ESCRS Guidelines on prevention, investigation and management of

5.6 FLOW CHART – TREATMENT GUIDELINES FOR ACUTE
VIRULENT ENDOPHTHALMITIS
(presumed and not proven) [205]
Make clinical diagnosis of endophthalmitis
Perform ultrasonography of vitreous and retina
Perform aqueous and vitreous tap and/or vitrectomy, through the pars plana, collecting
samples for microbiology investigation (Gram stain, culture & PCR)
Inject antibiotics empirically into the vitreous using a combination of either vancomycin
1mg in 0.1ml and ceftazidime 2mg in 0.1ml (first choice) or amikacin 400 µg in 0.1ml
and vancomycin 2mg in 0.1ml (second choice).
USE A SEPARATE SYRINGE AND 30 G NEEDLE FOR EACH DRUG
AND DO NOT MIX DRUGS TOGETHER IN THE SAME SYRINGE.
Do NOT point the needle towards the retina but forwards instead
and inject very slowly into the mid-vitreous
Inject dexamethasone 400 µg (preservative-free) in 0.1ml into the vitreous
at the same time by a separate syringe and needle
For acute virulent endophthalmitis begin adjunctive systemic therapy with the same
antibiotics as those used intravitreally for 48 hours to maintain higher levels within the
posterior segment of the eye (measure serum levels for intravenous vancomycin therapy);
this may not be needed for less severe cases due to CNS
Consider beginning systemic therapy with corticosteroids
(prednisolone 1 or even 2 mg/kg/day)
Consider referral to a vitreoretinal surgeon for an opinion on a full vitrectomy
(refer to text) and repeated intravitreal antibiotics
OBSERVE PATIENT (inflammation becomes worse before better again,
hence need for a defined initial empirical approach)
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