is one of the most devastating eye complications that can occur
following intraocular surgery. If the outcome is to be successful,
it is essential that the diagnosis is recognised and not denied.
Once the diagnosis is made, treatment should begin without delay
to avoid further erosion of visual acuity.
may include pain, loss of vision, swelling or redness of the eye
and discharge following surgery, but some cases may be asymptomatic.
Signs may include injection or chemosis, corneal oedema, flare and
cells or frank hypopyon, or fibrin clot in the anterior chamber.
A relative afferent defect may be found. Vitreous cells or abscess
may be seen but often no view of the posterior segment is possible;
sheathing of retinal vessels may occasionally be seen. When the
signs are pronounced, the diagnosis is not in doubt, but sometimes
only a relatively low-grade inflammation is observed. If these signs
cannot be explained, or if there is any doubt, the eye should be
treated as if it were infected.
trial of steroids' can be particularly misleading since, even in
endophthalmitis, there may be an initial favourable response. If
in doubt proceed to vitreous biopsy and anterior chamber tap.
date, there has only been one large prospective randomised study
on the management of endophthalmitis. The Endophthalmitis Vitrectomy
Study (EVS)1, recently completed in the USA, has greatly
simplified our approach to treatment, which should begin immediately
diagnosis is made.
all cases, where the acuity is better than light perception, a single-port
vitreous biopsy via the pars plana should be performed using a vitreous
cutting-suction device. (Disposable devices are now available which
allow the procedure to be done outside the operating theatre if
necessary with even less delay. this can be useful in outreach clinics).
The specimens are directly smeared, for Gram stain etc, and plated
space created by the biopsy is sufficient for direct intravitreal
injection of antibiotics. In the EVS, amikacin and vancomycin were
used. Gentamicin and cefuroxime would have supplied virtually the
same degree of broad spectrum cover. The study showed that there
was no advantage in the concurrent administration of intravenous
antibiotics. The antibiotics may be made up as detailed later.
when the visual acuity is perception of light is there an advantage
in performing a formal three port vitrectomy, from the point of
view of both final acuity and media clarity. Intensive topical antibiotics
are not required, unless there are specific wound-related problems
or co-existing microbial keratitis.
EVS did not address the specific question of intravitreal steroids
and to date their use remains unsubstantiated. In general terms,
high dose systemic prednisolone may be given eg 60-80mgs daily,
rapidly reducing to zero over a week to 10 days. Steroids are contraindicated
if there is a fungal infection. If the clinical course warrants
it, the biopsy and intravitreal antibiotic injection may be repeated
after 48 to 72 hours. this may allow review of the choice of antibiotic
in light of the culture results as well as the clinical progress.
study to date has effectively looked at the question of antibiotic
prophylaxis. Proper pre-assessment of the patient, identifying and
treating risk factors such as blepharitis, mucocoele of the lacrimal
sac, or conjunctivitis is probably more useful than blunderbuss
and conjunctival sac preparation with 5% aqueous povidone iodine,
at least five minutes before surgery, is safe and effective in significantly
reducing ocular surface flora. Instillation of this material into
the sac at the end of the procedure may be additionally effective.
use of antibiotics in irrigating solutions has been widely condemned
and the choice of vancomycin can be especially criticised from a
public health stance because resistance to vancomycin has been encountered
prophylaxis by intravitreal injection of antibiotics after repair
of penetrating trauma is probably beneficial.2 The EVS
did not consider the management of endophthalmitis developing other
than post-operatively. It may be reasonable, however, to adopt a
similar approach to management in these other cases but no firm
guidelines can be given.
Results of the Endophthalmitis Vitrectomy Study. The
Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995; 113;
The criteria for intravitreal antibiotics during surgery for
removal of intraocular foreign bodies. Seal DV, Kirkness
CM. Eye 1992; 6: 465-468.
1. Take 0.5ml from a vial of gentamicin containing
2. Make up to 10mls with normal saline or
balanced salt solution (BSS) in a syringe.
3. 0.1ml of this solution=200µg
Minims of gentamicin are unpreserved and contain 3000µg
per ml. These may be used.
1. Reconstitute one vial - 500mg - and make
up to 10ml with BSS
2. Withdraw 0.8ml (using 1ml syringe) and
make up to 10ml with BSS
3. Withdraw 0.1ml of this - 0.4mg
Cefuroxime or Vancomycin
1. Reconstitute a 250mg vial with 8mls of
saline or BSS
2. Withdraw entire contents and make up to
10mls with saline or BSS
3. Inject 2mls back into vial and make up
to 5mls in the vial with saline or BSS
4. 0.1ml of this solution - 1mg (1000µg)
smaller doses adjust the volumes accordingly.
1. Reconstitute a 50mg vial with 10mls of
saline or BSS
2. Withdraw 0.1ml of this and make up to
10mls in a syringe.
3. 0.1ml of this = 5µg
inject entire contents of a 50mg ampoule into a 1 litre bag
of Ringer-Iactate and 0.1ml of this contains 5µg.
1. Draw up the contents of a 2ml ampoule
(300mg) and make up to 3ml in a syringe with normal saline
2. Withdraw 1ml of that and make up to 10ml
in another syringe with normal saline or BSS
3. 0.1ml of that contains 1000µg
The intravitreal dose is given in 0.1ml except when combination
therapy is used and 0.2ml are given. In emergencies it may be necessary
to prepare drugs for intravitreal injection without the assistance
of the pharmacist. Avoid solutions or preparations containing preservatives.
The quantities for intravitreal injection may be drawn up in 1ml
syringes, and injected with a 25 or 27 gauge needle. Make sure to
fill the dead space with antibiotic solution.
Published by the Royal
College of Ophthalmologists 17 Cornwall Terrace, London NW1