Symptoms and Signs

Similar to 12.13, POSTOPERATIVE ENDOPHTHALMITIS. An occult or missed IOFB must be ruled out. See 3.15, INTRAOCULAR FOREIGN BODY.

NOTE:

Patients with Bacillus endophthalmitis may have a high fever, leukocytosis, proptosis, a corneal ring ulcer, and rapid visual deterioration.

Organisms

Staphylococcus species, Streptococcus species, Gram-negative species, fungi, Bacillus species, and others. Mixed flora may be present. Understanding the mechanism of injury is helpful in predicting the type of infecting organism (e.g., penetrating trauma from organic matter increases the risk of fungal infection).

• Phacoanaphylactic inflammation: A sterile hypersensitivity reaction as a result of exposed lens protein associated with anterior chamber reaction, KP, and sometimes elevated IOP. See 9.12, LENS-RELATED GLAUCOMA.
• Lens cortex: Fluffed up and hydrated cortical lens material, especially in younger patients with soft nuclei after violation of the lens capsule, associated with large anterior chamber lens particles, but no KP.
• Sterile inflammatory response from a retained IOFB, blood in the vitreous, retinal detachment, or as a result of surgical manipulation.

1. Consider hospitalization.
2. Management for a ruptured globe or penetrating ocular injury if present. See 3.14, RUPTURED GLOBE AND PENETRATING OCULAR INJURY.
3. Removal of an intraocular foreign body in traumatic endophthalmitis is paramount in controlling the infection. See 3.15, INTRAOCULAR FOREIGN BODY.
4. Intravitreal antibiotics (e.g., ceftazidime 2.2 mg in 0.1 mL and vancomycin 1 mg in 0.1 mL; clindamycin 1 mg in 0.1 mL or amikacin 0.4 mg in 0.1 mL may also be considered for anaerobic coverage, especially if high concern for Bacillus, intraocular foreign body, or when there is a penicillin allergy). Intravitreal aminoglycosides should be used with caution, given their potential risk of macular infarction. These medications may be repeated every 48 to 72 hours as needed. See Appendix 12, INTRAVITREAL ANTIBIOTICS.
5. Systemic antibiotics (e.g., ciprofloxacin 400 mg i.v. q12h or moxifloxacin 400 mg p.o. or i.v. daily; and cefazolin 1 g i.v. q8h). Consider an infectious disease consult for guidance in specific cases. May need to adjust dose for renal insufficiency and for children.
6. The benefit of pars plana vitrectomy is unknown for traumatic endophthalmitis without IOFB. However, pars plana vitrectomy reduces the overall infectious and inflammatory burden and provides sufficient material for diagnostic culture and pathologic investigation.
7. Give tetanus toxoid 0.5 mL intramuscularly if immunization is not up-to-date. See Appendix 2, TETANUS PROPHYLAXIS.
8. Steroids are typically not used until fungal organisms are ruled out, although recent reports have demonstrated that topical steroids may not be as deleterious as previously thought. Topical and oral steroids may be used at the discretion of the physician to control postinfection inflammation once the infection is sterilized.

Same as for 12.13, POSTOPERATIVE ENDOPHTHALMITIS.

This condition constitutes an emergency requiring prompt attention.