Bacterial Endophthalmitis Treatment & Management

Updated: Jun 20, 2016
  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

Bacterial endophthalmitis is an ocular emergency, and urgent treatment is required to reduce the potential of significant visual loss. [13, 14]

All patients should have therapy consisting of intravitreal and topical antibiotics, topical steroids, and cycloplegics. [15, 16, 17, 18]

The Endophthalmitis Vitrectomy Study (EVS) identified that the use of periocular and intravenous antibiotics are not required in endophthalmitis following cataract surgery. Medical therapy was found to be statistically as effective as surgical intervention when the presenting vision was hand motion or better. Use caution in interpreting the data from the EVS; apply it cautiously to non–cataract-related endophthalmitis. [33, 34, 35, 36, 37, 38]

When the inflammation is severe, systemic and periocular therapy may be used in non–cataract-induced, delayed onset, filtering bleb–associated, and posttraumatic endophthalmitis.

In endogenous endophthalmitis, systemic, topical, and possibly periocular therapy is usually required. [8]

Storey et al reported that increased rates of antibiotic-resistant bacteria in culture-positive endophthalmitis cases may result from the use of prophylactic topical antibiotics following intravitreal injections, [39] although, from 1999-2012, Gupta et al was unable to document emerging resistance to empirical antibiotics commonly used to treat bacterial endophthalmitis. [40]

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Surgical Care

Surgical intervention is usually performed urgently except in the delayed onset category where elective surgery may suffice.

Indications for surgical therapy

Acute pseudophakic postoperative - When the presenting vision is light perception or worse [21]

Delayed onset or chronic postoperative - If marked inflammation or a subcapsular plaque is identified, surgical removal is required.

Filtering bleb associated - If marked inflammation is present. Take care not to disturb the bleb if some function still exists. To allow the possibility of a shunt valve to be placed at a later time, make an attempt to minimize the disturbance to the superior conjunctiva. If the patient is aphakic, performing the pars plana vitrectomy from the temporal side using a limbal approach may be required.

Posttraumatic - If marked inflammation or rapid onset occurs

Technique

A 3-port core pars plana vitrectomy with intravitreal antibiotic injections is performed. [41] If visualization is poor from anterior segment pathology, then a 2-port limited pars plana vitrectomy or endoscopic guided 3-port pars plana vitrectomy may be performed. [42]

An increased risk for retinal tears and detachments occur when the vitreous close to the retina is removed aggressively due to the higher probability of retinal necrosis.

Intravitreal antibiotics usually are given after the completion of the vitrectomy; however, if an air-fluid exchange is to be performed, the antibiotics may be mixed into the vitrectomy solution. Dilute the antibiotics in the vitrectomy solution carefully to prevent possible toxic retinopathy from incorrect dosages.

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Consultations

In most exogenous cases of endophthalmitis, the ophthalmologist may manage the case sufficiently; however, in cases of less common or extremely virulent bacteria, consulting an infectious disease specialist may aid in the selection of antibiotics.

When endogenous cases of endophthalmitis are suspected, an internist should be consulted to look for a source.

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