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Purpose: To review the current state of evaluation and management of various forms of endophthalmitis., Methods: A review of the literature is included, encompassing endophthalmitis occurring after ocular surgeries, intravitreal injection, trauma, and systemic infection. Based on this review, current principles and techniques for evaluating and treating these forms of endophthalmitis are discussed., Results: Postoperative endophthalmitis after cataract surgery is the most common presentation. Conclusions from the Endophthalmitis Vitrectomy Study (EVS) remain a foundation for management of postcataract surgery endophthalmitis, notably prompt intravitreal antibiotic administration after vitreous sampling, with consideration for pars plana vitrectomy in severe cases. The potential impact of advances since the EVS, such as oral fourth generation fluoroquinolones and new vitrectomy techniques, are also discussed. The management of postcataract endophthalmitis is compared and contrasted to endophthalmitis occurring after other ocular surgeries, intravitreal injection, trauma, and systemic infection. Although some principles remain common, treatment rationales differ with other forms of endophthalmitis based on differing clinical circumstances, such as the virulence of organisms that are frequently encountered., Conclusions: Endophthalmitis is a serious, potentially vision threatening condition which can present in various settings. Prompt recognition and treatment are key in maximizing outcomes.

Objective: To determine whether human immunoglobulin attenuates the toxic effects of Staphylococcus aureus culture supernatant in a rabbit model of endophthalmitis., Methods: Immunoglobulin binding to products of S aureus strain RN4220 was tested by Western blot analysis using known toxins (beta-hemolysin and toxic shock syndrome toxin-1) and a concentrated culture supernatant containing S aureus exotoxins (pooled toxin). To induce endophthalmitis, pooled toxin was injected into the rabbit vitreous. For immunoglobulin treatment, immunoglobulin and pooled toxin were either mixed and injected simultaneously or immunoglobulin was injected immediately after or 6 hours after pooled toxin injection. Severity of endophthalmitis was graded according to a 9-day course with clinical examination (slitlamp biomicroscopy or indirect ophthalmoscopy) and evaluation of histologic sections., Results: The toxic effects of pooled toxin were markedly reduced when immunoglobulin was mixed with pooled toxin and injected simultaneously. Delayed injection of immunoglobulin diminished its ability to reduce toxicity. Clinical and histologic signs of toxicity were partially attenuated when immunoglobulin was injected immediately after pooled toxin, but only minimal clinically detectable reductions in toxicity were observed when immunoglobulin injection was delayed for 6 hours., Conclusion: Pooled human immunoglobulin can attenuate the toxic intravitreal effects of a concentrated culture supernatant containing S aureus exotoxins. Clinical Relevance Immunoglobulin may represent a novel adjuvant in the treatment of bacterial endophthalmitis. To optimize the potential therapeutic benefit, maximizing the mixture of immunoglobulin with bacterial products and early intervention are likely to be important.

Purpose: To evaluate the efficacy of adjunctive subconjunctival antibiotic injection in the treatment of acute postcataract extraction endophthalmitis., Design: Retrospective cohort study., Methods: Patients who presented with hand motions or better vision and received subconjunctival antibiotics (SC+ group) were compared with those who did not (SC- group) in the treatment of acute postoperative endophthalmitis., Results: The rate of obtaining a final vision of 20/40 or better was 60% in the SC+ group (n = 25) compared with 72% in the SC- group (n = 18) (P =.69), and the mean change in logMAR was -1.36 (improvement) versus -1.34 (P =.93). Based on a linear regression model controlling for presenting vision, there was no statistical difference in the mean logMAR change between the two groups (P =.73)., Conclusion: Subconjunctival antibiotic injection as an adjunct to intravitreal antibiotics was unassociated with treatment benefit in patients with acute postoperative endophthalmitis presenting with vision of hand motions or better.

Objectives: To test the feasibility of human immune globulin (IG, Gamimune N, 10%) as a new treatment for endophthalmitis, the ocular tolerance, distribution, and ability of intravitreal IG to attenuate the toxic effects of Staphylococcus aureus culture supernatant were evaluated in a rabbit model., Methods: Effects of intravitreally injected IG were assessed histologically and with Western blot analysis performed 1 to 5 days after injection. IG reactivity to products of S. aureus strain RN4220 was tested by Western blotting, using known toxins (beta hemolysin and toxic shock syndrome toxin-1) and a concentrated culture supernatant containing S. aureus exotoxins (pooled toxin, PT). Endophthalmitis was induced by intravitreal PT injection. For treatment, IG and PT were mixed and injected simultaneously, or IG was injected immediately after, or 6 hours after, PT injection. PT toxicity was graded clinically and histologically over 9 days., Results: IG persisted intravitreally at least 5 days, inducing no clinical inflammation and minimal mononuclear cell infiltration. In the endophthalmitis model, toxicity from PT was significantly reduced when IG was mixed with PT and injected simultaneously, or when IG was delivered immediately after PT. Only minimal clinically detectable reductions were observed when IG delivery was delayed 6 hours., Conclusions: Intravitreal IG is well tolerated in the rabbit eye and attenuates the toxicity of culture supernatant containing S. aureus exotoxins. Because toxin elaboration likely occurs gradually in true infection, reduced effects observed with delayed treatment in this toxin-injected model do not preclude clinical application. IG may represent a novel adjunct in endophthalmitis treatment.