Endophthalmitis (post-operative) (Exogenous endophthalmitis)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

  • Post-operative endophthalmitis is a rare but severe sight-threatening complication of ocular surgery e.g. cataract, corneal, glaucoma, retinal, and of intravitreal injections, e.g. anti-VEGF treatment
  • Occurs most commonly as a complication of cataract surgery. Pooled estimates of incidence range from 1.09-2.65 per 1,000 cataract operations.
  • A systematic review has demonstrated the value of intracameral cefuroxime with or without topical levofloxacin in reducing the incidence of post-operative endophthalmitis
  • Bleb-associated endophthalmitis has a reported incidence of 2.1% at an average 18 months following glaucoma drainage surgery
  • Pooled estimate of endophthalmitis following anti-VEGF treatment is 3 per 10,000 injections
  • Organisms (examples only, in descending order of frequency):
    • Staphylococcus sp. (50.5% of culture-positive cases)
    • Streptococcus sp. (12.1%)
    • Gram negative sp. (10.3%)
    • fungi (4.6%)
  • Onset may be acute (in first week) or chronic (in first month). 80% of cases present within 6 weeks of surgery
  • Post-operative endophthalmitis may also be non-infective (retention of foreign material, e.g. cotton fibres, or caused by toxic substances, e.g. component of unsuitable irrigating fluid)
  • Endophthalmitis is associated with significant visual morbidity (approx. 40% <6/60 after treatment)

Predisposing factors

  • Surgical
    • Increased operative time
    • Posterior capsular rupture
    • Wound leakage
  • Sources of contamination:
    • patient’s own bacterial flora (skin, lids, conjunctiva, lacrimal apparatus)
    • contaminated instruments, solutions, drapes, dressings, gloves
    • (in corneal transplants) donor cornea
  • Patient factors:
    • diabetes, immunosuppression, HIV infection

A large clinical trial demonstrated the value of intracameral antibiotics in reducing the incidence of post-operative endophthalmitis

Symptoms

  • Acute presentation:
    • visual loss
    • pain
    • redness
    • photophobia
  • Chronic presentation: similar, usually milder, delayed

Signs

  • Acute presentation:
    • lid oedema
    • conjunctival chemosis and hyperaemia
    • corneal haze
    • cells and flare in AC; fibrinous exudate and/or hypopyon if severe
    • pupil light reflex may be sluggish or absent
    • IOP can be normal, low or raised
    • vitritis (inflammation of the vitreous) may eliminate red reflex and preclude view of fundus
  • Chronic presentation: similar, usually milder, delayed

Differential diagnosis

  • Post-operative inflammation without infection
  • Other causes of acute red eye, for example acute anterior uveitis
  • Vitreous haemorrhage

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

None

Pharmacological

None

Management category

A1: emergency referral to ophthalmologist, no intervention. Telephone oncall ophthalmologist

Possible management by ophthalmologist

  • Admission to hospital
  • Ultrasound scan
  • Anterior chamber/vitreous tap, or vitrectomy (see evidence base), followed by microbiology of specimen
  • Antibiotics: topical, subconjunctival, intravitreal, systemic as indicated
  • Steroids: topical, intravitreal, systemic as indicated

Evidence base

Sources of evidence

Gentile RC, Shukla S, Shah M, Ritterband DC, Engelbert M, Davis A, Hu DN. Microbiological spectrum and antibiotic sensitivity in endophthalmitis: a 25-year review. Ophthalmology 2014;121(8):1634-42

Gower EW, Lindsley K, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2013;7:CD006364

Jackson TL, Paraskevopoulos T, Georgalas I. Systematic review of 342 cases of endogenous bacterial endophthalmitis. Surv Ophthalmol 2014;59(6):627-35

Reibaldi M, Pulvirenti A, Avitabile T, Bonfiglio V, Russo A, Mariotti C, Bucolo C, Mastropasqua R, Parisi G, Longo A. Pooled estimates of incidence of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents with and without topical antibiotic prophylaxis. Retina. 2017 Mar 6. doi: 10.1097/IAE.0000000000001583.
[Epub ahead of print]

Lay summary

The most frequently performed eye operation is cataract surgery and it is normally highly successful in restoring vision. However, in a very small proportion of cases (fewer than three per thousand) it is complicated by infection (endophthalmitis), usually caused by common bacteria such as those on the patient’s own skin. Endophthalmitis (which means inflammation inside the eye) can also occasionally be caused by retained surgical material or unsuitable fluids placed in the eye during surgery. It is called ‘acute’ if it occurs within the first week after surgery and ‘chronic’ if it occurs up to a month after surgery. It occurs more often in patients who are diabetic or who have an infection or drug treatment that suppresses the immune system.


Endophthalmitis causes pain, redness, undue light sensitivity and blurred vision when it is acute; symptoms are less severe when it is chronic. The signs seen by the optometrist or the ophthalmologist are typical of inflammation within the eye.


If the optometrist suspects endophthalmitis, the recommendation is emergency (same day) referral to an ophthalmologist, who will usually admit the patient to hospital. A specimen is taken from within the eye so that the infecting organism can be identified and antibiotic is placed directly inside the eye. Sometimes the vitreous (the jelly inside the eye) is removed. Antibiotics may also be given as eye drops, injections beneath the skin of the eye, and by mouth or by infusion into a vein.

Endophthalmitis (post-operative) Exogenous endophthalmitis
Version 11
Date of search 20.05.17
Date of revision 20.09.17
Date of publication 05.12.17
Date for review 19.05.19
© College of Optometrists 

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