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Ophthalmology (Eye Conditions)

Endophthalmitis (Postoperative)

Severe inflammation involving both the anterior and posterior segments of the eye, typically occurring as a complication after intraocular surgery (e.g., cataract surgery), due to introduction of microorganisms.

Also known as: Intraocular Infection

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Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL to Ophthalmologist/Eye Hospital (RR) for ANY suspected case of postoperative endophthalmitis.

Red flags

  • Pain and decreased vision after recent eye surgery.
  • Hypopyon (pus level in anterior chamber).
  • Significant vitreous haze obscuring fundal view.

Signs and symptoms

  • Onset usually within days to weeks after surgery.
  • Decreased vision (often significant).
  • Eye pain (can be severe).
  • Redness (conjunctival injection, ciliary flush).
  • Eyelid swelling.
  • Photophobia.
  • Anterior chamber inflammation (cells, flare, hypopyon - pus level).
  • Corneal oedema.
  • Vitreous inflammation (haze, cells - difficult to view fundus).

Risk factors

  • Intraocular surgery (cataract, glaucoma, vitrectomy, intravitreal injection).
  • Posterior capsule rupture during cataract surgery.
  • Prolonged/complex surgery.
  • Wound leak post-op.
  • Contaminated instruments or solutions.
  • Patient factors (diabetes, immunosuppression, blepharitis).

Diagnosis

Clinical assessment

High index of suspicion in any patient presenting with pain and decreased vision after recent intraocular surgery. Clinical examination findings (hypopyon, vitreous haze) are key.

Investigations

  • Visual Acuity assessment.
  • Slit Lamp Examination.
  • Dilated Fundus Examination (view may be poor).
  • B-scan Ultrasound: If view of posterior segment obscured, can show vitreous opacities/membranes.
  • Aqueous and/or Vitreous Tap (Vitreal Biopsy): Essential for Gram stain, Culture & Sensitivity to identify causative organism (bacteria most common, fungi less common). Performed by ophthalmologist.

Diagnostic criteria

Clinical diagnosis based on signs of intraocular inflammation (hypopyon, vitritis) in a post-operative eye, often supported by positive culture from intraocular fluid.

Management

Non-pharmacological management

  • Ophthalmic EMERGENCY requiring immediate specialist care.

Pharmacological treatment

  • Requires Immediate Management by Ophthalmologist (usually requires admission):
  • - Intravitreal Antibiotics: Injection of broad-spectrum antibiotics directly into the vitreous cavity. Standard combination: Vancomycin (covers Gram-positives) + Ceftazidime or Amikacin (covers Gram-negatives). (LOC: RR)
  • - Topical Antibiotics: Intensive fortified topical antibiotics (e.g., fortified Vancomycin + fortified Ceftazidime/Tobramycin) applied frequently (e.g., hourly).
  • - Topical Corticosteroids: Intensive topical steroids (e.g., Prednisolone acetate 1%) started shortly after antibiotics to control inflammation.
  • - Cycloplegics: (e.g., Atropine 1%) to prevent synechiae and relieve pain.
  • - Systemic Antibiotics: Role controversial, may be used in severe cases.
  • - Antifungals (Intravitreal/Systemic): If fungal infection suspected/confirmed.

Monitoring

Requires very close monitoring (often daily initially) of visual acuity, inflammation, IOP. Repeat intravitreal injections may be needed.

Complications

  • Severe, permanent vision loss / Blindness.
  • Retinal detachment.
  • Glaucoma.
  • Cystoid macular oedema.
  • Phthisis bulbi (shrunken, non-functional eye).

Prevention

  • Strict aseptic technique during intraocular surgery.
  • Preoperative Povidone-iodine 5% application to conjunctival sac.
  • Prophylactic measures (e.g., intracameral antibiotics at end of cataract surgery).
  • Management of patient risk factors (e.g., blepharitis) before surgery.
  • Prompt management of post-operative complications like wound leak.

Patient education

  • Explanation of the seriousness of the intraocular infection.
  • Need for urgent specialist treatment (often including injections into the eye).
  • Importance of adhering to intensive eye drop regimen.
  • Potential impact on vision.
  • Need for close follow-up.

Uganda-specific notes

A devastating complication, especially with increasing volume of cataract surgery. Prevention through sterile technique and Povidone-iodine prep is vital. Management requires specialized skills (intravitreal injection, vitrectomy) and medications available only at tertiary centres.

Surgical Management

  • Pars Plana Vitrectomy (PPV): Surgical removal of infected vitreous. May be considered early for severe cases with very poor vision or if poor response to intravitreal antibiotics.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.1.8

For learning and professional reference. Use current local guidance and clinical judgement.

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