AKT · Ophthalmology/Orbit & infectionlow yield

Endophthalmitis

Infection of the intraocular cavities (post-operative/post-injection, or endogenous)

Overview

A sight-threatening infection of the aqueous and/or vitreous cavities. Most commonly exogenous after intraocular surgery (cataract) or intravitreal injection, or following penetrating trauma; rarely endogenous (haematogenous, e.g. IV drug use, sepsis, candidaemia). Presents days after surgery with pain, dramatic visual loss and a hypopyon — an emergency requiring vitreous sampling and intravitreal antibiotics.

Recognise

Rapidly progressive PAIN and visual loss, typically a few days after cataract surgery or an intravitreal injection
Red eye, hypopyon (pus in the anterior chamber), vitritis (loss of the red reflex), lid swelling
Endogenous form in the septic/immunocompromised/IVDU patient (e.g. Candida)

Red flags

Any pain + visual loss after recent intraocular surgery/injection → endophthalmitis until excluded — emergency same-day vitreoretinal referral
Hypopyon + vitritis post-op = treat immediately (vision can be lost within hours)

Differentials & how to tell them apart

Anterior uveitispainful red eye with AC cells but no rapid profound visual loss; not post-operative with vitritis

Toxic anterior segment syndrome (TASS)sterile inflammation 12–24 h post-op, AC reaction, usually painless, responds to steroids

Retained lens fragment / post-op inflammationmilder, no hypopyon/vitritis, slower

Investigations

Urgent vitreoretinal assessment: aqueous/vitreous TAP for microscopy and culture (then inject). B-scan for vitritis. Blood cultures if endogenous.

Management

Emergency vitreoretinal referral → tap-and-inject intravitreal antibiotics

1Emergency same-day vitreoretinal referral. Vitreous/aqueous tap for culture then immediate intravitreal antibiotics (vancomycin + ceftazidime).Gate: Treat as endophthalmitis FIRST in any painful, vision-losing eye after recent surgery/injection — do not delay for cultures; vitrectomy is indicated when vision is reduced to light perception
2Vitrectomy for severe (light-perception) cases; antifungals for endogenous/fungal disease; identify and treat any systemic source.

Intravitreal antibiotics (vancomycin + ceftazidime/amikacin) — the core treatment — injected after the vitreous tap

Intravitreal/ systemic antifungals — endogenous/fungal (e.g. Candida) endophthalmitis

± Vitrectomy — for severe disease (light-perception vision)

Key points

Pain + visual loss + hypopyon a few days after cataract surgery = endophthalmitis = emergency tap-and-inject. The post-operative timeline is the giveaway.

Monitor & prognosis

Daily review; repeat injection/vitrectomy as needed.

Guarded; outcome depends on speed of treatment and organism.

Source: RCOphth Endophthalmitis guidelines