A patient called our office reporting a floater that started three days prior and was followed by loss of vision. My front desk triaged the call and scheduled the patient for an appointment two hours later that morning. The patient was two weeks status-post phacoemulsification and had been seen the previous week. Her visual acuity at that time was 20/20 OD at one week and 20/20 OS at three weeks after surgery.

A patient called our office reporting a floater that started three days prior and was followed by loss of vision. My front desk triaged the call and scheduled the patient for an appointment two hours later that morning. The patient was two weeks status-post phacoemulsification and had been seen the previous week. Her visual acuity at that time was 20/20 OD at one week and 20/20 OS at three weeks after surgery.

She presented with severe loss of vision OD, only seeing hand motions. She reported no pain, redness, or photophobia. She reported a floater OD appeared three days before, and then the vision went away. Pressure was normal, 18 mmHg OU. No conjunctival injection was noted. Her anterior chamber showed a grade 2 cell.

When I performed the dilated examination, I found a hazy vitreous. I was unable to view the posterior pole through the haze. The patient was immediately referred to our local retinal group for treatment. The vitreous was tapped and biopsy performed. Intravitreal injections of vancomycin (1.0mg/0.1ml) and ceftazidime (2.25mg/0.1ml) were administered. She was instructed to use prednisolone acetate QID, cyclogel QID, fortified vancomycin hourly (Q2 hrs while sleeping), fortified tobramycin hourly (Q2 hrs while awake). She developed a hypopyon on Day 4 despite injections, but the inflammation began to subside on Day 6. Over the next five weeks, the haze slowly improved and vision is now 20/100.

Endophthalmitis is one of the most devastating complications of cataract surgery, typically leading to severe vision loss. The incidence is reportedly 0.13% and 0.7%.(1) Endophthalmitis is one of the reasons cataract surgery is performed monocularly, to avoid a bilateral infection. Bilateral Pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery has been reported. Both eyes were eviscerated despite immediate bilateral vitrectomy and intravitreal antibiotics injection.(2)

The primary source is most commonly bacteria from the ocular surface or adnexa. The most common isolated bacteria are gram-positive Staphylococcus epidermidis, followed by Staphylococcus aureus and Streptococcus species. Gram-negative bacteria are less common, but Pseudomonas aeruginosa infection can be particularly devastating.(3) Fungal infections are the least common.(4,5) It typically presents 3 to 21 days after the procedure. Chronic or delayed postoperative infection is most often due to Propionibacterium acnes, Conreybaterium spp, Staph. Epidermidis, and fungi. The use of intracameral antibiotic injection has reduced the incidence considerably.(5)

Management is difficult, as the outcome is typically poor. Immediately treatment is usually a vitreal tap for culture and identification of the offending organism, and intravitreal antibiotic injection. Injections may be repeated, and vitrectomy may be performed. The endophthalmitis Vitrectomy Study (EVS), (1995), demonstrated that immediate pars plana vitrectomy after presentation of endophthalmitis does not have a statistically significant impact on visual outcomes in patients with better than light perception vision at initial presentation. The EVS found patients presenting with hand motion acuity or better showed no benefit from immediate vitrectomy, however, patients presenting with light-perception-only VA had substantial benefit from immediate vitrectomy.(6) Inflammation of the anterior segment and reduced view due to opacity can be barriers to an early safe and effective vitrectomy.(4) Early par planitis vitrectomy performed within three days of onset may be beneficial, but the outcome is still poor with no improvement in final visual acuity.(7)

Optometric Prevention

While optometrists cannot control the status of the OR, we can ensure our patient’s anterior segment is ready for intraocular procedures. Cataract evaluation should include assessment of the ocular adnexa, lids and lashes, conjunctiva, and cornea to ensure no ocular disease is present prior to referral for cataract surgery consult. Patients with chronic blepharitis, conjunctivitis or dacryocystitis, and systemic risk factors such as diabetes, autoimmune, immunodeficient or skin disorders, asthma and those taking immunosuppressant medications are more likely to harbor methicillin-resistant (MR) organisms.(8) Diabetic patients are at higher risk for endophthalmitis than the non-diabetic patients and should be monitored closely.(9) While most cases are exogenous, endogenous cases may occur. Endogenous sources for endophthalmitis include meningitis, endocarditis, urinary tract infection, wound infection, pharyngitis, pulmonary infection, septic arthritis, pyelonephritis, intraabdominal abscess, and gastrointestinal malignancy.(10)

Post-Operative Management

Most patients with acute endophthalmitis postoperatively present with 3—14 days after surgery with intraocular inflammation. Endophthalmitis should be considered for any patient presenting post-surgery with a sudden decrease in vision, with or without pain or signs of inflammation including vitreous infiltration, hypopyon, injection, or iritis. Staff should be trained to look out for these symptoms if patients call the office following cataract surgery. Patients should be told to contact the office immediately if increased redness, pain or blurred vision is noted after surgery. I instruct patients to do this postoperatively at one day and one week. This directive is printed on the drop instruction sheet.

Drop instruction sheets can be valuable tools to ensure your patients take drops are directed. I prefer instruction sheets with check-off boxes for each day, for each eye. This ensures patient take drops as prescribed and alerts them or family members to missed doses. Family members should be educated as well. I have had patients with dementia present at one week having taken essentially no drops due to lack of familial oversight.

In my patient’s case, it is unfortunate that she waited 3 days to alert us to her vision loss. Despite both verbal and written directions, she did not contact our office as instructed. I am not sure it would have changed the outcome. Thankfully her vision continues to slowly improve and I am hopeful for better than 20/100 acuity.

  1. Mamalis N, Kearsley L, Brinton E. Postoperative endophthalmitis. Curr Opin Ophthalmol. 2002;13:14–18.
  2. Mota SH.  Pseudomonas aeruginosa-induced bilateral endophthalmitis after bilateral simultaneous cataract surgery: case report.  Arq Bras Oftalmol. 2018 Jul-Aug;81(4):339-340. doi: 10.5935/0004-2749.20180066.
  3. Niyadurupola  N, Astbury N.  Endophthalmitis: controlling infection before and after cataract surgery. Community Eye Health. 2008 Mar; 21(65): 9–10.
  4. Almeida D, Chin EK.  Surgical Techniques for Managing Infectious Endophthalmitis.  Retina Today,  April 2018.  PP 24-26.
  5. Barry P, Cordovés L,  Gardner S.  ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas, and Conclusions 2013.  www.escrs.org.  http://www.escrs.org/downloads/Endophthalmitis-Guidelines.pdf.  Accessed 8/31/2018.
  6. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113: 1479-1496. 
  7. Yospaiboon Y, Meethongkam K, Sinawat S, Laovirojjanakul W, Ratanapakorn T, Sanguansak T, Bhoomibunchoo C.  Predictive factors in the treatment of streptococcal endophthalmitis. Clin Ophthalmol. 2018 May 8;12:859-864. doi: 10.2147/OPTH.S161217.
  8. Miño de Kaspar H, Shriver EM, Nguyen EV, Egbert PR, Singh K, Blumenkranz MS, Ta CN.Risk factors for antibiotic-resistant conjunctival bacterial flora in patients undergoing intraocular surgery.  Graefes Arch Clin Exp Ophthalmol. 2003 Sep; 241(9):730-3. 
  9. Phillips WB 2nd, Tasman WS.  Postoperative endophthalmitis in association with diabetes mellitus. Ophthalmology. 1994 Mar; 101(3):508-18.
  10. Aditya Kelkar, MS, FRCS, Jai Kelkar, FCPS, DNB, Winfried Amuaku, FRCS, PhD, Uday Kelkar, MD, and Aarofil Shaikh. How to prevent endophthalmitis in cataract surgeries? Indian J Ophthalmol. 2008 Sep-Oct; 56(5): 403–407.