Bacterial Endophthalmitis Treatment & Management

Updated: Sep 20, 2018
  • 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. [38, 39, 40, 41, 42, 43]

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, [44] although, from 1999-2012, Gupta et al was unable to document emerging resistance to empirical antibiotics commonly used to treat bacterial endophthalmitis. [45] Kodati et al performed a 23-year review that found vancomycin was still the optimal antibiotic for gram-positive endophthalmitis, and amikacin and ceftazidime offered equal protection for gram-negative endophthalmitis. [46]

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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. [47] 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. [48]

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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Prevention

See the list below:

  • Identify high-risk patients before elective surgery (see below)

    • Blepharitis

    • Abnormal lacrimal drainage

    • Active infection elsewhere

  • Preparation of operative field (see below)

    • Prep with 5-10% povidone-iodine solution in preoperative area

    • Prep with 5-10% povidone-iodine immediately before draping and allow solution to dry

    • Drape to cover lashes and lid margins

  • Prophylactic topical and/or periocular antibiotics [14, 49]

  • Prophylactic intravitreal antibiotics in trauma cases

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Further Outpatient Care

Patients should receive follow-up care on a daily basis. Clinical features indicating improvement include the following:

  • Reduced pain

  • Decreased inflammation and hypopyon

  • Increased red reflex

  • Retraction of any fibrin

  • Improved visual acuity

If no improvement occurs in 48-72 hours, consider the following:

  • Repeat tap/biopsy and antibiotic injections

  • Vitrectomy and injection of antibiotics, if no previous vitrectomy exists

If view is poor, B-scan ultrasound is useful to rule out retinal detachment.

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Further Inpatient Care

Patients may be admitted or may be treated as outpatients depending on the following:

  • Severity of endophthalmitis and treatment modalities

  • Underlying systemic diseases

  • Patient reliability and compliance

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Inpatient & Outpatient Medications

Topical antibiotic coverage with dosage dependent on severity, as follows:

  • Vancomycin 50 mg/mL 1 gtt qid to q1h

  • Ceftazidime 50 mg/mL 1 gtt qid to q1h

  • Prednisolone 1 gtt qid to q1h

  • Atropine 1 gtt bid

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