Emergency Department Care
Once the diagnosis has been made, or strongly considered, prompt consultation to an ophthalmologist is needed. Treatment depends on the underlying cause of endophthalmitis. Final visual outcome is heavily dependent on timely recognition and treatment. Although multiple different approaches to and advances in treatment have been made, according to recent data, the rate of preservation of visual acuity has not changed significantly since 1995. [24]
Treatment of postoperative endophthalmitis
Pars plana vitrectomy or vitreous aspiration may be performed by an ophthalmologist with administration of intravitreal antibiotics (ie, vancomycin, amikacin, ceftazidime).
Consider systemic antibiotic administration as well as intravitreal steroids.
Patients with postoperative endophthalmitis usually are not admitted to the hospital. However, the decision to admit the patient is determined in consultation with the ophthalmologist.
Treatment of traumatic endophthalmitis
Admit the patient to the hospital.
Treat ruptured globe (if present).
Systemic antibiotics including vancomycin and an aminoglycoside or a third-generation cephalosporin are indicated. Consider clindamycin until Bacillus species can be ruled out if soil contamination is suspected.
Topical fortified antibiotics are used.
Intravitreal antibiotics should be administered.
Consider pars plana vitrectomy.
Tetanus immunization is necessary if immunization record is not current.
Cycloplegic drops (ie, atropine) may be considered.
Treatment of endogenous bacterial endophthalmitis
Admit the patient to the hospital.
Broad-spectrum intravenous antibiotics including vancomycin and an aminoglycoside or third-generation cephalosporin. Consider adding clindamycin in intravenous drug users until Bacillus infection can be ruled out.
Periocular antibiotics are sometimes indicated.
Intravitreal antibiotics are indicated.
Cycloplegic drops (ie, atropine) may be administered.
Topical steroids may be considered.
Vitrectomy may be needed for virulent organisms.
Treatment of candidal endophthalmitis
Admit the patient to the hospital.
Oral fluconazole is indicated.
Amphotericin B intravenous or intravitreal may be considered.
Cycloplegic drops (ie, atropine) may be considered.
Consultations
Ophthalmologist: Emergent consultation is necessary if this diagnosis is entertained. This is an ophthalmologic emergency, as the patient is in danger of losing his or her vision.
Prevention
Few randomized controlled trials have been performed to determine the most effective methods to prevent endophthalmitis. Use of appropriate protective eyewear can decrease risk of ocular trauma or globe penetration in certain circumstances.
Transfer
The emergency department physician should consider transfer to another facility if ophthalmology consultation is not available at his or her institution.
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Severe endophthalmitis. Courtesy of Ron Afshari Adelman MD, MPH, MBA, FACS, Yale Medical Group.
