What is the treatment for Endophthalmitis?

Treatment of Endophthalmitis

Endophthalmitis requires immediate intravitreal injection of antibiotics as the cornerstone of treatment, with vitrectomy reserved for severe cases, and all treatment decisions must be made jointly by an ophthalmologist and infectious diseases physician. 1, 2

Immediate Diagnostic Steps

• Obtain vitreous tap or aqueous humor culture before initiating treatment to identify the causative organism 1
• Perform dilated retinal examination by an ophthalmologist within the first week to determine the extent of infection (chorioretinitis alone versus chorioretinitis with vitritis) 3, 1
• For neutropenic patients, delay the ophthalmologic examination until neutrophil recovery 3

Treatment Algorithm by Pathogen Type

Bacterial Endophthalmitis

• Administer intravitreal antibiotics immediately—this is the most critical intervention for bacterial endophthalmitis 4, 5, 6
• Early intravitreal treatment within 24 hours of diagnosis correlates with better visual outcomes and lower mortality 7
• Perform immediate vitrectomy (within 6 hours) combined with intravitreal antibiotics for severe cases, as this approach frequently results in vision recovery 8
• Systemic antibiotics are mandatory for endogenous bacterial endophthalmitis but controversial for exogenous cases 4, 5

Fungal Endophthalmitis - Candida Species

The treatment approach depends critically on whether vitritis is present:

For chorioretinitis WITHOUT vitritis:

• Systemic antifungal therapy alone may be sufficient 2
• Use fluconazole or voriconazole for susceptible Candida isolates 3, 1
• These azoles achieve adequate concentrations in the highly vascular chorioretinal layer 3, 2

For chorioretinitis WITH vitritis:

• Systemic antifungals PLUS intravitreal injection of amphotericin B deoxycholate or voriconazole 3, 1, 2
• The vitreous has poor vascularization, making systemic therapy alone insufficient 2
• Consider early pars plana vitrectomy to decrease organism burden and remove abscesses inaccessible to systemic antifungals 2

For resistant Candida isolates:

• Use liposomal amphotericin B with or without oral flucytosine 1

For macular involvement or sight-threatening lesions:

• Combine systemic antifungals with intravitreal injection of amphotericin B or voriconazole, with or without vitrectomy 3, 1

Fungal Endophthalmitis - Aspergillus

• Administer intravenous amphotericin B and intravitreal amphotericin B when appropriate 1

Surgical Intervention Criteria

• Pars plana vitrectomy is sight-saving in severe cases by removing inflammatory debris and infectious organisms 1
• Vitrectomy is particularly indicated when vitritis prevents visualization of underlying abscesses 2
• Candida arthritis of the hip requires open surgical drainage when present concurrently 3

Treatment Duration and Monitoring

• Continue treatment for at least 4-6 weeks, with final duration depending on resolution of lesions 1, 2
• Regular ophthalmologic follow-up is essential to monitor treatment response 1
• The ophthalmologist determines when and if to perform repeat intravitreal injections 3

Critical Pitfalls to Avoid

• Never use subconjunctival antibiotic injections alone—they are ineffective and must not replace intravitreal administration 1
• Do not delay intravitreal antibiotics; longer time between symptom onset and injection correlates with worse visual outcomes and increased mortality 7
• Do not perform intra-articular injection of antifungals for concurrent Candida arthritis, as systemic therapy produces adequate synovial fluid levels 3
• Recognize that direct macular involvement is a poor prognostic indicator for visual acuity recovery 1

Special Considerations

• For prosthetic joint infection with Candida, resection arthroplasty is generally required, with antifungal therapy for at least 12 weeks after resection and 6 weeks after reimplantation 3
• For fungal endophthalmitis with prosthetic valve involvement, consider lifelong antifungal therapy with an oral triazole 1
• If prosthetic devices cannot be removed, chronic suppression with fluconazole is necessary 3