Management of Endophthalmitis

Endophthalmitis is one of the most devastating diagnoses in ophthalmology. It is a serious intraocular inflammatory disorder affecting the vitreous cavity that can result from exogenous or endogenous spread of infecting organisms into the eye. With any breaching of the ocular bulbus, the potential exists for introducing an infectious inoculum large enough to cause an intraocular infection. This is most commonly seen after intraocular surgery but can also occur as a complication of penetrating ocular trauma or from the adjacent periocular tissues.

Endogenous endophthalmitis is less common and occurs secondary to hematogenous dissemination and spread from a distant infective source in the body. In patients with endogenous endophthalmitis, predisposing risk factors usually exist.

In most cases, independent of its origin, the presentation of endophthalmitis consists of reduced or blurred vision, red eye, pain, and lid swelling. Progressive vitritis is one of the key findings in any form of endophthalmitis, and in nearly 75% of patients a hypopyon can be seen at the time of presentation. Progression of the disease may lead to pan ophthalmitis, corneal infiltration, and perforation, affection of orbital structures, and phthisis bulbi.

Treatment of endophthalmitis remains challenging. Early diagnosis and treatment are essential to optimize visual outcome. Intravitreal antimicrobial drug application achieves the high intraocular substance levels needed for effective endophthalmitis treatment.

Vitrectomy seems to provide several substantial benefits in the treatment of endophthalmitis and remains accepted as a treatment option which is supplementary to intravitreal antimicrobial therapy in patients with moderate or severe disease. The EVS addressed the relative effectiveness of immediate pars plana vitrectomy after postoperative endophthalmitis. However, a general advantage of vitrectomy in endophthalmitis is still under discussion.

In general, for exogenous endophthalmitis treatment, intravitreal antibiotics need not be supplemented with intravenous antibiotics. In contrast, most cases of endogenous endophthalmitis, where the primary focus of infection is outside the eye, require systemic antimicrobial therapy. Supplementary intravitreal drug application and vitrectomy may be supportive.

In fungal endophthalmitis, vitrectomy and intravitreal amphotericin B are indicated in case of severe vitreous involvement. Recent advances in therapy using antimycotic drugs, including the second-generation triazole agent voriconazole and the echinocandin caspofungin, may offer new treatment options to manage fungal endophthalmitis, but these drugs need further evaluation.

Emergency Department Care

Once the diagnosis has been made, or strongly considered, prompt consultation to an ophthalmologist is needed. Treatment depends on the underlying cause of endophthalmitis. Final visual outcome is heavily dependent on timely recognition and treatment. Although multiple different approaches to and advances in treatment have been made, according to recent data, the rate of preservation of visual acuity has not changed significantly since 1995. 

Treatment of postoperative endophthalmitis

Pars plana vitrectomy or vitreous aspiration may be performed by an ophthalmologist with administration of intravitreal antibiotics (ie, vancomycin, amikacin, ceftazidime).

Consider systemic antibiotic administration as well as intravitreal steroids.

Patients with postoperative endophthalmitis usually are not admitted to the hospital. However, the decision to admit the patient is determined in consultation with the ophthalmologist.

Treatment of traumatic endophthalmitis

Admit the patient to the hospital.

Treat ruptured globe (if present).

Systemic antibiotics including vancomycin and an aminoglycoside or a third-generation cephalosporin are indicated. Consider clindamycin until Bacillus species can be ruled out if soil contamination is suspected.

Topical fortified antibiotics are used.

Intravitreal antibiotics should be administered.

Consider pars plana vitrectomy.

Tetanus immunization is necessary if immunization record is not current.

Cycloplegic drops (ie, atropine) may be considered.

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 are indicated.

Cycloplegic drops (ie, atropine) may be administered.

Topical steroids may be considered.

Vitrectomy may be needed for virulent organisms.

Treatment of candidal endophthalmitis

Admit the patient to the hospital.

Oral fluconazole is indicated.

Amphotericin B intravenous or intravitreal may be considered.

Cycloplegic drops (ie, atropine) may be considered.