Endophthalmitis
What Is Endophthalmitis?
Most eye infections like pink eye or a stye happen on the surface of the eye or eyelid. Endophthalmitis is different because the infection occurs deep inside the eye, within the vitreous humor (the gel inside the eye) or aqueous fluid.
Surface infections usually cause mild discomfort and clear up with eye drops. An infection inside the eye can cause severe pain, rapid vision loss, and permanent damage if not treated right away.
Exogenous endophthalmitis occurs when germs enter the eye from an outside source, such as during eye surgery or after an injury that penetrates the eye. This is the most common form and usually happens within days of the triggering event.
Endogenous endophthalmitis is much less common and develops when an infection somewhere else in your body spreads through the bloodstream to the eye. People with weakened immune systems or severe infections like sepsis face higher risk for this type.
The inside of your eye is a closed space with limited blood flow. When infection sets in, the immune response and bacterial toxins can quickly destroy the retina and optic nerve.
- Vision loss can progress within hours to days without treatment
- Delaying care increases the chance of permanent blindness
- Early treatment offers the best hope for saving useful vision
- Even with prompt care, some vision loss may occur
Recognizing the Warning Signs of Endophthalmitis
If you recently had eye surgery or experienced an eye injury, watch for signs that go beyond normal healing. Mild discomfort is expected after many procedures, but worsening symptoms signal a problem.
- Increasing pain rather than gradual improvement
- Swelling of the eyelid that gets worse instead of better
- New floaters or shadows in your vision
- Sensitivity to light that becomes more severe
Any sudden decline in vision after eye surgery or trauma should be treated as an emergency. We worry most when patients notice rapid changes over hours or a day or two.
Blurred vision, a curtain or veil blocking part of your sight, or complete vision loss are all red flags. Even if there is no pain, these symptoms require urgent evaluation by an eye doctor.
Moderate to severe eye pain that feels deep inside the eye is a hallmark symptom. The white part of your eye may look very red, and the eyelid may swell.
You might notice a yellow, white, or greenish discharge. The eye may also produce excessive tearing, and your vision could appear cloudy or hazy due to inflammation.
Symptoms of exogenous endophthalmitis typically appear within two to seven days after surgery or injury. However, some cases show up within 24 hours, especially with very aggressive bacteria. Some postoperative cases present weeks to months later with milder, persistent inflammation (often called delayed or chronic endophthalmitis), particularly with organisms such as Cutibacterium acnes.
Endogenous cases can develop more gradually over days to weeks. If you have a serious infection elsewhere in your body and notice any eye symptoms, let your doctor know immediately. Late bleb-related endophthalmitis can occur months to years after glaucoma surgery and often develops rapidly.
Who Is at Risk for Endophthalmitis?
Cataract surgery is the most common eye operation, and while endophthalmitis after this procedure is rare, it is a frequent cause of exogenous cases. Modern sterile techniques have made the risk very low, occurring in approximately one in 2,000 to one in 10,000 surgeries, depending on setting and use of intracameral antibiotics. Intracameral antibiotics at the end of cataract surgery and povidone-iodine preparation are key measures that lower risk.
Other procedures that carry risk include intravitreal injections for conditions like macular degeneration, glaucoma surgeries, and corneal transplants. We take extensive precautions during every procedure to minimize infection risk. Given the very high volume of intravitreal injections, injection-related endophthalmitis now accounts for a similar or larger share of iatrogenic cases in many practices. The risk of endophthalmitis after an intravitreal injection is low on a per-injection basis, generally on the order of a few cases per several thousand injections, and prevention relies on povidone-iodine and sterile technique rather than routine antibiotic drops.
Any injury that breaks through the surface of the eye creates a pathway for germs to enter. Penetrating injuries from sharp objects, high-speed particles, or accidents cause a much higher infection risk than surgical procedures.
- Workplace injuries involving metal fragments or tools
- Accidents with broken glass or projectiles
- Injuries from yard work or power tools
- Animal scratches or bites near the eye
- Injuries involving plant material, soil, or organic matter, which increase the risk of fungal infection
Endogenous endophthalmitis happens when bacteria or fungi from another part of your body travel through your blood to your eye. This route is less common but tends to affect people who are already quite ill.
Sources of infection that may spread to the eye include heart valve infections, urinary tract infections that turn severe, pneumonia, abdominal infections, and infected intravenous catheters. Fungal infections in the blood, though rare, can also reach the eye.
Certain health conditions weaken your immune system or make infections more likely. Diabetes, especially when poorly controlled, raises your risk for both developing infections and experiencing complications.
- Cancer or cancer treatments that suppress immunity
- Organ transplants requiring anti-rejection medications
- HIV or AIDS with low immune cell counts
- Long-term steroid use for autoimmune diseases
- Intravenous drug use
How We Diagnose Endophthalmitis
When you arrive with suspected endophthalmitis, we will act quickly but carefully. Our eye doctor will check your vision, measure eye pressure, and examine the front and back of your eye using special lights and lenses.
We look for signs of inflammation in the anterior chamber, cloudiness in the vitreous, and changes to the retina. Your history of recent surgery, injury, or systemic illness helps us understand how the infection may have started.
- Hypopyon or fibrin in the anterior chamber
- Corneal edema and conjunctival injection
- Dense vitreous haze with reduced or absent red reflex
- Limited fundus view requiring B-scan ultrasound
- Relative afferent pupillary defect in severe cases
To identify the specific germ causing your infection, we need to collect a sample of fluid from inside your eye. This procedure is called a tap or aspiration and is usually done right in the office or operating room.
We numb your eye to minimize pain during the sample collection. A tiny needle removes a small amount of aqueous humor from the front of the eye or vitreous from the back. The sample goes to a lab where technicians try to grow and identify the organism. Samples are also often tested with rapid stains and molecular methods to improve detection when cultures are negative.
Ultrasound imaging of the eye helps us see inside when the view is blocked by inflammation or bleeding. This test is painless and gives us important information about the vitreous, retina, and other structures.
- Ultrasound can reveal clumps of inflammatory material
- We may order blood tests if we suspect endogenous spread
- Cultures from other body sites help identify the source
- Imaging does not delay treatment, which starts immediately
- Imaging and sampling are coordinated with immediate intravitreal treatment so care is not delayed
Lab results from your fluid sample can take 24 to 48 hours or longer. We begin treatment before results return because waiting risks further vision loss.
Once we know the specific bacteria or fungus involved, we may adjust your medications to target that organism more effectively. Sometimes cultures do not grow anything, but we continue treatment based on your clinical response.
- Post-cataract surgery: coagulase-negative staphylococci, Staphylococcus aureus, streptococci
- Post-injection: oral flora streptococci and staphylococci
- Bleb-related: streptococci and Haemophilus species
- Endogenous: Candida species are common; bacteria vary with source
Treatment Options for Endophthalmitis
The fastest way to get high concentrations of antibiotics inside your eye is through direct injection into the vitreous. We use this approach as the primary treatment for most cases of endophthalmitis in 2025.
After numbing your eye, we inject antibiotics that cover the most common bacteria. Empiric therapy typically includes a gram-positive agent and a gram-negative agent. If fungal infection is suspected, intravitreal antifungals are added. Treatment often follows a tap-and-inject approach, with sampling and intravitreal therapy performed at the same visit. These medications reach much higher levels inside the eye than pills or IV antibiotics can achieve. You may need repeat injections depending on how you respond.
Vitrectomy is a surgery where we remove the infected vitreous from inside your eye. We may recommend this procedure if your vision is already very poor, if the infection appears severe, or if you do not improve quickly with injections alone. We consider early vitrectomy when vision is very poor at presentation, when there is dense vitreous opacity that limits response to injections, or when fungal infection is suspected.
During vitrectomy, we replace the cloudy, infected material with a clear solution. This removes inflammatory debris and infectious material while allowing us to collect better samples. The procedure also lets us deliver antibiotics directly and inspect the retina for damage.
In addition to injections, we prescribe systemic antibiotics or antifungals for endogenous infections and selected severe or high-risk exogenous cases.
- Systemic antifungals are essential for endogenous fungal infections. Choice and route depend on the organism and disease severity; many cases require intravitreal antifungals and sometimes intravenous therapy.
- IV antibiotics may be needed for severe or endogenous cases
- Treatment duration varies from one to several weeks
- We monitor for side effects and adjust as needed
- Systemic antibiotics are not routinely needed for most post-cataract or post-injection bacterial cases
Steroids help reduce the damaging inflammation that occurs with infection. However, we must be careful because steroids can also slow immune responses and worsen some infections.
We delay steroids until antimicrobial therapy has begun and there is early clinical control. We avoid steroids when fungal infection is suspected until antifungal therapy is established. Intraocular pressure is monitored and treated as needed. We may use steroid eye drops, injections, or pills depending on the severity. The goal is to protect your retina and optic nerve from inflammatory damage without helping the infection spread.
We will see you frequently during the first days and weeks of treatment. At each visit, we check your vision, eye pressure, and the appearance of the inside of your eye.
Improvement usually means less pain, less redness, clearing of the vitreous haze, and stabilization or recovery of vision. If you do not improve or worsen despite treatment, we may need to adjust medications, perform surgery, or consider other diagnoses. If there is insufficient improvement, we may repeat intravitreal injections or proceed to vitrectomy.
Recovery, Follow-Up Care, and Prevention
The first two days after starting treatment are critical. Many patients notice some reduction in pain and redness, though your vision may remain blurry or even worsen temporarily due to inflammation.
Rest your eyes as much as possible and avoid straining or rubbing. Use all prescribed medications exactly as directed. Report any increase in pain, further vision loss, or new symptoms to us immediately.
We will want to see you within 24 hours of starting treatment, then every few days for the first week or two. As you improve, visits become less frequent but remain important for months.
- Daily or every-other-day visits during the acute phase
- Weekly visits as inflammation starts to resolve
- Monthly checks to monitor for late complications
- Long-term follow-up to assess final vision and eye health
Outcomes depend on how quickly treatment started, which organism caused the infection, and how severe the damage was before treatment. Some patients recover most or all of their vision, while others experience permanent loss.
Even with the best care, endophthalmitis can lead to lasting problems like scar tissue, glaucoma, retinal detachment, or loss of the eye in severe cases. Our goal is to save as much vision as possible and prevent complications.
If you need another eye surgery or injection in the future, certain steps can reduce your infection risk. We follow strict sterile protocols, and you play an important role too.
- Treat any eyelid or skin infections before scheduled surgery
- Use prescribed drops exactly as instructed. Topical antibiotics are not routinely used after injections, and after cataract surgery many surgeons rely on intracameral antibiotics.
- Avoid touching or rubbing your eye after procedures
- Keep follow-up appointments so we can spot problems early
- Report any concerning symptoms right away
- Ensure povidone-iodine is applied to the ocular surface before procedures
- Arrive with clean eyelids and no eye makeup; avoid touching the eye after procedures
- During intravitreal injections, minimize speaking and wear a mask until the drape and speculum are in place
Other conditions can cause symptoms that resemble endophthalmitis. Distinguishing between them requires careful examination and sometimes testing.
- Toxic anterior segment syndrome (sterile inflammation after surgery)
- Severe uveitis
- Sterile post-injection vitreous inflammation
- Retinal detachment presenting with new floaters and vision loss
Even after successful treatment, watch for signs of recurrent infection or new complications. Contact us or go to an emergency room if you experience sudden vision loss, severe new pain, significant increase in redness, or flashes and floaters.
Any trauma to your treated eye also requires prompt evaluation. Quick action can prevent minor issues from becoming serious threats to your vision.
Frequently Asked Questions
It is very rare for both eyes to develop endophthalmitis at once. If infection spreads through your bloodstream from another part of your body, it is possible but still uncommon. Most cases involve only one eye, typically the one that had surgery or injury.
No, you cannot spread endophthalmitis to another person through casual contact. The infection is deep inside your eye and does not transmit the way pink eye does. Family members and friends do not need to take special precautions around you.
Vision outcomes vary widely based on the type of infection, how fast you received treatment, and your overall health. Some people regain good vision, while others have lasting impairment or blindness in the affected eye. Early treatment gives you the best chance for a favorable result.
Initial intensive treatment with injections and close monitoring lasts one to two weeks in most cases. You may take oral or IV antibiotics for several weeks longer, and steroid drops might continue for months. Total recovery and follow-up care can extend six months to a year.
Choose an experienced surgeon who follows current sterile techniques and antibiotic protocols. Before surgery, make sure any eyelid infections or skin problems are treated. After the procedure, use your prescribed drops on schedule, avoid getting water in your eye, and call immediately if you notice worsening pain or vision changes.
Getting Help for Endophthalmitis
If you have any symptoms of endophthalmitis, especially after eye surgery or an injury, seek care immediately. Contact your eye doctor right away or go to the nearest emergency room with eye care specialists. Prompt diagnosis and treatment offer the best opportunity to preserve your sight and prevent serious complications. Do not start leftover eye drops, especially steroid drops, before you are examined, since they can worsen some infections or obscure diagnosis.