Treatment of Endophthalmitis
Endophthalmitis requires immediate combined medical and surgical intervention with intravitreal antibiotics and vitrectomy in severe cases to prevent irreversible vision loss. 1
Diagnosis and Initial Assessment
- Endophthalmitis is a sight-threatening infection involving inflammation of the vitreous and/or aqueous humor that requires rapid ophthalmologic intervention 2
- Clinical presentation typically includes eye pain, decreased vision, and inflammatory findings such as hypopyon 1
- Definitive diagnosis requires direct ophthalmoscopic examination and culture of vitreous humor or aqueous humor specimens 3
- Diagnostic vitreous tap is essential before initiating treatment to identify the causative organism 3
Treatment Algorithm
Step 1: Immediate Intervention
- Obtain emergency ophthalmology consultation for all suspected cases 1
- Perform diagnostic vitreal tap to collect samples for culture and sensitivity testing 3
Step 2: Antimicrobial Therapy
For bacterial endophthalmitis:
- Administer intravitreal antibiotics immediately after vitreous sampling 4
- Consider pars plana vitrectomy for severe cases with significant vision loss 4
For fungal endophthalmitis (specifically Aspergillus):
- Following diagnostic vitreal tap, administer intravenous amphotericin B (AMB) and intravitreal AMB when appropriate 3
- Voriconazole administered intravitreally or systemically is an effective alternative regimen 3
For Candida endophthalmitis:
- For fluconazole/voriconazole-susceptible isolates, use fluconazole (loading dose 800 mg, then 400-800 mg daily) or voriconazole (loading dose 400 mg IV twice daily for 2 doses, then 300 mg IV or oral twice daily) 3
- For resistant isolates, use liposomal amphotericin B (3-5 mg/kg IV daily), with or without oral flucytosine (25 mg/kg 4 times daily) 3
Step 3: Surgical Management
- Pars plana vitrectomy is sight-saving in severe cases by removing inflammatory debris and infectious organisms 3
- For macular involvement, combine systemic antifungals with intravitreal injection of either amphotericin B deoxycholate (5-10 μg/0.1 mL sterile water) or voriconazole (100 μg/0.1 mL sterile water or normal saline) 3
- More conservative measures, such as subconjunctival injection, are generally less successful 3
Special Considerations
Based on Etiology
- Post-surgical endophthalmitis: Coagulase-negative staphylococci are most common after cataract surgery 2
- Post-traumatic endophthalmitis: Bacillus cereus is a major cause; can occur even with imperceptible trauma 2, 5
- Endogenous endophthalmitis: Staphylococcus aureus and streptococci are important causes associated with endocarditis; Candida species are common in hospitalized patients 2
Treatment Duration
- Treatment should continue for at least 4-6 weeks, with final duration depending on resolution of lesions as determined by repeated ophthalmological examinations 3
- For fungal endophthalmitis with prosthetic valve involvement, consider lifelong antifungal therapy with an oral triazole such as voriconazole or posaconazole 3
Prognosis and Monitoring
- Visual outcomes depend on the virulence of the pathogen, extent of infection, and speed with which treatment is initiated 6
- Direct macular involvement is a poor prognostic indicator for recovery of visual acuity 3
- Regular ophthalmologic follow-up is essential to monitor response to treatment 3
Important Pitfalls to Avoid
- Delayed treatment can result in permanent vision loss; endophthalmitis is a medical emergency 6
- Subconjunctival antibiotic injections alone are generally ineffective and should not replace intravitreal administration 3
- Failure to perform diagnostic vitreous sampling before initiating treatment may lead to inability to identify the causative organism 1
- Endophthalmitis can masquerade as uveitis, leading to inappropriate treatment with steroids that may worsen infection 5