Endophthalmitis

Endophthalmitis is severe inflammation within the eye, usually caused by infection involving the aqueous and vitreous. Organisms can be introduced during an operation or injection, through a penetrating wound or from an infected cornea. They can also arrive through the circulation from a systemic focus. The resulting inflammatory response can damage delicate retinal tissues quickly. The practical priority is therefore early recognition and delivery of effective treatment inside the eye, not completion of a routine red-eye prescription before seeking help.

Ask about cataract surgery, vitreoretinal surgery, intravitreal injections, glaucoma filtering surgery, trauma and the date symptoms began. Acute postoperative infection often appears during the early days after a procedure, but later infection can occur, including around a filtering bleb or with a slower-growing organism. A patient may initially improve and then deteriorate. Do not use elapsed time alone to exclude infection. A history of immunosuppression, diabetes, systemic illness, vascular access or recent bloodstream infection raises additional questions about an endogenous source.

Clinical findings include reduced acuity, pain, photophobia, conjunctival injection, lid swelling and marked anterior chamber inflammation. A hypopyon is a settled inflammatory cell layer; vitritis may reduce the red reflex and obscure the fundus. Not every patient has dramatic pain or a visible hypopyon, especially in an atypical or endogenous presentation. The specialist examines the anterior and posterior segments and compares the current course with expected postoperative inflammation. Sterile inflammation remains a differential diagnosis, but an uncertain case with significant visual decline must be assessed urgently rather than reassured remotely.

Vitreous sampling allows microscopy, culture and susceptibility testing, with molecular testing where available and appropriate. The laboratory needs prompt notification because the sample is small and handling matters. Aqueous or wound samples may also be selected. Sampling should be followed promptly by empirical intravitreal therapy, without waiting for microbiological confirmation. If the fundus cannot be seen, specialist B-scan ultrasound can assess the posterior segment when globe integrity permits; inability to obtain it immediately should not delay needed treatment.

The cited University Hospitals of North Midlands protocol gives vancomycin 1 mg in 0.1 mL and ceftazidime 2.25 mg in 0.1 mL intravitreally for presumed postoperative bacterial infection. These are a specific NHS protocol's doses rather than a claim that every UK centre uses identical preparations. Ophthalmology and pharmacy must verify the drug, concentration, volume, route and allergy history. Intravitreal administration is off-label, and dilution errors can be sight-threatening. Topical antibiotics alone do not deliver an adequate substitute for this intraocular treatment.

Vitrectomy removes infected and inflammatory vitreous material and can obtain additional specimens. It may be considered early in severe cases, including very poor presenting vision, traumatic or bleb-related infection, or inadequate response. The decision is made by the treating surgeon according to the complete presentation and available view. The cited pathway reviews early response within twenty-four to forty-eight hours and considers surgery if improvement is inadequate. Repeat intravitreal injection is not an automatic timed instruction; selection and timing depend on the specialist protocol, organisms, drug persistence and toxicity risk.

Endogenous infection requires coordinated systemic care. Obtain blood cultures promptly and investigate an appropriate source such as endocarditis, an infected vascular device or another deep focus, guided by symptoms and microbiology. Systemic antibacterial or antifungal treatment is essential to control the source as well as local eye treatment when indicated. Fungal infection changes the intravitreal drug choice and the role of steroids. Corticosteroids, whether topical or systemic, are specialist adjuncts after antimicrobial decisions; an unexamined red eye should not receive an empirical steroid escalation that delays identification of infection.