Endophthalmitis

After eye surgery or an eye injection, it is normal for the eye to feel a bit gritty, slightly red or blurry for a few days, and it should slowly get better each day.

Go straight away if, instead, you notice [1]:

• pain that is getting worse, not better
• vision that is getting worse, or a whitish haze or "fog" in front of the eye
• redness that is increasing
• swelling of the eye or eyelids
• sticky discharge (pus)

These signs usually start within a few days of surgery or an injection, but they can appear later [1]. If you are not sure, get checked. It is always better to be seen and told that all is well.

People who are unwell in the body (for example with a fever, a liver abscess or a blood infection) and who notice a red, painful eye or blurred vision should tell their doctor straight away, as the infection may have spread to the eye [1][4].

Endophthalmitis is an infection inside the eyeball, in the clear jelly (the vitreous) and fluid that fill the eye [1]. It is usually caused by bacteria, and sometimes by a fungus.

It is very different from common "sore eyes" (conjunctivitis), which affect only the surface of the eye. Endophthalmitis is rare, but it can damage the eye quickly, so it is treated as an emergency.

Most eye operations and injections go well. Your eye team takes many steps to prevent infection, such as cleaning the eye with antiseptic before every operation and injection. The point of this page is not to worry you, but to make sure you know what to watch for and act fast.

What causes it?

Germs get inside the eye [1]:

• during or after surgery or an injection, usually from the normal germs living on the eyelids and the surface of the eye
• through a wound from an injury
• through the bloodstream, from an infection somewhere else in the body (endogenous)

Endophthalmitis can happen [1]:

• after eye surgery, most often cataract surgery because it is the most common eye operation
• after eye injections, such as anti-VEGF injections for diabetic eye disease or macular degeneration
• after an eye injury that goes through the eye wall (a penetrating injury), especially with a dirty or metal object, or with soil or plant material
• from an infection elsewhere in the body that spreads through the blood to the eye. This is called endogenous endophthalmitis

The risk of the endogenous (blood-spread) type is higher in people who [1][4]:

• have diabetes, especially if it is poorly controlled
• have a liver abscess (a pocket of infection in the liver). A germ called Klebsiella is an important cause in East and Southeast Asia, including Malaysia [4]
• have a urine, skin or other serious infection
• have long-term drips or lines into a vein, or are on dialysis
• have a weakened immune system, for example from cancer treatment or medicines that lower immunity

The eye doctor will:

• check your vision and eye pressure
• look at the eye with a microscope (slit lamp) for signs of infection, such as white cells or pus in the front of the eye
• look at the back of the eye, or do an ultrasound scan if the view is too cloudy
• take a small sample of fluid from inside the eye to find the germ (see treatment below)

For endogenous endophthalmitis, the medical team will also search the whole body for the source of the infection, with blood tests, blood cultures, urine tests and scans (for example of the liver) [1][4].

What can happen?

Endophthalmitis can cause [1][2]:

• loss of vision, which can be permanent
• in severe cases, loss of the eye

How well the eye recovers depends on the type of germ and how quickly treatment starts. With prompt treatment, many people with endophthalmitis after cataract surgery keep useful vision [2][3]. The endogenous type often has a poorer outcome, partly because people are often very unwell and the diagnosis can be delayed [4].

Treatment is started as soon as possible, often on the same day [1].

1. Vitreous tap and injection of antibiotics: after numbing the eye, the doctor takes a tiny sample of fluid from inside the eye to test for germs, then injects antibiotics directly into the eye (intravitreal antibiotics). This is the main treatment [1][2].
2. Vitrectomy (sometimes): an operation to remove the infected jelly from inside the eye. A large trial, the Endophthalmitis Vitrectomy Study, found that for infection after cataract surgery, immediate vitrectomy helped mainly people whose vision had dropped to only seeing light. For most other people, the eye injection alone was enough [2][3].
3. Other medicines: eye drops to calm the inflammation, and sometimes steroids or extra antibiotic injections. Injections may need to be repeated.
4. Endogenous endophthalmitis: needs antibiotics (or antifungals) through a drip and treatment of the source of the infection, such as draining a liver abscess, as well as treatment to the eye. This is usually done together with the medical team in hospital [1][4].

You will need close follow-up, often daily at first.

You cannot control every risk, but you can help:

• After eye surgery or an injection, use your eye drops exactly as prescribed and keep the eye clean.
• Do not rub the eye, and keep tap water, soap and dust out of it for as long as your eye team advises.
• Wear the eye shield at night if you were given one.
• Know the warning signs and go to Emergency the same day if they appear.
• Protect your eyes with goggles during work with tools, grass cutting, DIY and sports.
• If you have diabetes, keep it well controlled, and get any infection treated early.

Where to get help in Brunei

After eye surgery, an eye injection or an eye injury, if your eye becomes more painful, more red or your vision gets worse, go to the hospital Emergency Department now. You can also contact the eye clinic that did your operation or injection, but do not wait for your next appointment.

For other eye problems that are not urgent, you can walk in to a Community Eye Clinic at your health centre. No referral is needed.