It is an inflammation of the internal coats of the eye along with inflammatory conditions of intraocular cavities, aqueous and vitreous humour, retina and uvea.

Endophthalmitis can be endogenous (due to hematogenous spread of infective agents) and exogenous (direct inoculation of infecting agents through breach in continuity of ocular coats e.g. post traumatic).

Clinical features:

Ø  Etiological agents include Staphylococcus aureus, coagulase negative Staphylococci, Streptococci, Pseudomonas aeruginosa, Hemophilus influenza and fungus like Candida, Aspergillus, Histoplasma etc.

Ø  History of eye surgery, penetrating injury, fever, infection or predisposing

systemic diseases leading to metastatic endophthalmitis.

Ø  Symptoms include visual loss, pain, discharge, photophobia, lid swelling. Signs include conjunctival congestion, hypopyon, vitrous exudates and loss of red fundus reflex.

Ø  Smear of aqueous humour, vitreous humour can be taken for smear and culture testing. Antibiotic susceptibility testing can also be done.

Pharmacological treatment:

1. Treatment for Post operative Endophthalmitis:

-Intravitreal injection of antibiotics - Inj. vancomycin hydrochloride 1 mg in 0.1 ml plus Inj. ceftazidime 2 mg in 0.1 ml or Inj. amikacin sulfate 0.4 mg in 0.1 ml.

-Subconjunctival Inj. vancomycin 25 mg/0.5 ml plus Inj. ceftazidime 100 mg/0.5 ml plus dexamethasone 0.25 mg/0.5 ml.

-Vancomycin eye drops 50 mg/ml plus amikacin eye drops 15 mg/ml 1 drop every 6 hours.

-Homatropine 2% eye drops 3 times a day or atropine 1% eye ointment 2 times a day.

-Prednisolone acetate 1% eye drops or dexamethasone or betamethasone 0.1% eye drops every 6 hours.

-Tab. prednisolone 1 mg/kg/day in a single morning dose after 24 hours of antibiotic use and continue for 10-14 days 2 times a day for 5-10 days.

-Parenteral antibiotics are of questionable value and given only as a supportive therapy.

-Surgical treatment

Pars plana vitrectomy is indicated if visual acuity is limited to light perception or if there is poor response to above treatment in 30-36 hours.

Treatment for Traumatic Endophthalmitis:

-Hospitalize the patient and give immunization for tetanus.

-Inj. vancomycin 1 g IV infused over 1 hour, 12 hourly.

-Inj. gentamicin 2 mg/kg every 12 hour or Inj. ceftazidime 2 g IV every 12 hour or inj. ceftriaxone 2 g IV/day.

-Topical fortified eye drops, subconjunctival injection and intravitreal injection and cycloplegic drops as in cases of postoperative bacterial endophthalmitis.

Surgery

-Repair the ruptured eyeball at the earliest.

-Pars plana vitrectomy - indications are similar to that of postoperative bacterial endophthalmitis.

Treatment for Fungal Endophthalmitis:

Exogenous fungal infections may occur postoperatively or secondary to trauma. Endogenous bacterial endophthalmitis should be treated as an emergency treatment.

-  Vitrectomy to debulk the vitreous of fungi.

-  Intravitreal Inj. amphotericin B 5-10 mcg/0.1 ml or Inj. fluconazole 25 mcg/0.1 ml.

-  Inj. amphotericin B 0.5-1.5 mg/kg/day slow infusion over 2-6 hours. (50 mg vial in powder form and is dissolved in 5% dextrose) for 10-14 days. Or

-  Tab. fluconazole 400 mg loading dose followed by 200 mg daily, total dose should not exceed 600 mg/day. In children 12 mg/kg loading dose followed by 6 mg/kg/day. Or

-  Tab. ketoconazole 200 mg orally 2 times a day or daily. In children above 2 years of age, 3.3-6.6 mg/kg/day.

-Homatropine 2% eye drops 4 times a day or atropine 1% eye ointment 2 times a day.

Patient education:

u  All patients with open globe injury must contact an ophthalmologist after getting initial treatment.

u  Cataract operated cases should never ignore pain, tearing and photophobia and decrease in vision in the operated eye and must consult the ophthalmologist at the earliest.