Endophthalmitis
Guideline for Ophthalmology use only.
Sight threatening disease. Refer to Ophthalmology and Micro/ID.
Microbiological sampling of vitreous recommended.
Endogenous - associated with bacteraemia and/or endocarditis. Blood cultures x 3 sets before antibiotics.
Exogenous - post surgery/trauma or bleb related. See Bleb-related endophthalmitis
Treat according to sensitivity test results
Suspected Bacterial Endophthalmitis (without penetration)
Preferred (including penicillin allergy):
Tap and inject Intravitreal vancomycin 2mg in 0.1 ml stat AND intravitreal ceftazidime 2mg in 0.1 ml stat
PLUS
moxifloxacin* 400mg po (or iv if NBM) od
*Ensure that the patient is given the Fluoroquinolone MHRA patient information leaflet. Fluoroquinolones, including moxifloxacin are associated with disabling and potentially long-lasting or irreversible side effects. See Fluoroquinolone antibiotics - severe adverse effects.
Consider prescribing the following after gram stain is back or on advice of uveitis team:
prednisolone 1mg/kg po od (max 60mg/day) (start the next day unless contraindicated systemically) - DO NOT START ORAL STEROID IF FUNGAL ENDOPHTHALMITIS IS SUSPECTED
WITH OR WITHOUT
chloramphenicol 0.5% eye drops qds (5-10 days)
PLUS
dexamethasone 0.1% eye drops hourly until review
PLUS
cyclopentolate 1% eye drops tds
If the above antibiotics are not suitable, contact Micro/ID for alternatives.
Suspected Bacterial Endophthalmitis (with penetration)
Speak to Micro/ID.
Fungal Endophthalmitis
If any lesion in the vitreous
Vitrectomy (do not bother tap and inject) within 48 hours of presentation
AND
Intravitreal voriconazole (50 micrograms/0.1ml)
AND
fluconazole 400 mg po stat then 200 mg BD
- Consider changing to oral voriconazole if not responding or filamentous fungi from culture or suspected.
If no vitreous involvement but retina involvement
Tap and inject with Intravitreal voriconazole (50 micrograms/0.1ml)
AND
fluconazole 400 mg po stat then 200 mg BD
- Reassess at 48 hours and if any features of vitreous involvement consider vitrectomy and re-inject.
If no vitreous or retinal involvement (only choroidal involvement only)
fluconazole 400 mg po stat then 200 mg BD
The ocular injectable monograph for intravitreal voriconazole can be found HERE
Viral Endophthalmitis
See Viral (including atypical) eye infections guideline