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Endophthalmitis, or endophthalmia, is inflammation of the interior cavity of the human eye, usually caused by an infection. It is a possible complication of all eye surgery, particularly cataract surgery, and can result in vision loss or loss of the eye itself. Infection can be caused by bacteria or fungi, and is classified as exogenous (infection introduced by direct inoculation as in surgery or penetrating trauma), or endogenous (organisms carried by blood vessels to the eye from another site of infection and is more common in people who have an immunocompromised state). Other non-infectious causes include toxins, allergic reactions, and retained intraocular foreign bodies. Intravitreal injections are a rare cause, with an incidence rate usually less than 0.05%.
Endophthalmitis requires immediate medical attention to ensure the condition is diagnosed as soon as possible and treatment is started in order to reduce the risk of the person losing vision in the eye. Treatment options depend on the cause and whether the condition is caused by an endogenous or exogenous mechanism. For people with suspected exogenous endophthalmitis, a biopsy (vitreous tap) and treatment with antibiotics (usually by injection) is usually the first line of treatment. Once the person's response to the antibiotics is assessed, different further treatment options may be considered including surgery.
A recent systematic review found that the most common source of infectious transmission following cataract surgery was attributed to a contaminated intraocular solution (i.e. irrigation solution, viscoelastic, or diluted antibiotic), although there is a large diversity of exogenous microorganisms that can travel via various routes including the operating room environment, phacoemulsification machine, surgical instruments, topical anesthetics, intraocular lens, autoclave solution, and cotton wool swabs.
Late-onset endophthalmitis is mostly caused by Cutibacterium acnes.
Causative organisms are not present in all cases. Endophthalmitis can emerge by entirely sterile means, e.g. an allergic reaction to a drug administered intravitreally.
Exogenous endophthalmitis is estimated to occur in 0.04 to 0.1% of all cataract surgeries and intravitreal injections. Whereas 0.9 to 10% of all penetrating eye trauma is complicated by exogenous endophthalmitis. Risk factors for the development of endophthalmitis after penetrating eye trauma include a delay (usually greater than 24 hours) in closure of the wound, metal objects being involved in the trauma, disruption of the lens and a retained foreign body in the eye. Bacillus cereus associated endophthalmitis is characterized by an especially fulminant clinical course and rapid vision loss.
Endogenous endophthalmitis is estimate to comprise 2-15% of all endophthalmitis. Diagnosis may be challenging as 30-60% of those with endogenous endophthalmitis are afebrile, with blood cultures being positive in only 30-55% of cases, and only 6% in those with candidal endophthalmitis. Fungal sources of endogenous endophthalmitis are usually seen in those who are immunocompromised, with IV drug use and central venous catheter also being important risk factors. The incidence of endophthalmitis associated with drug use has increased 4-fold from 2003 to 2016.
For people undergoing intravitreal injections, antibiotics are not as effective at preventing this type of infection. Studies have demonstrated no difference between rates of infection with and without antibiotics when intravitreal injections are performed. There is evidence to suggest that a solution of povidone-iodine and antibiotics applied pre-injection may be effective at preventing some cases of endophthalmitis in people undergoing intravitreal injections.
Intravenous antibiotics given prophylactically in those with penetrating eye trauma has shown a reduction in the incidence of exogenous endophthalmitis.
In people with acute endophthalmitis, combined steroid treatment with antibiotics have been found to improve visual outcomes, versus patients only treated with antibiotics, but any improvements on the resolution acute endophthalmitis is unknown.
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