Decreased vision in an acutely ill (e.g., septic) or recently hospitalized patient, the immunocompromised, a patient with an indwelling catheter, an intravenous drug user, or in a patient with a history of a recent systemic procedure (e.g., heart valve replacement or repair). No history of recent intraocular surgery.

Organisms

Bacillus cereus (especially in i.v. drug users), streptococci, Neisseria meningitidis, S. aureus, H. influenzae, Klebsiella in East Asia, and others.

• Endogenous fungal endophthalmitis: May see fluffy, white vitreous opacities. Organisms include Aspergillus and Candida. See 12.17, CANDIDA RETINITIS/UVEITIS/ENDOPHTHALMITIS.
• Viral retinitis: one or more foci of retinal whitening with variable levels of vitreous inflammation. See 12.8 ACUTE RETINAL NECROSIS.
• Retinochoroidal infection (e.g., toxoplasmosis and toxocariasis): Yellow or white retinochoroidal lesions.
• Noninfectious posterior or intermediate uveitis (e.g., sarcoidosis and pars planitis). Unlikely to get the first episode coincidentally during sepsis.
• Neoplastic conditions (e.g., large cell lymphoma and retinoblastoma).

All treatment should be coordinated with an internal medicine physician.

1. Hospitalize the patient.
2. Broad-spectrum (i.v. and/or oral) antibiotics are started after appropriate smears and cultures are obtained. Antibiotic choices vary according to the suspected source of septic infection (e.g., gastrointestinal tract, genitourinary tract, and cardiac) and are determined in consultation with an infectious disease specialist. Dosages recommended for meningitis and severe infections are used. If oral antibiotics are used, confirm that the regimen includes antibiotics with good vitreous penetration.
3. Topical cycloplegic (e.g., atropine 1% b.i.d. to t.i.d.).
4. Topical steroid (e.g., prednisolone acetate 1% q1–6h titrated to the degree of anterior segment inflammation).
5. Consider intravitreal antibiotics if there is significant or worsening vitreous involvement (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 there is high concern for Bacillus, intraocular foreign body, or when there is a penicillin allergy). Intravitreal aminoglycosides, including amikacin, may cause macular infarction. The timing of intravitreal antibiotics is controversial although they offer higher intraocular concentrations. Consider intravitreal antifungal agents, if clinically suspicious. See Appendix 11, INTRAVITREAL TAP AND INJECT, and Appendix 12, INTRAVITREAL ANTIBIOTICS.
6. Consider pars plana vitrectomy if severe or nonresponsive to initial therapy. Vitrectomy offers the benefits of reducing infective and inflammatory load and providing sufficient material for diagnostic culture and pathologic study. Additionally, intravitreal antibiotics may be administered at the time of surgery.
7. Periocular antibiotics (e.g., subconjunctival or subtenon injections) are sometimes used. See Appendix 10, TECHNIQUE FOR RETROBULBAR/SUBTENON/SUBCONJUNCTIVAL INJECTIONS.

NOTE:

Intravenous drug users are given an aminoglycoside and clindamycin to eradicate Bacillus cereus.

1. Daily in the hospital.
2. Peak and trough levels for many antibiotic agents are obtained every few days. Renal function needs monitoring during aminoglycoside therapy. The antibiotic regimen is guided by the culture and sensitivity results, as well as the patient’s clinical response to treatment. Intravenous antibiotics are maintained for at least 2 weeks (pending identification of clinical source and response to treatment).