This condition constitutes an emergency requiring prompt attention.

Sudden onset of decreased vision and increasing eye pain after a traumatic ocular injury.

Critical

Hypopyon, fibrin, severe AC reaction, vitreous cells and haze, and decreased red reflex, ruptured globe. An occult or missed IOFB must be ruled out. See 3.11, Intraocular Foreign Body.

Other

Eyelid edema, corneal edema, intense conjunctival injection, and chemosis (all are highly variable).

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). 

• Phacoantigenic uveitis: A sterile hypersensitivity reaction as a result of exposed lens protein associated with AC reaction, KP, and sometimes elevated IOP. See 9.11.3, Phacoantigenic Glaucoma (Formerly Phacoanaphylaxis).

• Lens particle uveitis: Fluffed up and hydrated cortical lens material, especially in younger patients with soft nuclei after violation of the lens capsule, associated with large AC lens particles, but no KP. See 9.11.2, Lens Particle Glaucoma.

• Sterile inflammatory response from a retained IOFB, blood in the vitreous, retinal detachment, or as a result of surgical manipulation.

1. Complete ocular history and examination. Look for penetrating injury and foreign body. Diffuse subconjunctival chemosis or hemorrhage can hide small penetrating wounds, consider an exploration in the operating room.

2. Consider B-scan US if there is limited view to the posterior segment, which may confirm marked vitritis, membrane formation, and/or foreign body presence.

3. Orbital CT scan (axial, coronal, and parasagittal views) with thin 1-mm cuts to evaluate for IOFB.

4. Vitreous aspiration, or an AC paracentesis if the vitreous specimen cannot be obtained, of 0.2 mL is performed sent for Gram stain, culture, and sensitivities. See Appendix 13, Anterior Chamber Paracentesis.

5. Consider a diagnostic and therapeutic vitrectomy for Gram stain, culture, and sensitivities if the infection and vision loss are severe.

1. Consider hospitalization.

2. Management for a ruptured globe or penetrating ocular injury if present. See 3.10, Ruptured Globe and Penetrating Ocular Injury.

3. Removal of an IOFB in traumatic endophthalmitis is paramount in controlling the infection. See 3.11, 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, IOFB, 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 systemic antifungals (e.g., voriconazole loading dose 400 mg i.v. q12h for two doses, then i.v. 300 mg/d) if organic matter is involved. 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.

1. Monitor the clinical course q12–24h early on.

2. Relief of pain is a useful early sign of response to therapy.

3. Consider reinjecting antimicrobials if there is no improvement or if Gram stain shows an unusual organism (targeted at that organism).

4. Consider vitrectomy if the patient is deteriorating.

5. The antimicrobial regimen is refined according to the treatment response, culture results, and culture sensitivity.

6. If the patient is responding well, topical antimicrobials and steroids may be slowly tapered. Close outpatient follow up is warranted.