CLINICAL PRACTICE GUIDELINE

CLINICAL PRACTICE GUIDELINE: Emergency Department

Endophthalmitis

Disclaimer: This Clinical Practice Guideline (‘CPG’) was written for use in The Royal Victorian Eye and Ear Hospital
Emergency Department. It should be used under the guidance of an Ophthalmology or ENT registrar. If clinical advice is
required, please contact the Eye and Ear Admitting Officer for assistance: EYE: +61 3 9929 8033; ENT: +61 3 9929
8032. Links to internal Eye and Ear documents cannot be accessed from the website CPG.

See also: Intravitreal Injection Procedure for the Treatment of Endophthalmitis in the
Emergency Department PC6.3, Appendix 1: Preparation and Reconstitution of
Intravitreal Injections for the Treatment of Endophthalmitis

Description:
Endophthalmitis is inflammation involving both the anterior and posterior segments of
the eye. It is most commonly infectious in origin. Infectious endophthalmitis can be
exogenous, or less commonly, endogenous. Post-operative, infectious endophthalmitis
following an intraocular procedure is classified as acute if diagnosed within 6 weeks of
the procedure or chronic (delayed onset) if it occurs after six weeks. Non-infectious
sterile endophthalmitis is rare.
IMPORTANT: target time from presentation to intravitreal tap and injection
(‘door to needle’) is ≤ 60 minutes.

Red Flags:
• Acute, infectious endophthalmitis is an ophthalmic emergency that requires
immediate intervention. Suspect in any patient with pain, decreased vision,
intraocular inflammation and a history of:
o Recent intraocular ophthalmic procedure (eg. cataract surgery, intravitreal
injection)
o Ocular trauma
o Previous glaucoma filtering surgery with bleb
• Consider endogenous endophthalmitis. Ask if there has been a current or recent
history of fevers, sepsis, malaise, intravenous drug use or of a concurrent
systemic infection.
• Non-infectious (sterile) endophthalmitis is a diagnosis of exclusion

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How to Assess:
Aetiology:
• Infectious:
o Exogenous: recent history of intraocular surgery (most commonly 3-7
days post-surgery, but can be earlier or later), intravitreal injection,
penetrating ocular trauma, previous glaucoma filtering surgery.
o Endogenous: immunosuppressed, diabetic, indwelling catheters (eg.
urinary catheter or peripherally inserted central catheter (PICC) line),
intravenous drug use
• Non-infectious (sterile):
o Acute post-operative inflammatory reaction to non-infectious substances
introduced to the anterior chamber during surgery: Toxic anterior
segment syndrome (TASS). Typically presents within 24 hours of
surgery with painless, limbus-to-limbus corneal oedema, marked
anterior chamber inflammation +/- hypopyon, increased intraocular
pressure, a dilated or irregular pupil and absent vitreous inflammation.
TASS responds to intensive topical steroids.
• Differential Diagnosis:
o Uveitis related to conditions such as sarcoidosis, Beçhet’s, Herpetic
disease
o Masquerade syndromes such as: leukemia, intraocular lymphoma, etc
History:
• Symptoms: pain, decreased vision, redness and photophobia. Pain is more
characteristic of endophthalmitis, whereas TASS is usually painless.
Examination:
• Eyelid oedema
• Conjunctival chemosis, injection
• Anterior segment:
o Corneal oedema
o Anterior chamber: cells, flare, fibrin, hypopyon
• Posterior segment:
o Vitreous cells
▪ Progressive vitritis
▪ Presence of “string of pearls” (Candida spp.)
o Retinitis and periphlebitis
o Note: there may be no view of the retina if there is significant corneal
oedema, anterior chamber fibrin or vitritis.
Investigations
• B-Scan ultrasound of the posterior segment to look for vitritis, if examination
with a fundus lens or indirect ophthalmoscopy is not possible

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Acute Management:
Note: target time from presentation to intravitreal tap and injection (‘door to
needle’) is ≤ 60 minutes
Post-operative/exogenous infective endophthalmitis suspected:
• Discuss with Admitting Officer (AO) +/- Vitreoretinal (VR) fellow to confirm need
for tap and inject
• Complete consent form (MR45/MR159)
• Anterior chamber paracentesis and vitreous aspiration for microscopy, cultures
and sensitivities, followed by intravitreal injections of ceftazidime (2 mg/0.1 ml),
vancomycin (1 mg/0.1 ml) and dexamethasone (400 mcg/0.1 ml) (see
Intravitreal Injection Procedure for the Treatment of Endophthalmitis –
Emergency Department PC6.3) Also see: Appendix 1: Preparation and
Reconstitution of Intravitreal Injections for the Treatment of Endophthalmitis
• Be aware of risks of intravitreal injection for the treatment of endophthalmitis:
o Retinal detachment
o Acute IOP rise
o Vitreous haemorrhage
• Admit the patient under the VR unit after discussion with the VR fellow
• Ongoing topical treatment
o Prednefrin Forte® 1 drop every 1-2 hours while awake
o Atropine 1% 1 drop bd,
o Chloramphenicol 0.5% 1 drop qid
o Substitute g.ofloxacin 0.3% hourly (day +/- night) for chloramphenicol if
corneal/scleral wound, bleb/corneal infection is suspected
o Oral ciprofloxacin 750 mg BD for 5-7 days. Reduce dose in renal
impairment (Calculated Creatinine Clearance <50mL/min)
Endogenous endophthalmitis suspected:
• Discuss with AO and Medical Retina/Ocular Immunology fellow
• Immediate anterior chamber paracentesis and vitreous aspiration for
microscopy, cultures and sensitivities. If viral aetiology suspected, viral PCR
should also be requested.
• Intravitreal injections depending on suspected aetiology
o Bacterial: intravitreal 2mg/0.1mL ceftazidime, 1mg/0.1mL vancomycin
o Fungal endophthalmitis: intravitreal 100mcg/0.1mL voriconazole
o Viral endophthalmitis: intravitreal 2.4mg/0.1mL foscarnet
• Consult Infectious Disease (ID) department at St Vincent’s Hospital
o Discuss appropriate empiric systemic antibiotic treatment depending on
suspected aetiology, until culture results are available.
o If sepsis/medically unwell, may require transfer to St Vincent’s Hospital
• Systemic work-up based on clinical suspicion
o Baseline FBE, UEC, LFTs and BSL
o Consider cultures: blood, urine, indwelling catheter etc
• Admit Medical Retina/ Ocular immunology Unit
CPG45.0. Endophthalmitis Clinical Practice Guidelines. V.1.0. Date Approved 02/02/2022. This document is
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Appendix:
Appendix 1: Preparation and Reconstitution of Intravitreal Injections for the Treatment
of Endophthalmitis

CPG45.0. Endophthalmitis Clinical Practice Guidelines. V.1.0. Date Approved 02/02/2022. This document is
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Evidence Table

Level of Evidence
Author(s) Title Source
(Ι – VΙΙ)
Jackson, Timothy L. Moorfields Manual of Ophthalmology. Book IV

Bruce, A., Loughnan, M. Anterior Eye Disease and Therapeutics A-Z. Book IV
Chatswood, NSW: Churchill Livingstone Elsevier,
2011.
Crock, C., Sandhu S., Miln L., et al. The Royal Victorian Eye VI
Intravitreal Injection Procedure for the Treatment of
and Ear Hospital CPG.
Endophthalmitis – Emergency Department.
Connell, P.P., O'Neill, E.C., Fabinyi, Endogenous endophthalmitis: 10-year experience at Journal (Eye) IV
D.,Islam, F.M.A., Buttery, R., a tertiary referral centre
McCombe, M., Essex, R.W., Roufail,
E., Clark, B., Chiu, D., Campbell, W.
& Allen, P

The Hierarchy of Evidence

The Hierarchy of evidence is based on summaries from the National Health and Medical Research Council (2009), the Oxford Centre for Evidence-based Medicine
Levels of Evidence (2011) and Melynk and Fineout-Overholt (2011).

I) Evidence obtained from a systematic review of all relevant randomised control trials.
II) Evidence obtained from at least one well designed randomised control trial.
III) Evidence obtained from well-designed controlled trials without randomisation.
IV) Evidence obtained from well-designed cohort studies, case control studies, interrupted time series with a control group, historically controlled studies,
interrupted time series without a control group or with case series.
V) Evidence obtained from systematic reviews of descriptive and qualitative studies.
VI) Evidence obtained from single descriptive and qualitative studies.
VII) Expert opinion from clinician, authorities and/or reports of expert committees or based on physiology.

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Version Details:

CPG No: CPG45.0

Responsible Executive: Executive Director, Medical Services

Review Officer: Director, Emergency Department

• Clinical Practice Guideline Working Group

• Director Emergency Department
Contributor(s): • Consultant Emergency Department
• Consultant Ophthalmologist
• Registrar Ophthalmologist

National Standard(s): Comprehensive Care

Version Number: 1.0

Approval Date: 02/02/2022

Next Review Due: 02/02/2027

CPG45.0. Endophthalmitis Clinical Practice Guidelines. V.1.0. Date Approved 02/02/2022. This document is
uncontrolled when printed or downloaded. To ensure you have the latest version please check the website or
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Appendix 1: Preparation and Reconstitution of Intravitreal Injections for the
Treatment of Endophthalmitis
Note: maintain asepsis, swab rubber port after removal of cap prior to
introducing dilutions, and MIX WELL AFTER EACH DILUTION
USE PREFILLED CEFTAZIDIME 6mg/0.3mL & VANCOMYCIN 3mg/0.3mL
SYRINGES IN ED OMNICELL FRIDGE
WHENEVER AVAILABLE:
Preparation steps for CEFTAZIDIME intravitreal injection dose =2mg/0.1mL (Gram-
negative coverage)3,4,5
Step Complete (please initial)
1. Add 9.4 mL of ‘Sodium Chloride 0.9% for Injection’ to the 1g vial of
Ceftazidime (1g/10mL=100mg/mL=10mg/0.1mL)
o ………………………
2. Withdraw 0.2mL of the solution from the vial using a 1mL syringe
(20mg/0.2mL)
o ………………………
3. Add 0.8mL of ‘Sodium Chloride 0.9% for Injection’ to this syringe
(20mg/mL= 2mg/0.1mL)
o ……………………….
4. Discard 0.9mL of solution leaving 0.1mL to inject intravitreally.
Label syringe.
o ………………………..

Preparation steps for VANCOMYCIN intravitreal injection dose =1mg/0.1mL (Gram-

positive coverage)4,5
Step Complete (please initial)
1. Add 10mL of ‘Sodium Chloride 0.9% for Injection’ to the 500mg vial
of Vancomycin (500mg/10mL = 50mg/mL=5mg/0.1mL)
o ………………………..
2. Withdraw 0.2mL of solution from the vial using a 1mL syringe
(10mg/0.2mL)
o …………………………
3. Add 0.8mL of ‘Sodium Chloride 0.9% for Injection’ to this syringe
(10mg/mL = 1mg/0.1mL)
o …………………………
4. Discard 0.9mL of solution leaving 0.1mL to inject intravitreally.
Label syringe.
o …………………….....

Preparation steps for DEXAMETHASONE intravitreal injection dose = 400mcg/0.1mL

Step Complete (please initial)
1. Using a 1mL syringe withdraw 0.1mL of solution form the 4mg vial
of Dexamethasone (4mg/1mL = 400mcg/0.1mL)
o ……………………….
2. Label syringe ready to inject 0.1mL of this solution intravitreally.
o ……………………….

Preparation steps for FOSCARNET intravitreal injection dose = 2.4mg/0.1mL (Anti-viral

coverage)
Step Complete (please initial)
1. Using a 1mL syringe withdraw 0.1mL of solution from the 250mL
vial of Foscarnet (6g/250mL = 24mg/mL= 2.4mg/0.1mL)
o ………………………
2. Label syringe ready to inject 0.1mL of this solution intravitreally.
o ………………………

Preparation steps for VORICONAZOLE intravitreal injection dose = 100mcg/0.1mL

(Anti-fungal coverage)5,6
Step Complete (please initial)
1. Add 19mL of ‘Water for Injections’ to 200mg vial of Voriconazole
(200mg/20mL = 10mg/1mL = 1mg/0.1mL)
o ……………………….
2. Withdraw 0.1mL of solution using a 1mL syringe (1mg/0.1mL)
o ……………………….
3. Add 0.9mL of ‘Water for Injections’ to this syringe (1mg/1mL =
100mcg/0.1mL)
o ……………………….
4. Discard 0.9mL of this solution leaving 0.1mL to inject intavitreally.
Label syringe.
o ……………………….

CPG45.0. Endophthalmitis Clinical Practice Guidelines. V.1.0. Date Approved 02/02/2022. This document is
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