Search

Vitreo-retinal surgical techniques have transformed since the introduction of pars plana vitrectomy in 1970. Advancements include smaller gauge instrumentation, faster cut rates, improved illumination methods, wider-field viewing systems, and the use of various tamponade agents and perfluorocarbon.

Treatment outcomes are highly variable and are related to the infecting organism as well as the time to diagnosis and treatment. Prompt treatment is more important than any other consideration, including the decision between TAP and PPV. Treatment outcomes may be substantially worse in certain categories of endophthalmitis, such as post-traumatic and post-PPV, due to preexisting or concomitant posterior segment disease.

Intravitreal antimicrobials : For presumed bacterial cases (in separate syringes): Vancomycin 1 mg/0.1 mL (for coverage of gram-positive organisms) Ceftazidime 2.25 mg/0.1 mL (for coverage of gram-negative organisms) For presumed fungal cases: Amphotericin B 0.005 mg/0.1 mL Voriconazole 0.1 mg/0.2 mL For presumed bacterial cases: Vancomycin and ceftazidime in separate syringes For presumed fungal cases: Amphotericin B or voriconazole without intravitreal steroids Amikacin may be substituted for ceftazidime (EVS proven efficacy). Ceftriaxone (2 mg/0.1 mL) may be substituted for ceftazidime if more readily available. Dexamethasone 4 mg/0.1 mL may be considered for acute-onset bacterial cases but should be avoided in suspected fungal endophthalmitis and delayed-onset (chronic) endophthalmitis until the organism is identified. Periocular/subconjunctival antimicrobials and steroids: Periocular antibiotics may be helpful in bleb-related endophthalmitis. Systemic antimicrobials : For endogenous fungal endophthalmitis Voriconazole 200 mg PO bid for 2–4 weeks Fluconazole 200 mg PO bid for 2–4 weeks Itraconazole 200 mg PO bid for 2–4 weeks Ketoconazole 200 mg PO bid for 2–4 weeks Amphotericin B 0.25–1.0 mg/kg IV every 6 hours as tolerated For endogenous bacterial endophthalmitis Vancomycin 1 g IV bid plus ceftazidime 1 g IV bid Systemic fluoroquinolones for susceptible organisms Topical antimicrobials: Antibiotic topical therapy: Fortified vancomycin: 25 mg/mL (2.5%) or 50 mg/mL (5%) Fortified ceftazidime: 50 mg/mL (5%) Fortified cefazolin: 50 mg/mL (5%) Fortified gentamicin: 14 mg/mL (1.4%) Fortified tobramycin: 14 mg/mL (1.4%) Fortified amikacin: 8 mg/mL (2.5%) Fortified linezolid: 2 mg/mL (0.2%) Fortified imipenem–cilastin: 10 mg/mL (1%) Antifungals eye drops: Fortified amphotericin B: 1.5 mg/mL (0.15%) Fortified voriconazole: 10 mg/mL (1%) Itraconazole Intrastromal antimicrobials: Amphotericin B: 5–10 μg/0.1 mL Voriconazole: 50 μg/0.1 mL

In patients with endophthalmitis, the occurrence of rhegmatogenous retinal detachment (RD) is uncommon and is generally associated with poor visual outcomes. Management of such patients can pose a surgical challenge. While managing the endophthalmitis, RD can be identified at the time of presentation, during vitrectomy or in the postoperative time period. Indirect ophthalmoscopy, echography or direct visualization under microscope may confirm the diagnosis. Frequency Visual outcomes Presentation Risk factors associated with poor visual outcomes

Acute-onset postoperative endophthalmitis occurs within 6 weeks of cataract surgery or secondary intraocular lens (IOL) implantation.

1. Postoperative endophthalmitis (a) Following cataract surgery: Acute-onset postoperative endophthalmitis Coagulase (−) Staphylococci, Staphylococcus aureus, Streptococcus, gram-negative bacteria (b) Following cataract surgery: Delayed-onset postoperative endophthalmitis P. acnes, coagulase (−) Staphylococci, fungi (c) Following glaucoma surgery: Conjunctival filtering bleb-associated infection and endophthalmitis Streptococcus species, Haemophilus influenzae, Staphylococcus species (d) Following glaucoma surgery: Endophthalmitis associated with glaucoma drainage devices (e) Following elective corneal transplant 2. Posttraumatic endophthalmitis Bacillus species (30–40%), Staphylococcus species 3. Endogenous endophthalmitis Candida species, Staphylococcus aureus, gram-negative bacteria 4. Endophthalmitis associated with keratitis Pseudomonas, Staphylococcus species 5. Endophthalmitis associated with intravitreal injection Staphylococcus/Streptococcus species (Figs. 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 1.10, 1.11, 1.12, 1.13, 1.14, 1.15, 1.16, 1.17, 1.18, 1.19, 1.20, 1.21, 1.22, 1.23, 1.24, 1.25)

The diagnosis of endophthalmitis can be made based on clinical examination findings. The patient may present with gradual or sudden onset of symptoms including lid swelling, pain, redness, discharge, and decrease in the vision. Slit-lamp examination may show lid swelling, conjunctival congestion, chemosis, glaucoma implant exposure, corneal edema, epithelial defect, corneal infiltrate, hypopyon, infiltrates/fibrin membrane in the anterior chamber, plaque inside the capsular bag, loss of fundus red reflex, or infiltrates in the vitreous cavity (Figs. 3.1, 3.2, and 3.3).

Acute-onset postoperative endophthalmitis is an uncommon but potentially severe complication of intraocular surgery. Acute-onset postoperative endophthalmitis is a clinical diagnosis, which is then confirmed by culture of vitreous or aqueous. The Endophthalmitis Vitrectomy Study (EVS) provided valuable treatment guidelines which are still relevant today. However, visual outcomes are frequently poor, even after prompt and appropriate treatment. Endophthalmitis cannot be completely prevented, but its incidence can be significantly reduced with the use of preoperative povidone-iodine antisepsis and attention to risk factors. Intracameral antibiotics are gaining in popularity, especially in Europe, although their efficacy is controversial.