Panophthalmitis - Residency Notes & Viva Questions

PART 1: CASE PRESENTATION

Presenting Complaint

History of Present Illness

• H/o penetrating ocular injury with organic (wooden) material 5 days ago
• Primary wound closure done at a peripheral centre 4 days back
• Progressive worsening pain since day 2 post-injury, now severe and throbbing
• Vision: Was finger counting at 2 metres at primary centre, now only perceives light
• Swelling of both eyelids, discharge (purulent), marked redness
• Low-grade fever, malaise
• No similar history in the other eye
• No h/o diabetes, immunosuppression, or prior eye surgery

Past History

• No systemic illness
• No prior ocular surgery or trauma
• No drug allergies

Examination

Investigations

1. B-scan ultrasonography right eye: Dense vitreous echoes, choroidal thickening, posterior scleritis pattern
2. CT orbit: Orbital cellulitis with extension; proptosis right eye
3. Blood cultures x2 (sent before antibiotics)
4. CBC: TLC 14,200 (neutrophilia), ESR elevated
5. Blood sugar (rule out DM)
6. Vitreous/AC tap: Gram stain, culture, and sensitivity (if surgical intervention planned)

Diagnosis

PART 2: DISEASE OVERVIEW FOR RESIDENCY NOTES

Definition

• Endophthalmitis = inflammation confined to the interior of the eye (vitreous ± uveal tract), not extending beyond sclera
• Panophthalmitis = endophthalmitis + involvement of uvea and sclera + orbital extension

"Endophthalmitis is a term used to describe inflammation of the interior of the eye involving the vitreous humor, and panophthalmitis is the term used to describe inflammation of the interior of the eye that extends into the uvea and sclera."

• Robbins, Cotran & Kumar Pathologic Basis of Disease

Classification

A. By Source of Infection

B. By Onset (Post-surgical)

• Acute - within days of surgery (most common; S. epidermidis)
• Subacute/Delayed - weeks to months post-surgery (Cutibacterium acnes, fungi)
• Bleb-related - complicating filtering surgery

Aetiology and Causative Organisms

Post-cataract extraction:

• Most common: Staphylococcus epidermidis
• Common: S. aureus, Streptococcal species
• Less common: Gram-negative bacilli (Pseudomonas, Klebsiella, Bacillus, E. coli, Proteus, Haemophilus influenzae)
• Anaerobes

Post-traumatic (penetrating injury with IOFB):

• Staphylococcus spp. and Bacillus spp. - ~90% of culture-positive cases
• Bacillus cereus - especially in agricultural injuries; notoriously virulent and rapidly destructive

Bleb-associated:

• Streptococcus spp. and Gram-negative infections (more virulent than post-cataract)

Endogenous:

• Gram-positives: S. aureus, Streptococci
• Gram-negatives: Klebsiella pneumoniae (especially in Asians with liver abscess), E. coli, Pseudomonas
• Fungi: Candida albicans (IV drug users, post-surgical), Aspergillus

Subacute:

• Cutibacterium acnes (formerly Propionibacterium acnes) - requires anaerobic culture held for 14 days; classic white capsular plaque

Robbins Pathology notes that Candida may disseminate hematogenously to the retina, especially in IV drug users or systemic candidemia, producing multiple retinal abscesses

Pathogenesis

Penetrating trauma / Post-surgical wound / Haematogenous seeding
              ↓
Entry of organisms into vitreous cavity
              ↓
Suppurative vitritis (Endophthalmitis)
              ↓
Extension through choroid and sclera
              ↓
Panophthalmitis (orbital involvement, proptosis, restricted EOM)

• The retina is extremely sensitive to suppurative inflammation - irreversible injury can occur within a few hours
• Viable bacteria in the vitreous have few host defences (avascular, poor neutrophil access)

Clinical Features

Symptoms

• Severe, throbbing ocular pain
• Rapid loss of vision (may progress to no light perception)
• Redness, swelling of eyelids
• Purulent discharge
• Photophobia, lacrimation
• Systemic: fever, malaise (especially endogenous)

Signs - Anterior Segment

• Lid oedema, erythema
• Conjunctival chemosis, 360° injection
• Purulent discharge
• Corneal oedema, infiltrate, ring abscess (in severe cases)
• Hypopyon (pathognomonic of suppurative intraocular infection)
• Fibrin/exudate in anterior chamber, 4+ cells and flare
• Muddy, congested iris
• Absent red reflex

Signs - Posterior Segment

• Vitreous haze, vitritis
• Vitreous abscess
• Retinal infiltrates, flame haemorrhages ± white centres
• Retinal/subretinal/choroidal abscesses
• Retinal detachment (late)

Signs of Panophthalmitis Specifically (Orbital Extension)

• Proptosis
• Restricted extraocular movements (all directions)
• Chemosis extending to the forniceal region
• Eyelid cellulitis
• Orbital pain on movement

(Wills Eye Manual: "Panophthalmitis with orbital involvement (proptosis, restricted ocular motility)")

Investigations

1. B-scan ultrasonography (mandatory if posterior pole not visible)
   • Dense vitreous echoes (vitritis/abscess)
   • Choroidal thickening
   • Retinal detachment
   • Scleral/orbital involvement
2. CT orbit - rule out orbital cellulitis extension, retained foreign body, intracranial extension
3. Intraocular fluid sampling for culture:
   • Vitreous aspirate (preferred - higher yield)
   • Aqueous paracentesis
   • Stains: Gram stain, Giemsa stain, Methenamine-silver (fungi)
   • Cultures: Blood agar, Chocolate agar, Sabouraud agar (fungi), Thioglycolate broth (anaerobes)
   • Critical: For C. acnes - anaerobic culture must be held for 14 days
4. Blood cultures x2 (before antibiotics, especially in endogenous cases)
5. CBC, ESR, CRP, blood sugar, LFT, RFT, HIV, immunosuppression workup
6. Removed IOFB should be sent for culture

Treatment

1. Medical Management

• Vancomycin 1 mg/0.1 mL (Gram-positive coverage)
• Ceftazidime 2.25 mg/0.1 mL (Gram-negative coverage)
• Alternative if penicillin allergic: Amikacin instead of ceftazidime
• Intravitreal dexamethasone 0.4 mg/0.1 mL - considered in severe vitreous inflammation (after cultures obtained)

• Vancomycin + Tobramycin, q1h around the clock for 24-48 hours
• Especially important for bleb-related cases, wound leaks

• Prednisolone acetate 1% q1h (after 48 hours)

• Atropine 1% b.i.d. to t.i.d.

• IV/oral fluoroquinolones (moxifloxacin) - especially for bleb-related, traumatic, or endogenous endophthalmitis
• Systemic antibiotics not routinely indicated for post-cataract endophthalmitis (poor intraocular penetration)
• For fungal: Intravitreal amphotericin B 5-10 μg/0.1 mL or voriconazole 100 μg/0.1 mL + systemic antifungals

2. Surgical Management

• Indication: Vision of light perception or worse at presentation (post-cataract extraction - per Endophthalmitis Vitrectomy Study)
• PPV removes the microbial load, inflammatory debris, and allows direct sampling
• May also be beneficial in bleb-related, traumatic, or endogenous cases

• Removal of ocular contents while preserving the scleral shell
• Indicated when the eye is unsalvageable and infection is limited to the globe
• Preferred over enucleation in active infection (less risk of spreading meningitis)

• Removal of the entire globe
• Indicated in cases where orbital extension cannot be controlled, painful blind eye, or sympathetic ophthalmia risk

In panophthalmitis with orbital extension, evisceration/enucleation may be necessary to control life-threatening orbital sepsis.

3. Prevention

• 5% povidone-iodine conjunctival preparation before intraocular surgery (evidence-based)
• Intracameral antibiotics at time of cataract surgery (reduces risk)
• Prophylactic intravitreal antibiotics for high-risk penetrating trauma (agricultural injuries)
• Prompt removal of IOFB

Prognosis

• Post-traumatic panophthalmitis (especially with Bacillus cereus or Streptococcus) - very poor visual prognosis; often requires evisceration
• Bleb-related endophthalmitis - worse prognosis than post-cataract (more virulent organisms)
• Endogenous - poor if bilateral or Bacillus/Klebsiella; better with early systemic treatment
• Post-cataract - relatively better if treated promptly (S. epidermidis)

PART 3: PATHOLOGY IMAGE

PART 4: VIVA QUESTIONS AND ANSWERS

1. Immediate PPV was beneficial only when vision was light perception or worse at presentation
2. When vision was hand motions or better, tap and inject (without PPV) had comparable outcomes
3. Systemic antibiotics (IV amikacin + vancomycin) added NO benefit over intravitreal antibiotics alone
4. Intravitreal vancomycin + amikacin/ceftazidime were the standard treatment

• Note: The EVS was specific to post-cataract extraction endophthalmitis. PPV may be beneficial in other settings (bleb-related, post-traumatic) independent of vision level.

• Vancomycin: 1 mg/0.1 mL (covers Gram-positives including MRSA)
• Ceftazidime: 2-2.25 mg/0.1 mL (covers Gram-negatives including Pseudomonas)
• If penicillin-allergic: Amikacin 0.4 mg/0.1 mL instead of ceftazidime
• Fungal: Amphotericin B 5-10 μg/0.1 mL or Voriconazole 100 μg/0.1 mL
• Intravitreal dexamethasone: 0.4 mg/0.1 mL (adjunctive, in select severe cases)
• Bleb-related: Vancomycin 2 mg/0.1 mL + Ceftazidime 2 mg/0.1 mL

• White capsular plaque or opacity on the posterior lens capsule (organisms sequestered in capsular bag)
• Recurrent anterior uveitis with granulomatous KP
• Minimal pain and injection
• Transient response to steroids only
• Diagnosis: Anaerobic culture held for 14 days
• Treatment: Vitrectomy with posterior capsulectomy + intravitreal vancomycin; removal of IOL and entire capsular bag if recurs

1. Evisceration is a faster, simpler procedure with less surgical trauma
2. Preserves the scleral shell for a better cosmetic outcome with an implant
3. In active meningitis risk - evisceration leaves sclera intact, reducing the theoretical risk of spreading infection along the optic nerve to the CNS (though this is debated)
4. Enucleation is preferred when: sympathetic ophthalmia risk (perforating injury with uveal prolapse), orbital extension that cannot be controlled by evisceration, or intraocular malignancy is suspected

• Any penetrating trauma with uveal prolapse carries this risk
• Onset: typically 2 weeks to 3 months after injury (rarely up to years)
• Management: Enucleation of the exciting eye within 2 weeks of injury may prevent development
• If sympathetic ophthalmia has already developed, enucleation of the exciting eye will NOT protect the sympathizing eye
• Treatment of established cases: high-dose systemic steroids + immunosuppressants

• In post-cataract endophthalmitis: systemic antibiotics provide NO additional benefit (EVS, 1995) and are NOT routinely recommended
• However, fluoroquinolones (moxifloxacin) achieve reasonable intraocular levels and are used in:
  • Bleb-related endophthalmitis - oral moxifloxacin for 10-14 days
  • Post-traumatic panophthalmitis - especially high-risk cases
  • Endogenous endophthalmitis - systemic antibiotics are KEY to treatment (targeting the primary source)
• IV antibiotics are reserved for severe systemic sepsis or endogenous cases

1. Informed consent, sterile technique
2. Topical/subconjunctival/retrobulbar anaesthesia as appropriate
3. Use a 23-25G needle on a tuberculin syringe
4. Entry site: 3.5 mm (aphakic/pseudophakic) or 4 mm (phakic) from limbus in the inferotemporal quadrant
5. Aspirate 0.2-0.3 mL of vitreous (not more - risk of retinal detachment)
6. Dry tap may occur in very inflamed eyes - proceed with intravitreal antibiotics anyway
7. Send immediately for cultures (blood agar, chocolate agar, Sabouraud, thioglycolate for anaerobes)
8. Smears: Gram stain, Giemsa, Methenamine-silver

• Surgical factors: Wound leak, posterior capsular rupture with vitreous loss, intraoperative vitreous in the wound
• Patient factors: Blepharitis, conjunctivitis, nasolacrimal duct obstruction, diabetes, immunosuppression
• Exposed/intact sutures, filtering bleb (trabeculectomy patients)
• Failure to use povidone-iodine preoperatively
• Prolonged surgery time

• Rapid, catastrophic visual loss
• Often bilateral
• Choroidal and retinal abscesses on fundoscopy/B-scan
• Associated with bacteraemia

1. Urgent ophthalmology consultation
2. Blood cultures, vitreous tap for cultures
3. IV antibiotics targeting Klebsiella (ceftriaxone or fluoroquinolone based on sensitivity)
4. Intravitreal antibiotics (ceftazidime + vancomycin)
5. Pars plana vitrectomy in selected cases
6. Management of the primary source (liver abscess - drainage)

• Prognosis: Very poor; many patients lose vision permanently despite aggressive treatment.

• Robbins, Cotran & Kumar Pathologic Basis of Disease - Chapter 29 (Eye), pp. 1199/1216
• Wills Eye Manual - Office and Emergency Room Diagnosis and Treatment of Eye Disease (12.13 Postoperative Endophthalmitis; 12.14 Chronic Postoperative Uveitis)
• Kanski's Clinical Ophthalmology: A Systematic Approach, 10th Edition

PANOPHTHALMITIS

Residency Notes, Case Presentation & Viva Q&A

Ophthalmology

PART 1 - CASE PRESENTATION

Chief Complaint

History of Present Illness

• Right eye struck by a wooden stick while working in the field (day 0)
• Taken to a peripheral centre; primary wound repair done same day
• Day 2: Pain increasing, eye became increasingly red
• Day 3: Vision dropped to finger counting
• Day 5 (today): Vision only light perception, lids swollen shut, purulent discharge
• Fever and malaise for 2 days
• No similar episode before; no injury to the left eye

Past History / Review of Systems

• No diabetes, no immunosuppression, no long-term medication
• No prior ocular surgery
• No known drug allergies
• Immunisation history: Tetanus status unknown

Examination

Right Eye

Left Eye

Investigations

1. B-scan ultrasonography RE - dense vitreous echoes (vitritis/abscess), choroidal thickening, no obvious IOFB; membrane formation posteriorly
2. CT orbit (axial + coronal, 1 mm cuts) - proptosis RE, thickened posterior coats, orbital fat stranding; no retained metallic IOFB
3. Vitreous tap (0.2 mL) - sent for:
   • Gram stain (polymorphs, Gram-positive rods suggestive of Bacillus spp.)
   • Giemsa stain
   • Culture: Blood agar, Chocolate agar, Sabouraud agar, Thioglycolate broth (anaerobes)
4. Blood cultures x2 (before antibiotics)
5. CBC: WBC 15,200 (neutrophilia 84%), Hb 12.8, platelets normal; ESR 72 mm/hr; CRP elevated
6. RBS: 98 mg/dL
7. Renal function: Normal
8. Tetanus toxoid status: Unverified

Diagnosis

Provisional Microbiological Diagnosis

PART 2 - COMPLETE DISEASE NOTES

1. DEFINITION

"Panophthalmitis is the term used to describe inflammation of the interior of the eye that extends into the uvea and sclera... applied to eye inflammation involving the retina, choroid, and sclera extending into the orbit."

• Robbins, Cotran & Kumar Pathologic Basis of Disease

2. CLASSIFICATION

By Source of Infection

"Endophthalmitis is classified as exogenous (originating in the environment and gaining access to the eye's interior through a wound as a complication of surgery or penetrating injury) or endogenous (delivered to the eye hematogenously, e.g., secondary to pulmonary infections)."

• Robbins Pathology

By Timing (Post-surgical)

• Acute - days after surgery (most common)
• Subacute/Chronic - weeks to months post-surgery (Cutibacterium acnes, fungi)
• Bleb-associated - complication of filtering surgery (trabeculectomy)

3. CAUSATIVE ORGANISMS

Post-cataract extraction (Wills Eye Manual)

Post-vitrectomy

• S. epidermidis

Post-intravitreal injection

• S. epidermidis, oral Streptococci

Bleb-associated (filtering surgery)

• Streptococcus spp. and Gram-negatives (more virulent than post-cataract)

Post-traumatic (penetrating injury)

• Staphylococcus spp. and Bacillus spp. - ~90% of culture-positive cases
• Bacillus cereus - especially agricultural injuries; notoriously virulent; mixed flora from organic matter increases fungal risk too
• Classic Bacillus triad: high fever + leukocytosis + corneal ring abscess + proptosis + rapid visual deterioration

Endogenous bacterial

• Bacillus cereus (IV drug users)
• Streptococcus, Neisseria meningitidis, S. aureus, H. influenzae
• Klebsiella pneumoniae - East Asia, associated with liver abscess and diabetes

Endogenous fungal

• Candida albicans - IV drug users, post-surgical immunocompromised, indwelling catheters, candidemia
• Aspergillus - immunocompromised (neutropenic)
• Fluffy white vitreous opacities are characteristic of fungal endophthalmitis

Subacute/Chronic post-surgical

• Cutibacterium acnes (formerly Propionibacterium acnes) - anaerobe; white lens capsular plaque; needs 14-day anaerobic culture

4. PATHOGENESIS

Penetrating trauma OR Post-surgical wound leak OR Haematogenous seeding
                        ↓
      Microbial entry into vitreous cavity
                        ↓
     Vitritis - rapid, unimpeded growth
     (vitreous = avascular, immune-privileged,
      poor neutrophil access = minimal defence)
                        ↓
  Retinal injury (may be irreversible within hours)
                        ↓
      Suppurative choroiditis + scleritis
                        ↓
   PANOPHTHALMITIS - orbital extension
   (proptosis, ophthalmoplegia, orbital cellulitis)
                        ↓
   Cavernous sinus thrombosis / Meningitis (rare)

"The retina poorly tolerates suppurative inflammation in the vitreous humor; a few hours may be sufficient to cause irreversible retinal injury."

• Robbins Pathology

5. CLINICAL FEATURES

Symptoms

• Severe, throbbing, deep orbital pain (worse than endophthalmitis)
• Rapid, progressive loss of vision (PL or worse)
• Redness - globe and eyelids
• Swelling of lids
• Mucopurulent discharge
• Photophobia
• Systemic: fever, chills, malaise (especially in endogenous type)

Anterior Segment Signs

• Lid oedema and erythema (may prevent lid opening)
• 360° conjunctival injection
• Chemosis
• Mucopurulent discharge
• Corneal oedema, stromal infiltrate, ring abscess/ulcer
• Hypopyon - fluid level of pus in anterior chamber (pathognomonic of suppurative intraocular infection)
• Dense fibrinous exudate in anterior chamber
• Flare 4+, cells 4+
• Muddy/congested iris
• Absent or severely reduced red reflex
• Critical signs: Hypopyon + fibrin + absent red reflex = endophthalmitis until proven otherwise

Posterior Segment Signs

• Vitritis (vitreous haze/cells)
• Vitreous abscess
• Retinal infiltrates, flame haemorrhages ± white centres (Roth spots)
• Retinal/subretinal/choroidal abscesses
• Retinal detachment (late complication)
• Iris microabscesses (endogenous)

Signs Specific to Panophthalmitis (Orbital Extension)

• Proptosis (exophthalmos)
• Restricted extraocular movements in all directions (painful)
• Lid oedema extending beyond orbital rim
• Orbital pain on palpation and on movement
• Soft tissue swelling of the entire orbit
• (May progress to cavernous sinus thrombosis - emergency)

6. INVESTIGATIONS

Ocular

1. B-scan ultrasonography (mandatory when posterior pole not visible):
   • Dense vitreous echoes (vitritis)
   • Vitreous membranes / abscess
   • Choroidal thickening / detachment
   • Retinal detachment
   • Rules out IOFB (metallic/non-metallic)
   • Establishes baseline for monitoring treatment response
2. Intraocular fluid sampling (cultures - cornerstone of management):
   • Vitreous aspirate preferred (higher diagnostic yield than aqueous)
   • Aqueous paracentesis if vitreous cannot be obtained
   • Volume: 0.2-0.3 mL (not more - retinal detachment risk)
   • Stains: Gram stain, Giemsa stain, Methenamine-silver (fungi), KOH prep (fungi)
   • Culture media:
     • Blood agar (aerobic bacteria)
     • Chocolate agar (Haemophilus, Neisseria)
     • Sabouraud's agar (fungi)
     • Thioglycolate broth (anaerobes)
     • For C. acnes: Anaerobic culture held for 14 days
3. CT orbit (axial + coronal, 1 mm cuts):
   • Assess orbital extension
   • Detect retained IOFB (metallic)
   • Rule out intracranial extension / cavernous sinus thrombosis
   • Assess sinus pathology (endogenous from sinusitis)
   • Note: MRI is contraindicated if metallic IOFB suspected

Systemic (Endogenous / Uncertain Aetiology)

• Blood cultures x2 (before antibiotics)
• CBC, ESR, CRP
• Blood sugar (rule out undetected diabetes)
• Renal and liver function tests
• Urine culture
• Chest X-ray
• Echocardiogram (rule out infective endocarditis if bacteraemia)
• Lumbar puncture (only if meningeal signs present)
• HIV serology, CD4 count (if immunocompromised suspected)
• Infectious disease specialist consultation

7. TREATMENT

A. Immediate Medical Treatment

• Intravitreal antibiotics may be repeated every 48-72 hours if needed
• For Bacillus: Vancomycin + Clindamycin are the agents of choice (Bacillus is resistant to beta-lactams)

• Vancomycin (50 mg/mL) + Tobramycin (15 mg/mL) - every hour around the clock for 24-48 hours
• Especially for bleb-related cases, wound leaks, or exposed sutures

• Atropine 1% eye drops 2-3 times daily
• Prevents posterior synechiae, reduces ciliary spasm, provides pain relief

• Prednisolone acetate 1% every hour (after 48 hours; do not start before cultures obtained and fungi ruled out)

B. Systemic Antibiotics

• Traumatic panophthalmitis: ciprofloxacin 400 mg IV q12h OR moxifloxacin 400 mg PO/IV daily + cefazolin 1 g IV q8h
• Bleb-related: oral moxifloxacin for 10-14 days
• Endogenous endophthalmitis: systemic antibiotics are the CORNERSTONE (targeting primary source), dosages appropriate for meningitis/severe infection, guided by cultures and ID specialist, IV antibiotics for at least 2 weeks
• IV drug users with suspected Bacillus: aminoglycoside + clindamycin

C. Surgical Management

• When vision is hand motions (HM) or better at presentation (post-cataract)
• Aspirate 0.2 mL vitreous + intravitreal antibiotics at bedside
• Provides specimen + delivers highest possible drug concentration

• Indication post-cataract (EVS): Vision = light perception or worse at presentation
• PPV + intravitreal antibiotics when vision is LP for post-cataract endophthalmitis
• May benefit bleb-related, traumatic, or endogenous cases regardless of vision level (EVS does not apply to these)
• Benefits: removes microbial load + inflammatory debris, allows diagnostic sampling, direct antibiotic delivery
• PPV role in C. acnes: vitrectomy + posterior capsulectomy ± IOL removal

• Removal of retained IOFB is paramount in controlling post-traumatic infection
• All removed IOFBs should be sent for culture

• Removal of all ocular contents while preserving the scleral shell
• Indicated when the eye is unsalvageable and infection is confined to the globe
• Preferred over enucleation in active panophthalmitis (faster, less surgical trauma, better cosmesis with implant)
• Note: Evisceration does NOT protect from sympathetic ophthalmia (uveal tissue may be left behind)

• Removal of the entire globe and optic nerve stump
• Indicated: risk of sympathetic ophthalmia (uveal prolapse + fellow eye threatened), orbital spread that cannot be controlled by evisceration alone, suspected intraocular malignancy, painful blind eye

8. PREVENTION

• 5% povidone-iodine conjunctival and eyelid preparation before all intraocular surgery - proven to reduce endophthalmitis risk
• Intracameral antibiotics at end of cataract surgery (reduces post-operative endophthalmitis risk)
• Topical perioperative antibiotics reduce bacterial load but have not been proven to reduce endophthalmitis rate, and may promote resistance
• Prophylactic intravitreal antibiotics for high-risk penetrating trauma (agricultural injuries)
• Prompt recognition and treatment of wound leaks and bleb infections
• Culture of all removed IOFBs
• Avoidance of talking/coughing by surgeon during intravitreal injection procedures

9. PATHOLOGY IMAGE

10. PROGNOSIS

PART 3 - VIVA QUESTIONS AND ANSWERS

• Agricultural/soil-contaminated penetrating injury
• High fever and leukocytosis (systemic toxin effect)
• Rapid visual deterioration within 12-24 hours
• Ring corneal abscess at the periphery of the cornea
• Severe proptosis
• Hypopyon with dense fibrinous membrane

1. Immediate PPV is beneficial ONLY when vision at presentation is light perception (LP) or worse. When vision was hand motions (HM) or better, tap-and-inject and PPV had equivalent outcomes.
2. Systemic IV antibiotics (vancomycin + amikacin) added NO benefit to intravitreal antibiotics alone and are not routinely recommended.
3. Intravitreal vancomycin + amikacin/ceftazidime were the standard treatment.

• Applies ONLY to post-cataract extraction endophthalmitis
• Does NOT apply to: bleb-related, post-traumatic, or endogenous endophthalmitis
• In these other types, PPV may benefit regardless of visual acuity level

• Recurrent, granulomatous anterior uveitis with mutton-fat KP
• White plaque or opacities on the posterior lens capsule
• Minimal pain and injection
• Transient improvement with steroids only (then recurs)
• Hypopyon may be present

1. Vitrectomy + posterior capsulectomy + intravitreal vancomycin
2. If recurs: removal of entire posterior capsule + IOL

• Acute, active panophthalmitis with unsalvageable eye
• Infection limited to the globe (no orbital extension that cannot be controlled)
• Advantages: faster, simpler, less blood loss, better cosmetic result with orbital implant, preserves socket volume

• Risk of sympathetic ophthalmia is high (perforating injury with uveal prolapse - enucleation of exciting eye within 2 weeks may prevent SO)
• Orbital extension cannot be controlled by evisceration
• Intraocular malignancy is suspected or cannot be excluded
• Evisceration has failed to control infection

• Any penetrating trauma with uveal prolapse carries SO risk
• Enucleation of the exciting eye within 2 weeks of injury may prevent SO developing in the sympathising eye
• If SO has already developed, enucleation of the exciting eye will NOT protect the sympathising eye
• Treatment of established SO: high-dose systemic steroids + immunosuppressants (mycophenolate, azathioprine, cyclosporine)

• Bacillus cereus (IV drug users)
• Klebsiella pneumoniae (East Asia, liver abscess, diabetes)
• S. aureus, Streptococci, H. influenzae, N. meningitidis
• Candida (fungemia, indwelling lines, post-surgical)
• Aspergillus (immunocompromised)

1. Hospitalisation; co-management with infectious disease
2. Blood cultures x2 + cultures from all indwelling lines, urine, wound
3. Chest X-ray, echocardiogram (rule out endocarditis)
4. Lumbar puncture only if meningeal signs present
5. IV broad-spectrum antibiotics (dosages for severe infection/meningitis) - guided by cultures; maintained for at least 2 weeks
6. Topical cycloplegic + steroid
7. Intravitreal antibiotics if significant vitreous involvement
8. PPV if severe or non-responsive to therapy
9. Treat underlying source (drain liver abscess, remove infected line, etc.)
10. IV drug users with Bacillus: aminoglycoside + clindamycin

• Blepharitis, chronic conjunctivitis, dacryocystitis (nasolacrimal duct obstruction)
• Diabetes mellitus
• Immunosuppression (steroids, chemotherapy, HIV)
• One-eyed patient (increased threshold for surgery but higher perceived risk)

• Posterior capsular rupture with vitreous loss
• Wound leak, gaping incision, exposed/intact suture
• Vitreous to wound (suction onto incision)
• Prolonged operative time
• Failure to use preoperative povidone-iodine

• Filtering bleb (trabeculectomy patients - lifelong increased risk)
• Wound dehiscence
• Non-compliance with postoperative drops

• 5% povidone-iodine preparation (proven)
• Intracameral cefuroxime at end of surgery (ESCRS data)
• Topical antibiotics: reduce bacterial load but not proven to reduce endophthalmitis rates

1. Informed consent; explain the procedure
2. Topical anaesthesia (proparacaine/amethocaine); peribulbar/retrobulbar block if needed
3. Strict aseptic technique: povidone-iodine preparation, sterile drape, sterile gloves
4. 25 or 27G needle attached to a tuberculin syringe
5. Entry site: 3.5 mm from limbus (pseudophakic/aphakic) or 4.0 mm from limbus (phakic) in the inferotemporal quadrant
6. Aspirate 0.2-0.3 mL of vitreous fluid (undiluted, "dry" tap)
   • Dry tap may occur in very inflamed eyes; proceed with injection regardless
7. Send immediately for: Gram stain, Giemsa, Methenamine-silver stain; Blood agar, Chocolate agar, Sabouraud agar, Thioglycolate culture
8. Change needle; inject antibiotics (vancomycin 1 mg/0.1 mL, then ceftazidime 2.2 mg/0.1 mL) as two separate injections at the same site or different sites
9. Check IOP after injection (avoid central retinal artery occlusion)
10. Pad and patch; review next day

• They reduce the inflammatory response that contributes to retinal and visual damage
• However, they can potentially suppress host immunity and impair clearance of infection
• Intravitreal dexamethasone (0.4 mg/0.1 mL) is used in select cases with severe vitreous inflammation, after obtaining samples and starting antibiotics
• Topical steroids are started after 48 hours (once fungi are ruled out and antibiotic therapy initiated)
• Systemic steroids: Defined role only after infection is controlled; used in specific contexts (e.g., once culture-directed antibiotics are working in endogenous cases)
• Critical rule: Do NOT start steroids before ruling out fungal infection (can lead to catastrophic fungal proliferation)

1. Hospitalise; ophthalmology + infectious disease co-management
2. Blood cultures, urine, all line cultures
3. Echocardiogram (rule out endocarditis)
4. Systemic antifungals: IV fluconazole or micafungin (echinocandin), depending on Candida species and sensitivity
5. Intravitreal antifungal: Amphotericin B 5-10 μg/0.1 mL OR Voriconazole 100 μg/0.1 mL
6. Partial vitrectomy if significant vitreous involvement unresponsive to intravitreal therapy
7. Remove all indwelling lines/catheters
8. Drug rehabilitation referral
9. Monitor closely - can progress during antifungal therapy

• Permanent blindness (no light perception)
• Retinal detachment
• Phthisis bulbi (shrunken, disorganised, non-functional eye)
• Corneal scarring, perforation
• Secondary glaucoma or hypotony
• Sympathetic ophthalmia (if penetrating trauma with uveal prolapse)

• Orbital abscess
• Orbital cellulitis (if not already present)
• Subperiosteal abscess

• Cavernous sinus thrombosis (emergency - septic thrombosis, high mortality)
• Meningitis (spread along optic nerve sheaths)
• Brain abscess
• Systemic sepsis and septicaemia
• Death (rare; more likely with endogenous source and immunocompromised host)

• Robbins, Cotran & Kumar Pathologic Basis of Disease - Chapter 29 (Eye), pp. 1199/1216
• Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease - Sections 12.13, 12.15, 12.16, 12.17
• Kanski's Clinical Ophthalmology: A Systematic Approach, 10th Edition
• Tietz Textbook of Laboratory Medicine, 7th Edition - Eye Infections
• Tintinalli's Emergency Medicine: A Comprehensive Study - Ophthalmologic Infections