Prevention and management of endophthalmitis

Overview

This perspective, published in the American Journal of Ophthalmology in 2018 as Endophthalmitis: Then and Now, traces how prevention and treatment of endophthalmitis have changed over a century. The authors describe three eras: before antimicrobials, the era of systemic antimicrobials, and today's era of intravitreal antimicrobials. Today, cataract surgery and intravitreal injections are the leading causes.

Causes by clinical setting

The article explains that the setting predicts the likely organisms and guides management. Endogenous endophthalmitis spreads through the bloodstream. It occurs mainly in severely ill or immunocompromised patients, and it is increasingly linked to intravenous drug use, where fungal infection is common. After intravitreal injection, current guidance emphasises antiseptic preparation of the eyelid margins and conjunctiva and avoiding needle contact with the lids, and it finds no evidence supporting routine prophylactic antibiotic drops. After cataract surgery, ocular surface antisepsis is the prevention measure with the strongest evidence. Antibiotics injected into the eye at the end of surgery are widely used, but they remain debated because of dilution errors, contamination, cost and antibiotic stewardship.

Chronic infections after surgery involve low-virulence organisms sequestered in the lens capsule, and these may require removal of the capsular bag and lens implant. Infections linked to glaucoma blebs or exposed drainage devices often have poor visual outcomes. After open globe injury, early wound closure, prophylaxis and timely removal of organic foreign bodies are key.

Treatment

Current management involves taking a vitreous sample, performing a vitreous tap or vitrectomy, and injecting antimicrobials into the eye in most cases. A landmark randomised trial showed a benefit of immediate vitrectomy in patients presenting with very poor vision. Its findings may not apply to every cause. Adjunctive intravitreal corticosteroids remain controversial. Most patients are now treated as outpatients.

Clinical implications

Emerging antimicrobial resistance threatens current treatment, which makes antibiotic stewardship essential. Molecular diagnostic methods are promising, but their clinical role is not yet established. Even with modern care, visual outcomes can be poor, so prevention remains the priority.