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Endophthalmitis: Causes, Symptoms and Treatment

Endophthalmitis is a severe inflammation of the interior of the eye, usually caused by bacteria or fungi. It can lead to blindness and is a medical emergency.

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Things worth knowing about "Endophthalmitis"

Endophthalmitis is a severe inflammation of the interior of the eye, usually caused by bacteria or fungi. It can lead to blindness and is a medical emergency.

What is Endophthalmitis?

Endophthalmitis is a serious inflammatory condition affecting the interior of the eye. The intraocular fluids and tissues – particularly the vitreous body and the anterior chamber – become infected by microorganisms or, less commonly, are affected by non-infectious inflammatory processes. Without prompt treatment, the condition can lead to permanent, severe vision loss or complete blindness. It is therefore considered an ophthalmic emergency.

Causes and Types

Endophthalmitis is classified into two main types based on how the infection arises:

Exogenous Endophthalmitis

This more common form results from direct entry of pathogens into the eye from the outside. Typical triggers include:

Ocular surgery, especially cataract surgery – the most frequent cause
Intravitreal injections (medication injections into the vitreous body)
Penetrating eye injuries caused by foreign bodies or trauma
Corneal infections (keratitis) that spread into the interior of the eye

Endogenous Endophthalmitis

This rarer form occurs when pathogens spread through the bloodstream to the eye (haematogenous spread). It is most often seen in patients with weakened immune systems, sepsis, intravenous drug use, or severe underlying conditions.

Common Pathogens

Bacteria: Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus species, gram-negative bacilli
Fungi: Candida albicans (especially in endogenous form), Aspergillus species

Symptoms

Symptoms of endophthalmitis typically develop rapidly – often within hours to days following the triggering event. Common signs and symptoms include:

Severe pain in the affected eye
Rapid deterioration of vision, potentially leading to complete loss of sight
Light sensitivity (photophobia)
Red eye (conjunctival injection)

Swollen eyelids

Pus or cloudy fluid in the eye (visible as hypopyon – a collection of pus in the anterior chamber)

Diagnosis

Diagnosis is primarily clinical and made by an ophthalmologist. The following examinations are typically used:

Slit-lamp examination: Assessment of the anterior and posterior segments, detection of inflammatory signs and hypopyon
Ophthalmoscopy: Examination of the fundus (back of the eye)
Ultrasound (B-scan): Used when the optical media are cloudy, to assess the vitreous and retina
Microbiological culture: Sampling of vitreous or aqueous humor to identify the causative organism
PCR diagnostics: Rapid pathogen identification from ocular fluid samples

Treatment

Treatment must be initiated as quickly as possible to minimize vision loss. Therapy is guided by the causative pathogen and the severity of the condition.

Antibiotic or Antifungal Therapy

Intravitreal antibiotic injection: Direct injection of antibiotics into the vitreous (e.g., vancomycin and ceftazidime) – first-line treatment for bacterial endophthalmitis
Systemic antibiotics: Required in addition for severe or endogenous forms
Antifungal agents: For fungal infections (e.g., voriconazole, amphotericin B)

Surgical Treatment

Vitrectomy: Surgical removal of the vitreous body; recommended in severe endophthalmitis or in patients with vision limited to light perception or worse. It also allows for simultaneous sample collection and direct drug administration.

Corticosteroids

In certain cases, corticosteroids (e.g., intravitreal dexamethasone) may be used to suppress the inflammatory response and protect ocular tissue. Their use remains controversial and is decided on an individual basis.

Prognosis

The prognosis of endophthalmitis depends critically on the speed of diagnosis and treatment. Despite modern therapies, many patients retain some degree of permanent vision loss. The exogenous form following cataract surgery generally has a somewhat better prognosis than the endogenous form.

Prevention

Key measures to prevent postoperative endophthalmitis include:

Strict sterile technique during all ophthalmic surgical procedures
Preoperative disinfection with povidone-iodine
Prophylactic intracameral antibiotic administration (e.g., cefuroxime)
Proper handling of contact lenses to prevent eye injuries

References

Endophthalmitis Vitrectomy Study Group: Results of the Endophthalmitis Vitrectomy Study. Archives of Ophthalmology, 1995; 113(12): 1479–1496.
Lemley CA, Han DP: Endophthalmitis: A Review of Current Evaluation and Management. Retina, 2007; 27(6): 662–680.
American Academy of Ophthalmology (AAO): Preferred Practice Pattern – Endophthalmitis. Available at: https://www.aao.org

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