Variable. Insidious decreased vision, increasing redness, and pain.

Organisms

• S. epidermidis or other common bacteria (e.g., streptococci with a filtering bleb).

Cutibacterium acnes (formerly Propionibacterium acnes), or other rare, indolent bacteria: Recurrent, anterior uveitis, may have a hypopyon and granulomatous KP, but with minimal conjunctival injection and pain. A white plaque or opacities on the lens capsule may be evident. Only a transient response to steroids.

• Fungi (Aspergillus, Candida, Cephalosporium, Penicillium species, and others).

• Lens-particle uveitis: Perform gonioscopy and dilated exam to look for retained lens fragment(s) in angle or vitreous.
• IOL-induced uveitis (iris chafing): Look for iris transillumination and IOL decentration. Most common with one-piece acrylic IOL (thick, square-edge haptics) in the sulcus and with any lens that impinges on the iris or ciliary body.
• See 12.14, CHRONIC POSTOPERATIVE UVEITIS.

Workup

1. Complete ocular history and examination.
2. Aspiration of vitreous for smears (Gram, Giemsa, and methenamine–silver) and cultures (blood, chocolate, Sabouraud, thioglycolate, and a solid medium for anaerobic culture).

See Appendix 11, INTRAVITREAL TAP AND INJECT. Intravitreal antibiotics are given as described previously. See Appendix 12, INTRAVITREAL ANTIBIOTICS.

NOTE:

C. acnes will be missed unless proper anaerobic cultures are obtained and held for extended culture (14 days).

1. Initially treat as acute postoperative endophthalmitis, as described previously, but do not start steroids.
2. Immediate pars plana vitrectomy is beneficial if visual acuity on presentation is light perception within 6 weeks after cataract surgery. Prompt vitrectomy for endophthalmitis due to other procedures has not been studied in a large randomized trial.
3. If a fungal infection is suspected, administer intravitreal amphotericin B (5 to 10 µg/0.1 mL) or intravitreal voriconazole (100 µg/0.1 mL).
4. Removal of the intraocular lens and capsular remnants may be required for diagnosis and treatment of C. acnes endophthalmitis, which may be sensitive to intravitreal penicillin, cefoxitin, clindamycin, or vancomycin.
5. If S. epidermidis is isolated, intraocular vancomycin (including irrigation of the capsular bag) alone may be sufficient.
6. Antimicrobial therapy should be modified in accordance with culture results, sensitivity testing, clinical course, and tolerance of therapeutic agents.
7. A vitrectomy with limited capsulectomy of the capsular plaque may be considered if vitreous aspiration cultures are negative or if the clinical response is incomplete. In cases with an incomplete response, removal of the entire capsule and IOL, along with intravitreal antibiotics, should be considered.

1. Dependent on the organism.
2. In general, follow up is as described previously for acute postoperative endophthalmitis.