.1 ml.
• Ceftazidime 2.25 mg In 0.1 mL
• Dexamethasone 0.4 mg in 0.1 ml.
• Amphotericin B (5 to 10 µg) or voriconazole (100 µg) in 0.1ml
• VA= PL
– PPV / vitreous tap, and intravitreal antibiotics.
– In the EVS, attempts were made to clear 50% or more of the vitreous. Also,
no attempt to induce a PVD if none was previously present.
– Consider earlier PPV for diabetics
• Fortified topical antibiotics may be used in addition.
• Vancomycin 50 mg/ml every hour.
• Ceftazidime 100 mg/ml every hour.
• The standard dosage of intravitreal antibiotics could be used even in a
50% gas-filled eye.

19. Treatment of Acute postoperative
endophthalmitis
• Intravitreal antibiotics alone were curative only when
injections were given within the first 24 h of infection.
• VA > HM  Vitreous aspiration with administration of
Intravitreal Antibiotics (i.e., vancomycin, amikacin,
ceftazidime) ± intravitreal steroids.
• VA = PL  Pars plana vitrectomy with administration of
Intravitreal Antibiotics (i.e., vancomycin, amikacin,
ceftazidime)
• Topical fortified antibiotics.
• Adjunctive Systemic (oral) antibiotic administration for 5-
10days
• Cycloplegic drops (i.e. atropine).
• Patients with postoperative endophthalmitis usually are not
admitted to the hospital.

20. • Difficult to treat because the sequestered
organisms are isolated from host defences and
antibiotics.
• 1) Topical and periocular steroids and antibiotics
may be tried but the response is transient.
• 2) Intravitreal Vancomycin (1mg/0.1 ml) alone or
combined with PPV is successful in 50%.
• 3) Removal of the capsular bag, residual cortex
and IOL may be required.
Treatment of delayed onset postoperative
endophthalmitis

21. Treatment of traumatic endophthalmitis
• Admit the patient to the hospital.
• Treat ruptured globe (if present).
• Systemic antibiotics for 5-19 days including vancomycin and
an aminoglycoside or a third-generation cephalosporin.
Consider Clindamycin if soil contamination is suspected,
until Bacillus species can be ruled out.
• Topical fortified antibiotics.
• Intravitreal antibiotics.
• Pars plana vitrectomy.
• Tetanus immunization .
• Cycloplegic drops (i.e. atropine).

22. Treatment of endogenous bacterial endophthalmitis
• Admit the patient to the hospital.
• Broad-spectrum intravenous antibiotics including vancomycin and
an aminoglycoside or third-generation cephalosporin. Consider
adding clindamycin in intravenous drug users until Bacillus infection
can be ruled out.
– Periocular antibiotics are sometimes indicated.
• Intravitreal antibiotics .
• Cycloplegic drops (i.e. Atropine).
• Topical steroids.
• Pars plana Vitrectomy may be needed for virulent organisms.
Treatment of candidal endophthalmitis
• Admit the patient to the hospital.
• Oral fluconazole.
• Intravenous or Intravitreal Amphotericin B.
• Cycloplegic ( atropine) drops.

23. Considerations of re-injection
• Should be considered if the infection fails to stabilize or
improve more than 48 hours after the first injection
• Based on consensus view, the EVS protocol recommended
re-injection if the infection was worsening at 36-60 hours
after initial injection
• Often, 36 hours after treatment, culture results are
available
• Decision to reinject antibiotics should not be taken lightly,
since repeat injection may increase risk of retinal toxicity
• Patients with no culture growth, equivocal growth, or
coagulase negative staph had a 5% rate of additional
procedures, compared to 30% in pts with cultures that
grew GN or other GP organisms

24. Additional Treatment
General Measure
• Patients with endogenous endophthalmitis will
need complete evaluation by infectious disease
specialist diagnose and treat underlying disease
source (e.g. Abscess, endocarditis, sepsis).
• All patients require evaluation and treatment by
an ophthalmologist/retinal specialist.
• Patients require daily dose re-evaluation until
stabilization is achieved.
• Patient may require delayed vitrectomy to treat
non-clearing vitreous debris.

25. Postoperative endophthalmitis
(a) Postoperative endophthalmitis due to
Staphylococcus epidermidis presenting 6 days after
extracapsular cataract extraction with posterior chamber
lens implantation. Visual acuity was at hand-motions level,
and conjunctival hyperemia, hypopyon, and inflammatory
membrane on the IOL are seen. (b) Slit lamp photograph of
hypopyon in the patient. (c) Visual acuity improved to
20/500 (limited by preexisting AMD) 2 weeks later after
vitrectomy with intravitreal administration of vancomycin
(1 mg), amikacin (400 µg), and dexamethasone (200 µg).
The inflammatory membrane on the IOL was removed at
surgery. The IOL was not removed.
a b
c

26. Postoperative endophthalmitis
(a) Postoperative endophthalmitis due to S. epidermidis presenting
4 days after extracapsular cataract extraction complicated by
vitreous loss, with anterior chamber lens implantation. Visual acuity
is at light-perception level, and conjunctival hyperemia, mild corneal
edema, hypopyon, and inflammatory membranes on the iris and
both surfaces of the IOL are evident. (b) Fundus photograph after
vitrectomy documents petechial retinal hemorrhages frequently
observed in association with active endophthalmitis. (c) Two months
after vitrectomy with intravitreal administration of cefazolin (2.25
mg), amikacin (400 µg), and dexamethasone (200 µg), visual acuity
has improved to 20/300. The IOL is preserved after intraoperative
removal of the inflammatory membranes noted preoperatively.
a b
c

27. Bleb Related Endophthalmitis
(a) Blebitis (localized infection of a conjunctival bleb) due to Staphylococcus
epidermidis presenting in a patient with previous trabeculectomy. A milky-white
appearance of the bleb and intense conjunctival injection are seen. The patient was
treated with an intensive course of topical antibiotics and close observation. (b)
Examination after 1 week of therapy shows resolution of the infection.
Streptococcus species and gram-negative organisms, particularly H. influenzae, are
most commonly implicated
a b

28. Prognosis
• The prognosis is extremely variable because of the variety of organisms
involved.
• Presenting visual acuity and the causative agent are most predictive of
outcome. Also Corneal infiltrate or ring ulcer, an open posterior capsule,
and absence of the red reflex predict a decreased visual outcome
• The outcome of endogenous endophthalmitis is generally worse than
exogenous endophthalmitis due to the profile of the organisms typically
involved with this form (i.e., more virulent organisms, compromised host,
delay in diagnosis).
– Streptococcal infections tend to do worse than coagulase-negative
staphylococcal infections.
• Patients in the traumatic subgroup, especially those caused by Bacillus
infection, typically have a poor visual outcome.
• In the Endophthalmitis Vitrectomy Study group, 74% of patients had visual
recovery of 20/100 or better.
• The prognosis appears to also be related to the patient's underlying health
conditions, with worsened outcomes among diabetic patients.

29. Thank You

30. Intravitreal Antibiotics Preparation
• Injection Ceftazidime
• Mix 2.25ml of normal
saline in 500mg of
ceftazidime=222.2mg/ml
• (Mix 1.1ml of normal
saline in 250mg of
ceftazidime)
• Take 0.1ml and dilute in
0.9ml NS to make 22.2-
22.7mg/1ml
• Inject 2.22-2.27mg/ 0.1ml
of constituent
• Injection Vancomycin
• Mix 5ml normal saline in
500mg of vancomycin =
100mg/ml
• Take 0.1ml and dilute in
0.9ml NS to make
10mg/1ml
• Inject 1mg/ 0.1ml of
constituent

31. Intravitreal Antibiotics Preparation
• Injection Amphotericin B
• Mix 10ml 5% dextrose in 500mg Amphotericin B
• Draw 0.1ml = 5mg/0.1ml of Amphotericin B
• Mix 0.1ml in 9.9ml of 5% dextrose = 0.5mg/ml
• Draw 0.1ml=0.05mg of Amphotericin B and dilute
in 0.9ml of 5% dextrose = 0.05mg/ml of
Amphotericin B  Mix
• Inject 0.1 ml of constituted solution = 5 µg of
Amphotericin B