History
- Pain, eye redness, decreased visual acuity, floaters, glare, eyelid swelling
- 3-10 days after intraocular surgery (IVT, phaco-IOL, complicated phaco, vitrectomy, glaucoma surgery, trauma)
- Incidence 0.04-0.07-0.2%, more common with diabetes mellitus, older patients, male sex, complicated cataract surgery
- Prophylaxis
- Intracameral cefuroxime (Aprokam) or moxifloxacin (4-5x lower risk) Endophthalmitis Study Group, JCRS 2007, Haripriya A et al, Ophthalmology 2017
- Limbal incision (6x lower risk)
Differential Diagnosis
- Normal course after intraocular or complicated intraocular surgery
- Toxic anterior segment syndrome (TASS)
Diagnostics
- Eyelids: swelling
- Conjunctiva: injection
- Cornea (Seidel test, vitreous incarceration in the incision), stromal edema
- Anterior chamber: cells/fibrin/hypopyon (DD: triamcinolone in the anterior chamber)
- Iris/pupil: fixed, synechiae
- Fundoscopy (reduced view)
- Vitreous: cells, infiltrate
- Retina: infiltrates, hemorrhages
- Ultrasound: cells, infiltrates, retina attached?
Management
If TASS is suspected (signs of inflammation already 1-2 days after surgery, absence of pain, absence of vitreous infiltrates)
- Prednisolone (Pred Forte eye drops hourly), Ultracortenol ointment at night
- Cycloplegia with scopolamine 0.25% eye drops 3x/day
- Follow-up the next day
- Inform the surgeon if applicable
If endophthalmitis is suspected
- Inform the surgeon
- Emergency referral to a tertiary center
Tertiary Center
- If applicable, anterior chamber tap: testing for bacteria, fungi
Mild intraocular inflammation and BCVA > 0.5
- Emergency intravitreal injection:
- Vancomycin (1mg)
- Dissolve 500mg Vancocin in 10ml distilled water, draw up 15ml NaCl 0.9% into a 20ml syringe and add 10ml of the vancomycin solution = 25ml
- Draw up 1ml of the vancomycin-NaCl solution into a tuberculin syringe > inject 0.05ml according to standard IVT procedure
- Amikacin (0.4mg)
- Draw up 0.2ml Amikin (dilute 500mg (2ml) with 4.8ml NaCl 0.9% in a 5ml syringe (1ml=10mg Amikin))
- Draw up 0.1ml of the Amikin solution into a tuberculin syringe > inject 0.04ml according to standard IVT procedure
No visible vessels, BCVA < 0.05
- Vitrectomy, intravitreal injection with vancomycin and amikacin, dexamethasone 0.1ml (0.4mg/0.1ml) if applicable
Late-onset endophthalmitis, persistent endophthalmitis, endogenous endophthalmitis, status post open globe trauma, status post intraocular foreign body
- additionally systemic therapy with clarithromycin 500mg 2x/day (caution: contraindications per Compendium.ch)
Sources: Will's Eye Manual 2022, Blaubuch Inselspital 2024, Eyewiki.org, AAO BCSC 2024
