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Surgery Treatment of Post-operative Endophthalmitis Leopoldo Spadea and Arianna Fiasca University of L’Aquila, Department of Biotechnological and Applied Clinical Sciences, Eye Clinic, L'Aquila, Italy Abstract The rates of post-operative endophthalmitis have been low for many years, but recent reports suggest that this type of ocular infection may be on the rise. Fluctuations in the number of cases appear to correlate with the type of intraocular surgery performed. Post-operative endophthalmitis has been reported as a consequence of nearly every type of ocular surgery, but is most common following cataract surgery. Numerous reports have demonstrated that Gram-positive bacteria cause the vast majority of post-operative endophthalmitis cases. Coagulase-negative staphylococcal isolates are the most common. Most intraocular infections resulting from infection with coagulase-negative staphylococci can be treated with antibiotic and anti-inflammatory agents, resulting in restoration of partial or complete vision. However, the more virulent the bacterial strain, the more devastating the visual outcome. Intraocular infections with Staphyloccus aureus, enterococci, Bacillus or Gram-negative strains are often intractable, and blindness or loss of the eye itself is not uncommon. The therapeutic success of treating post-operative endophthalmitis depends largely on accurate and prompt diagnosis. Antibiotic therapy can be topical, sub-conjunctival, systemic or intravitreal. Vitrectomy must be reserved for patients who present with initial visual acuity of light perception. Only in these cases has vitrectomy been shown to be more advantageous with respect to the intravitreal antibiotic injection. Keywords Endophthalmitis, bacteria, cataract, infections, retina, vitreous, therapy Disclosure: The authors have no conflicts of interest to declare. Acknowledgement: Financial support received from the Department of Surgical Sciences, University of L’Aquila, Italy. Received: 16 September 2011 Accepted: 1 November 2011 Citation: European Ophthalmic Review, 2012;6(3):149–56 Correspondence: Leopoldo Spadea, Via Benozzo Gozzoli 34, 00142 Rome, Italy. E: Endophthalmitis is a severe inflammation of the interior of the eye caused by the introduction of contaminating micro-organisms following trauma, surgery or haematogenous spread from a distant infection site. Despite appropriate therapeutic intervention, bacterial endophthalmitis frequently results in visual loss, if not loss of the eye itself. The two types of endophthalmitis are endogenous (metastatic) and exogenous. Endogenous endophthalmitis results from the haematogenous spread of organisms from a distant source of infection (i.e. endocarditis). Endogenous endophthalmitis is rare, occurring in only 2–15 % of all cases of endophthalmitis. Average annual incidence is about five per 10,000 hospitalised patients. In unilateral cases, the right eye is twice as likely to become infected as the left eye, probably because of its more proximal location to direct arterial blood flow from the right innominate artery to the right carotid artery. Since 1980, candidal infections reported in intravenous drug users have increased. The number of people at risk may be increasing because of the spread of AIDS, more frequent use of immunosuppressive agents and more invasive procedures (i.e. bone marrow transplantation). 1 Exogenous endophthalmitis results from direct inoculation as a complication of ocular surgery, foreign bodies and/or blunt or penetrating ocular trauma. Most cases of exogenous endophthalmitis (about 60  %) occur after intraocular surgery. Under normal 149 circumstances, the blood–ocular barrier provides a natural resistance against invading organisms. 2 Destruction of intraocular tissues may be due to direct invasion by the organism and/or inflammatory mediators of the immune response. Endophthalmitis may be as subtle as white nodules on the lens capsule, iris, retina or choroid. It can also be as ubiquitous as inflammation of all the ocular tissues, leading to a globe full of purulent exudates. In addition, inflammation can spread to involve the orbital soft tissue. Any surgical procedure that disrupts the integrity of the globe can lead to exogenous endophthalmitis (cataract, glaucoma, retinal, radial keratotomy, keratoplasty). Although uncommon, endophthalmitis can also result from keratitis, an infection of the cornea that, if left untreated, can result in corneal perforation and intraocular seeding of organisms. There are many classifications of endophthalmitis, but the most commonly recognised categories are the following: post-surgical: acute, and delayed or chronic; post-traumatic; bleb-related; and endogenous: fungal, bacterial and other. Post-operative infectious endophthalmitis that occurs within six weeks of surgery is classified as acute. The most commonly cultured micro-organism is Staphylococcus epidermidis, which is less virulent than the others. Propionobacterium acnes and fungi, commonly considered among the causes of more delayed onset © TOUCH BRIEFINGS 2012