Author: Ameen Marashi, MD
Documenting the age, photophobia ocular pain, and visual loss is essential, which includes the onset usually between 3 and 14 days post-surgical intervention with detailed ocular history, including associated ophthalmic diseases such as glaucoma, uveitis, ocular inflammation, etc.
It is essential to document the precise previous ocular surgical interventions such as cataract surgery, filtrating glaucoma surgery , pars plana vitrectomy, corneal graft surgery , buckle surgery, strabismus , YAG laser. Intravitreal injections with documentation of medication such as AntiVEGF, steroids (an anti-inflammatory effect may mask clinical signs) or other.
Detailed information about the undergone surgery should be documented, such as date of surgery, and, if available or possible, a reported complication, recent suture removal, and duration of surgery.
History of trauma  and intraocular foreign body, along with the medical history of diabetes mellitus, endocarditis, hospitalization, immune-suppressive drugs or disease, indwelling catheter I.V. drug abuse such as an antibiotic, septicemia, fever, etc.. are documented.
A list of ocular examination should set
1) Visual acuity, this is an essential step which can be performed by a trained optometrist or certified ophthalmologist to document the visual impairment. And this will help in the follow-up visits to assess the efficacy of the treatment.
2) A slit-lamp examination done with a thorough exam to rule out eyelid edema and to inspect clarity and regularity of the cornea. The cornea may be presented with edema with an accumulation of pigmented cells in the posterior surface along with corneal, wound integrity, or exposed suture to rule out the presence of vitreous incarceration. The slit-lamp examination should include a full exam to rule out conjunctival abnormalities such as chemosis, yellow exudate, injection of conjunctival vessels along with conjunctival bleb integrity, and infection of the bleb, which appears in yellow or white color. In case the patient has undergone glaucoma filtration surgery should be documented. Any signs of scleral penetration site in cases of endophthalmitis post-trauma should be documented.
Assessment of the anterior chamber is essential to rule out a fibrin reaction over the lens surface (cover both sides in case of IOL) in severe cases, an exudative abscess.
One of the most important signs of endophthalmitis is the presence of hypopyon, which should be ruled out along with vitreous strands and retained nuclear fragments in the anterior chamber exam and gonioscopy. Meticulous iris exam to rule out iris tissue damage or defects along with posterior synechia along with a pupillary reaction to light is crucial. It is very important to document, if possible, the presence of cataract and position of intraocular lens (IOL) along with integrity and clarity of the posterior capsular. The presence of posterior capsular rupture with vitreous loss or signs of YAG laser treatment , the slit-lamp examination should rule out the presence of whitish plaques that may contain microbial colonies.
3) Intra Ocular Pressure (IOP) documentation is essential as high IOP associated with post-surgical complications such as vitreous loss and retained nuclear fragments or patients with glaucoma history; however, endophthalmitis can be presented with low and normal IOP as well.
4) Anterior hyaloid examination with retro illumination (if possible) using slit-lamp microscopy shows loss of red reflex in most of the cases and range from inflammatory cells in mild cases. In severe cases, vitreous shows a focal white opacification or in the form of sheets.
5) Bilateral dilated fundus exam is an essential and detailed examination of the optic disc, macula, posterior pole, a mid-peripheral, and peripheral retinal exam with specialized indirect wide-field lenses using slit-lamp biomicroscopy or indirect ophthalmoscopy which is usually hard to see clear fundus view due to vitritis. Still, some cases may show wide areas of vitreous opacification, periphlebitis , and retinal hemorrhages; however, in cases presented with pars plana vitrectomy and silicone oil, there would be an accumulation of white material between silicon oil and the retina.  In cases of endogenous fungal endophthalmitis presented with creamy yellow preretinal lesion with or without retinal hemorrhages and vasculitis.
B-scan is a critical ancillary test for assessment and management infectious endophthalmitis, which helps to differentiate infectious endophthalmitis from sterile endophthalmitis and anterior segment toxic syndrome.
Infectious endophthalmitis in early stages shows increased chorioretinal thickness for 2.1 mm, and more as endophthalmitis progresses a hyperreflective dots resembling inflammatory cells disseminate in the vitreous cavity. They may induce white opacification of the vitreous-cavity forming intravitreal cavity abscess. In contrast, sterile endophthalmitis doesn’t show an increase in the chorioretinal thickness, and toxic anterior segment syndrome doesn’t usually show intravitreal inflammatory cells.
B-scan is essential to rule out the presence of a retinal detachment in complicated cases, which appears as increased high reflectivity membrane like in the vitreous cavity with one free edge, and the other attached to the optic disc with and induce high A-scan spikes and do not disappear in low gains. In contrast, posterior vitreous detachment (PVD) may have a washing machine movement and with no attachments in cases of complete PVD and disappears in low gain and usually doesn’t cause A-scan spikes, B-scan can rule out the presence of vitreoretinal tractions. However, determining the location of PVD and vitreoretinal adhesions in the B-scan is very useful when planning pars plana vitrectomy.
B-scan can rule out the presence of retained nuclear fragments in complicated cases of infectious endophthalmitis. However, in cases of infectious endophthalmitis post-trauma, there would be a local reaction at the entrance site. B-scan helps to rule out the presence of an intraocular foreign body but has limits in locating the foreign body due to it may produce shadowing due to increased reflectivity; however, the C.T. scan shows the location of the intraocular foreign body accurately.
Collecting vitreous samples for culturing is a very crucial step in managing patients with endophthalmitis, which will help to identify the offending microorganism, which helps to sensitize it the appropriate antibiotic and thus can be very helpful to choose the proper antimicrobial treatment. Nevertheless, knowing the offending microbe will aid in identifying the source of infection when a full investigation of the operating theater, by culturing instrumentation, and used material such as viscoelastic, BSS, etc. In cases of endogenous endophthalmitis, blood culturing is collected, and foreign body (in cases of penetrating trauma) should be cultured as well.
Vitreous samples should be collected before the use of antibiotics if possible, and samples should be stained with Gram and Giemsa and culture on blood agar, chocolate agar, brain-heart infusion, and Sabouraud’s media or broth and thioglycolate broth.
In cases of infectious endophthalmitis post-cataract surgery:
Gram-positive cocci are responsible for 75% to 90% of cases, which Staphylococcus epidermidis followed by Staphylococcus aureus and Streptococcus spp . Usually, the offending microorganism gram-positive coagulase-negative such as Staphylococcus epidermidis , found in cases that have onset within five days post-surgery and chronic cases; however P. Acnes are common in chronic cases  as well while culture kept for two weeks, and PCR can be used to support the diagnosis wherein diabetic patients gram-positive coagulase-negative micrococci are more common.
In severe cases of infectious endophthalmitis post-cataract surgery, and cases of secondary IOL implantation, the Staphylococcus aureus and Streptococcus are more common.
Gram-negative are only accounted for 6 % of infectious endophthalmitis post-cataract surgery  where fungal infection rare found in contaminated irrigating solution; nevertheless, it is important to check for epidemics contamination of viscoelastic and phacoemulsification equipment .
Keep in mind that up to 35% of cases of infectious endophthalmitis post-cataract surgery may be culture negative .
In cases of infectious endophthalmitis corneal transplant surgery: Most offending microorganisms are Gram-positive cocci such as Staphylococcus and Streptococcus, where fungal are less likely .
In cases of infectious endophthalmitis glaucoma filtration surgery: The most offending microorganisms are Streptococcus spp in 57% of cases.
In cases of infectious endophthalmitis intravitreal injections: The most offending microorganisms are gram-positive coagulase-negative Staphylococci .
In cases of post-traumatic infectious endophthalmitis: The most offending microorganisms are gram-negative such as Bacillus spp, especially in cases associated with the intraocular foreign body where cases contaminated with soil a fungal infection should be suspected .
In cases of endogenous endophthalmitis:
Fungal infection is responsible for up to 62% of cases with candida spp and Aspergillus, while Gram-negative is less common .
The PCR and whole-genome sequencing (WGS) may offer a more specific and sensitive diagnosis Especially in culture-negative cases , WGS may reveal the offending organism from both aqueous or vitreous .
PCR may offer diagnosis within hours, helping ophthalmologists to use specific anti-bacterial treatment to deal with the offending organism.
Managing patients with infectious endophthalmitis
Medical treatment with antimicrobial therapy is considered in cases of infectious endophthalmitis when pars plana vitrectomy is not available or not possible and attached retina. Especially in cases, patients are presented with vision hand motions or better in cases of post-cataract infectious endophthalmitis . However, in cases of post-glaucoma blebitis, topical with a systemic antibiotic, can be enough for management.
In cases of infectious fungal endophthalmitis, systemic antifungal can be used in early endogenous fungal endophthalmitis.
There are several ways to administer antibiotics to treat infectious endophthalmitis. Still, the most effective way is an intravitreal route , and the most used antibiotics are 1 mg / 0.1 mL Vancomycin, which is effective for gram-positive bacteria, especially for Staphylococcal spp, Propionibacterium acnes, and Bacillus. On the other hand, Ceftazidime 2 mg/0.1 mL, has a broad spectrum to gram-positive and gram-negative with Pseudomonas coverage. However, Amikacin 0.4mg/ 0.1mL is used in cases the patient is allergic to Ceftazidime.
Intravitreal doses of antibiotics accurately calculated as they may induce retinal toxicity in case doses are calculated incorrectly. Nevertheless, Amikacin is toxic; therefore, it is chosen as the second line if the patient is allergic to Ceftazidime; keep in mind that repeated intravitreal injections increase the risk of retinal toxicity.
Intravitreal dexamethasone 0.4mg/ 0.1mL is used in cases of infectious bacterial endophthalmitis only, which reduces inflammation rapidly but may not improve visual outcomes.
Systemic antibiotics such as Moxifloxacin 400 mg (fluoroquinolones fourth generation) has good intravitreal penetration via the oral route and is effective on Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, Enterococcus faecalis, Proteus mirabilis, Escherichia coli, and Propionibacterium acnes but not on Pseudomonas aeruginosa .
In cases of infectious fungal endophthalmitis, systemic antifungal can be used in early endogenous fungal endophthalmitis such as Voriconazole. Which is effective against candida spp and aspergillus and intravitreal antifungal Amphotericin B 5 micrograms/0.1 mL  or Voriconazole 50 micrograms/0.1 mL is used as well, and intravitreal steroids are contraindicated.
When the decision is made to use medical therapy to treat infectious endophthalmitis, the route intravitreal is used.
Vitreous tap is done to collect a vitreous sample for culturing in a sterile condition and immediately before administering any antibiotic. Vancomycin 1 mg/ 0.1mL, Ceftazidime 2 mg/0.1 mL, and intravitreal dexamethasone 0.4mg/ 0.1 mL are injected at the same sitting but every medication alone and not mixed.
Along with the intravitreal route, a systemic oral antibiotic such as Moxifloxacin 400 mg for ten days and oral prednisolone 1 mg/kg/day for ten days with omeprazole for gastric protection. However, in cases that systemic steroids are contraindicated, then periocular injection of triamcinolone or dexamethasone is used instead though systemic steroids are contraindicated in cases of fungal endophthalmitis.
Topical steroids such as dexamethasone 0.1 % two hourly and topical mydriatic such as atropine 1% once-daily considered treating anterior uveitis initially, and topical antibiotics such as Moxifloxacin can be added as well.
Preparation of intravitreal antibiotics:
Vancomycin 1 mg in 0.1 mL prepared by adding 10 mL of saline to 250 mg vial of Vancomycin, then only 1 mL is withdrawn with a 3 mL syringe. This 1 mL (25 mg) of Vancomycin diluted with 1.5 mL of saline. After that, a 0.2 mL is withdrawn using 1 mL syringe, and only 0.1 mL (0.1 mL/ 1.0 mg of Vancomycin) is injected after disposing of 0.1 mL.
Ceftazidime 2 mg in 0.1 mL prepared by adding 10 mL of saline to 500 mg vial of Ceftazidime, then only 1 mL is withdrawn with 3 mL syringe. This 1 mL (50 mg) of Ceftazidime diluted with 1.5 mL of saline. After that, a 0.2 mL is withdrawn using 1 mL syringe, and only 0.1 mL (2 mg of Ceftazidime) is injected after disposing of 0.1 mL.
To prepare Amikacin 0.4 mg/0.1 ml, use 10 ml syringe to draw 1.6 ml of Amikacin (250 mg/ml) then fill to 10 ml in the syringe with saline after that dispose 9 ml from the syringe, and add more saline to the remaining 1 ml up filling the 10 ml and then use 1 ml syringe to draw 0.1 ml of this solution (0.4 mg/0.1 ml)
Intravitreal dexamethasone 0.4 mg/0.1 mL is prepared by withdrawing 0.1 mL directly from the vial 4mg/mL vial.
In cases of infectious fungal endophthalmitis, intravitreal Amphotericin B 5 micrograms/0.1 mL or Voriconazole 50 micrograms/0.1 mL is used, and intravitreal steroids are contraindicated.
The injection should be carried out in sterile conditions where the injection site is prepared by disinfecting the skin using povidone-iodine 10%. After installing topical anesthesia, and the conjunctiva disinfected using povidone-iodine 4%. The vitreous tap can be done with a vitreous cutter or tapping after placing sterile drape and lid speculum isolating eyelashes.
The injection is carried out in the superior temporal, nasal, and inferior temporal quadrant, or the same needle used to inject medications using different syringes. Injection site measured with calipers 3.5 mm from limbus for pseudophakic or aphakic eyes and 4.00 mm for phakic eyes. A 30 gauge half-inch needle is used to inject antibiotics or steroids. After that, a cotton tip applicator is placed over the injection site to prevent the reflux of fluid. Consider anterior chamber paracentesis in case of a sustained post-injection rise of IOP.
Pars plana vitrectomy (PPV)
PPV is considered the first-line therapy for infectious endophthalmitis, especially after the recent advancement of small-gauge PPV as vitrectomy can remove the inflammatory infiltrations, which contains bacterial loads surgically along with obtaining a proper vitreous sample for culturing.
PPV considered in cases of post-cataract infectious endophthalmitis, especially in cases presented with poor visual acuity of light perception and less .
PPV recommended in cases of infectious endophthalmitis post-glaucoma filtrating surgery, post-trauma , chronic postoperative endophthalmitis (especially for recurrent cases) , post intravitreal injections, infectious endophthalmitis failed to respond to medical therapy mentioned above and in cases of endogenous endophthalmitis .
Usually, general anesthesia is chosen, especially in severe cases; however, local anesthesia is chosen if general anesthesia is contraindicated.
Infectious endophthalmitis usually presented with anterior chamber infiltration featuring fibrin and hypopyon hindering the fundus view. Therefore, it is important to remove inflammatory infiltrations from the anterior chamber before initiating PPV. Thus can be done by making two small corneal incisions one is used to insert the irrigation; the other is used to insert cutter to remove hypopyon and fibrin in cases that inflammatory membranes are adherent to the iris then intraocular forceps or sharp needle is used.
In cases are presented with a crystalline lens, the inflammatory membrane removed from the edge of the pupil if the crystalline lens decided to be spared, especially in cases with poor dilatation; however, in most cases, the crystalline lens is removed by pars plana lens fragmentation in hard cataracts or by the cutter if the nucleus is soft.
In cases presented with IOL, the inflammatory membranes are removed from the anterior and posterior surface of the IOL with posterior capsulotomy; however, in cases of chronic postoperative endophthalmitis, a complete capsulectomy and IOL exchange (which can be sent for culture) is mandatory in a secondary procedure .
In cases presented with corneal edema, then debridement of the corneal epithelium will enhance visuality; however, in cases with extreme corneal opacification, then keratoprosthesis is used and followed up with keratoplasty.
When using the trocar system, the available sizes are 23, 25, and 27 gauge the conjunctiva displaced using cotton applicator or conjunctival forceps. The trocar knife is inserted 30 degrees into the sclera then perpendicular to create a self-sealed scleral incision 4.00 mm from the limbus in phakic eyes and 3.5 mm in pseudophakic or aphakic eyes.
The trocar (better use 6 mm) is inserted in the inferior temporal just below the horizontal meridian, and this site is used for infusion cannula. The infusion is turned on before inserting it to release air bubbles, then inserted.
Insertion of infusion in the intravitreal cavity should be inspected under the microscope with an external light source. Care is taken, not to insert the infusion cannula in the suprachoroidal space.
While the other trocars one trocar is inserted in the superior nasal. The trocar is inserted from the lowest point of the nose bridge, and the additional trocar is interested in the superior temporal.Areas of conjunctival scar or abnormalities should not be used as trocar insertion sites.
If a 20 gauge system is used then, conjunctival peritomy is needed and sclerotomies made with MVR blade and the inferior temporal sclerotomy made after placing fixation suture which will fixate the infusion cannula.
An Undiluted vitreous sample is collected by connecting the syringe to the vitreous cutter suction tube, and 0.2 ml of vitreous filled in the syringe, and then this sample is cultured immediately.
After obtaining the vitreous sample and making sure that the infusion cannula is in the vitreous cavity, then the infusion is turned on, and core vitrectomy is initiated.
After finishing with core vitrectomy, the presence of PVD helps to complete vitreous removal. However, attempts of posterior cortical hyaloid removal should be made gently, and any sub hyaloid infiltration is gently aspirated and removed, but if they are solid and adherent, care must be taken not to insist on removing it completely.
Nevertheless, peripheral vitreous infiltration can be brought to the center by scleral indentation, and attention is made not to be aggressive in the removal of vitreous base infiltration to avoid iatrogenic retinal breaks.
In cases complicated with intraocular bleeding, the IOP is raised by increasing the height of the infusion bottle and doing diathermy. In cases of choroidal hemorrhage, it is early spotted, then increasing and maintaining a stable IOP to avoid hypotony is recommended, as choroidal hemorrhage is a devastating intraoperative complication.
In cases complicated with retinal breaks with no vitreous adhesions around the retinal break and any subretinal fluids should be drained, endo laser photocoagulation around the retinal break is recommended. However, in cases, the vitreous still attached, then attempts to release the vitreous traction around the break may induce more tearing of the retina; hence scleral buckle may be considered.
After completing the PPV, intravitreal antibiotics are injected with the same concentrations and preparation, as mentioned above.
The end of operation suturing all sclerotomies is recommended, and the cases presented with necrotic retina the silicone oil tamponade is used. Nevertheless, bacteria doesn't grow on silicone oil.
When an ophthalmologist faces a suspected case of infectious endophthalmitis, then the situation should be dealt with as emergent.
The first thing that can be done after the clinical assessment is performing B-scan. If the B-scan reveals the biomarkers of infectious endophthalmitis such as thickening of the chorioretinal thickness or/and showing signs of vitritis, then the next decision should be made to perform PPV promptly with obtaining an adequate vitreous sample for culturing and injecting intravitreal antibiotics. If PPV is not possible or not available, then intravitreal antimicrobial therapy, along with systemic and topical medication, as mentioned above, with tapping the vitreous to collect a vitreous sample for culture.
Culturing is a very crucial step that should be done in cases that are treated medically or surgically before administering antibiotics and study bacterial growth and the effect of the antibiotic, which will aid our treatment strategies in the future.
Therefore when the infectious endophthalmitis got worsen after medical therapy within 72 hours, PPV should be considered and if PPV yet not available, then reinjection is recommended but this time with antibiotics are effective against the offending organism after identifying both the effective antibiotic and the offending microorganism on the lab results from the vitreous sample culture.
In cases of recurrent inflammatory reaction post-PPV, then revision of PPV is recommended to remove more vitreous with injecting the effective antibiotic against the offending microorganism according to lab results after vitreous sample culture with lenticular capsule removal in cases of pseudophakic eyes.
In a nutshell, PPV should be considered as first-line therapy as soon as the diagnosis of infectious endophthalmitis is established with vitreous culture, especially in cases of acute post-cataract infectious endophthalmitis presented severe clinical presentations and vision of with light or worse. PPV indicated in recurrent cases of chronic post-cataract infectious endophthalmitis, which may respond to medical therapy but the half-life of antimicrobial therapy less than the slow growth of the bacteria. Hence the PPV can achieve better inflammatory control along with the removal of the posterior capsule, which can be the host of the offending microorganisms.
As mentioned above, PPV is indicated in cases of post-traumatic, post intravitreal injections, post glaucoma filtration surgery, and endogenous infectious endophthalmitis.
Prevention is better than cure; therefore, there are several ways to reduce the risk of infectious endophthalmitis; though, applying povidone-iodine 4% to disinfect the conjunctiva is one of the most established on evidence-based medicine to reduce the risk of infectious endophthalmitis.
However, in addition to applying povidone-iodine 4% to disinfect the conjunctiva, there are other measures to reduce the risk of infectious endophthalmitis such as:
A. Surgery should be done in an operating theater that has a proper three steps isolation with negative and positive pressure between the three steps isolation; the operating theater should be equipped with UV light for disinfecting the theater overnight.
B. All air pathways filters, including air conditions, should be disinfected regularly.
C. All furniture surfaces of operating theaters such as tables should be disinfected daily before and after each operation.
D. Both eyes should be examined with slit-lamp to rule out signs of conjunctivitis and blepharitis before surgery, in case there are any ocular inflammation should be managed, and the surgery should be deferred.
E. All the surgical team should wear facial masks covering both nose and mouth along with surgical caps covering the head without letting any hair filaments to drop after a complete change of outdoor clothes with surgical scrubs.
F. Scrubbing hands should be done properly for both scrubbing doctors and nurses.
G. All the reusable instrumentations should be sterilized with steam sterilization, including a phaco hand-piece on the day of the operation. If this is not possible, then the instrumentations are packed in special Sterilisation Pouches and steam, ETO, or plasma sterilization. However, using disposable instrumentation may reduce the risk of cross-contamination.
H. Never re-use the same instrumentation, viscoelastic, phaco blade cannulas, blue dye, etc.. between surgeries on the same day and always use new surgical consumables such as blades, viscoelastic, blue dye, etc. and for reusable instrumentation such as phaco hand-piece and surgical instrumentation should be used only sterilized and not transfer them between surgeries without re sterilization. It is better to use disposable instrumentation to avoid cross-contamination.
I. It is imperative to disinfect the eyelids of the patient with povidone-iodine 10 % and to use lid speculum after placing a sterile drape with adhesives that isolated the eyelids and lashes from the surgical field.
J. After the operation, all disposable instrumentation should be discarded, and the reusable instrumentations should be cleaned by soaking them in sterilized distilled water only (NEVER USE TAP WATER). However, the lumened instrumentation such as phaco hand-piece or irrigation, aspiration hand-pieces, etc. are cleaned with washing the lumen with injecting sterilized distilled water in the lumen of the instrument with a clean sterilized syringe and then dry it with pumping air several times using the same syringe.
K. Preoperative systemic antibiotics such as Moxifloxacin 400 mg can be considered as prophylaxis, especially in cases of penetrating trauma and cases scheduled for cataract surgery.
L. Injecting preservative-free Moxifloxacin in the anterior chamber by the end of the surgery has shown to reduce the risk of infectious endophthalmitis post-cataract surgery. However, Cefuroxime 1 mg can be injected in the anterior chamber as well but holds the risk of cross-contamination while preparing.
M. The risk of endophthalmitis can be lowered in cases suspected with cases of contaminated foreign bodies by using prophylactic systemic antibiotics such as intravenous Vancomycin (or clindamycin if allergic) and Ceftazidime (or fluoroquinolone if allergic) continuously for 48 hrs promptly.
Follow up and prognosis
-When following up patients with endophthalmitis, the response to medical therapy usually occurs within 48 hours in the form of contracting of inflammatory membrane and reduction of pain. If no improvement of an inflammatory process or the inflammation got worse, then the patient should be scheduled for PPV or/and re-injecting antimicrobial therapy based on the sensitivity of microorganisms to an effective antibiotic, as mentioned above in the treatment plan.
-However, up to 35% of patients require additional intervention as a single intervention  as a single intervention may not be enough to manage endophthalmitis.
-Therefore physicians should monitor inflammatory changes post-treatment with fundus examination and B-scan and expect that inflammatory reaction may persist for weeks after intervention and persisted vitreous opacities post successful treatment can be managed with PPV.
-Corneal edema may improve within days, but pigmentary changes on the posterior surface of the cornea may take months to clear up. However, high IOP is a sign of a resolution of the inflammatory process and managed medically. At the same time, low IOP is a sign of active inflammation and may be combined with choroidal detachment.
-The anterior chamber might show flare and cells for weeks post initial management if the inflammation was severe at baseline.
-In cases, cataract formed, then an elective surgery after the inflammation is quiet to remove the cataract with or without PPV if there are still intravitreal opacities.
-The retinal detachment is the main cause of surgical failure , although retinal detachment repair can be successful anatomically up to 78% but hold a poor visual prognosis.  However, one of the contributing factors of development retinal detachment is proliferative retinopathy .
- In general, the visual acuity that improves post-treatment is about 20/40 and better in 53% of patients where 20/200 and better at 74%, and 15 % of patients will have a vision of 5/200, and 5% will have the only vision of no light perception. However, cases infected with gram-positive and coagulase-negative micrococci has a better visual prognosis. In contrast, Bacillus cereus and streptococci have a poor visual prognosis. In comparison, two-third of fungal infections will have a loss of useful vision.
-Patients managed with PPV have clear media up to 86% within three months .
-Patients who are treated within the first 24 hrs have better visual prognosis and have the chance of improving vision to 20/40 up to three folds than those delayed beyond 36 hrs . Nevertheless, cases presented with infected bleb and associated with trauma and proliferative retinopathy have poor visual prognosis up to 20/400 and worse .
- Patients treated with antifungals are required to monitor liver function every two weeks; however, when Amphotericin is used, then CBC, electrolytes, and creatinine should be monitored.
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These guidelines were reviewed and updated in January 2021