One of the most feared complications of any surgery is infection. Eye surgery is no different. An infection in the eye can cause severe damage, it is associated with a very intense inflammatory reaction and can cause severe pain while it is present. Because the eye is such a specialized organ (and precious in our view), infection in the eye is devastating if it is not handled early, aggressively and decisively. If acted upon too late, vision can be lost, and blindness can be around the corner. Not all infectious endophthalmitis occurs after surgery. Some cases occur because of an infection elsewhere in the body (endogenous cause). It can also follow trauma to the eye, particularly when it occurs following trauma in rural areas or involving animal care. Some people also speak of non infectious endophthalmitis - in those cases where we are not able to confirm the infectious cause - these are quite rare and often can also be seen as due to an auto-immune process (phacoanaphylaxis, sympathetic ophthalmia, or other).

Most infectious endophthalmitis are due to bacteria, often from the skin flora present along the eyelids and eyelashes (that’s why you need to make sure these are always clean before and after surgery). Some bacteria are more aggressive than others (coagulase negative gram +, the gram - bacteria, and the anaerobes). In addition to bacteria, fungi, viruses, worms, flukes and other pathogens can infect the eye.

What do you see and experience with endophthalmitis?

Most infections after an eye operation or ocular trauma will occur within a few days, often between day 3 and 7. After an initial improvement in vision with an eye that is increasingly comfortable, suddenly the eye becomes increasingly painful. The pain quickly reaches a point that there is no position that is comfortable, all movements of the eye are painful and you are constantly aware that the eye is not comfortable. There is also a severe loss of vision, though you are not blind. One key characteristic is the rapid downward evolution. The eye will probably become more intensely red and painful but infectious discharge outside the eye is not usually present.

While pain is nearly always present, in elderly people particularly over the age of 80, pain is not always very severe, but the vision loss is always present. In case of doubt, call your eye surgeon or find an EyeMD that can check the condition of your eye promptly. Better be safe!.

The same symptoms will appear if not associated with surgery or eye trauma, but may be less intense. In any case, if you have pain in the eye, and loss of vision, your eye should be examined promptly!. Probably there is another cause but you want to be sure it is not an infection!.

Being examined

Your EyeMD will measure you visual acuity and attempt to carry out a full eye examination with the slit lamp and of the ophthalmoscope. Sometimes, it is not possible to see the internal structures of the eye. In this case, an ocular ultrasound may be necessary to complete the evaluation.

Determining your level of vision when you enter the office is important, it helps determine the type of care you will require. Further treatment may be carried out in an office setting, or you may be sent to a clinic or hospital facility for further care.

We also want to clearly see the level of inflammation before any further treatment, as it helps in managing your eye after you have received the initial treatment against the infection. With appropriate treatment (intraocular antibiotics with or without more extensive surgery), your pain will disappear within 24 hours.

Improvement in vision will take a long time up to 6 months. Dramatic improvements are possible with near complete recovery of vision. In all cases though, the quicker you are diagnosed and treated, the better are your chances of recovering vision.

How and what is done as treatment?

In all cases, the treatment will have to be optimized to your specific situation. We prefer to treat acute cases, but chronic infections, or the consequences of an infection (scar tissue) can be dealt with to lead to vision recovery.

In acute endophthalmitis. with vision better than hand motions (particularly after cataract surgery), an injection of antibiotics in the eye is all that is required. This is often combined with obtaining a small sample of vitreous fluid for analysis. This analysis and the culture of this fluid help to confirm the cause of the infection and confirm that the microorganism is sensitive to the antibiotics given. One intraocular treatment is all that is required in these cases. If the inflammatory reaction is very severe, further surgeries may be necessary to deal with the consequences of the inflammatory response and this is beyond the scope of this discussion.

When the vision is worse than hand motions, the antibiotic injection will still be required but is often associated with a pars plana vitrectomy. This surgery helps to minimize the risk of scar tissue formation. Again in most cases, this is the only surgical intervention required, but if scar tissue forms, more surgery may be necessary.