Clinical Commander

Back to dossier
ophtho.endophthalmitis.core.v1PRODUCTION
ophtho.endophthalmitis.core.v1

Endophthalmitis (intraocular infection)

general_internal_medicineacutesubacuteadultpediatric
Hard-required inputs
0 / 11
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a VISION-DESTROYING intraocular-infection EMERGENCY whose prognosis is measured in hours — the EVS tap-and-inject spine, NOT undifferentiated red-eye triage (that is ophtho.acute-red-eye.core.v1, which routes here). Set the five-category partition (post-cataract / post-injection / post-trauma / bleb-associated / endogenous) and the hard rules: empiric intravitreal vancomycin + ceftazidime BEFORE culture; vitrectomy if light-perception-only; no routine systemic abx for post-cataract; systemic therapy + source hunt for endogenous. Orbital/panophthalmitis extension is recognised then routed OUT.

Inputs
0
Actions
0
Advance rule
Set
Advance when

endophthalmitis emergency scope confirmed; upstream-triage and orbital concerns delineated by engine_id

Patient inputs (16)

Latency from cataract surgery / intravitreal injection / open-globe trauma / glaucoma-bleb surgery sets the category and pathogen prior and separates infection from sterile post-op inflammation/TASS (EVS Results PMID 7487614; Barry ESCRS J Cataract Refract Surg 2006 PMID 16631047)

Pain disproportionate to early signs + fulminant course suggests virulent organisms (Bacillus in trauma, streptococci in bleb/injection); painless/mild favours TASS or chronic/saccular disease (Gupta Eur J Ophthalmol 2007 PMID 17671943)

Hypopyon + dense AC cellular reaction is a cardinal sign; its presence with vitritis after surgery/injection drives immediate tap-and-inject (EVS microbiologic factors Am J Ophthalmol 1996 PMID 8956638)

Vitritis and a lost/dim red reflex localise infection to the vitreous and are the pivot separating endophthalmitis from severe anterior uveitis / keratitis-with-hypopyon (EVS Results PMID 7487614)

A filtering/leaking bleb shifts the prior to virulent streptococci/Haemophilus bleb-associated endophthalmitis with a worse prognosis and a distinct, often delayed, presentation

Candidemia / bacteremia / IVDU / central line / Klebsiella liver abscess / endocarditis defines ENDOGENOUS disease — a systemic-source process needing systemic therapy + source control (Chuang Taiwan J Ophthalmol 2025 PMID 40584198; Yang Ophthalmic Res 2020 PMID 31940653)

Rapidly progressive vision loss over hours-to-days defines the emergency; presenting acuity (light-perception-only vs hand-motions-or-better) is THE EVS treatment-fork variable (EVS Results Arch Ophthalmol 1995 PMID 7487614)

Vitreous (± aqueous) tap for Gram/Giemsa/KOH + bacterial & fungal culture is obtained AT the tap-and-inject; empiric intravitreal antibiotics are given immediately without waiting for it (EVS Results PMID 7487614; EVS microbiologic factors PMID 8956638)

Bilateral disease is almost never exogenous — it strongly implies an endogenous (esp. fungal) source and mandates a systemic work-up + bilateral treatment (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)

Light-perception-only vs hand-motions-or-better is the EVS vitrectomy decision threshold and the primary prognostic anchor (EVS Results Arch Ophthalmol 1995 PMID 7487614)

Proptosis, restricted/painful motility, lid tightness, or scleral/orbital extension = panophthalmitis/orbital cellulitis — recognise then route the orbital arm OUT (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)

B-scan when the fundus view is obscured by vitritis — vitreous opacities/membranes, retinal/choroidal status, retained IOFB, and a baseline to track response (Silpa-Archa Int J Ophthalmol 2020 PMID 33344198)

Immunosuppression / IVDU / neutropenia broadens the endogenous spectrum (Candida, atypical fungi, Bacillus in IVDU) and worsens prognosis (Rodríguez-Adrián Medicine 2003 PMID 12792305)

For endogenous (or any unexplained) disease: blood cultures, urine/line/abdominal source hunt, echocardiography for endocarditis — drives the systemic arm and route-out (Chuang Taiwan J Ophthalmol 2025 PMID 40584198; Yang Ophthalmic Res 2020 PMID 31940653)

Systemic antifungal/antibiotic safety gating for endogenous disease (voriconazole teratogenic; amphotericin/echinocandin and aminoglycoside considerations) (Rodríguez-Adrián Medicine 2003 PMID 12792305)

Renal dosing of systemic antibacterial/antifungal agents in endogenous/bleb/trauma disease (vancomycin, ceftazidime, amphotericin, voriconazole) (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateninglight_perception_only_vitrectomy
    Presenting visual acuity light-perception only in a suspected endophthalmitis (EVS Results Arch Ophthalmol 1995 PMID 7487614)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_trauma_bacillus_fulminant
    Open-globe / retained-IOFB trauma with fulminant pain, ring infiltrate, fever, hours-to-blindness course — Bacillus cereus until excluded (Gupta Eur J Ophthalmol 2007 PMID 17671943)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbilateral_endogenous
    Bilateral endophthalmitis — almost always endogenous (esp. fungal), mandating a systemic work-up and bilateral treatment (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningorbital_or_panophthalmitis_extension
    Proptosis, restricted painful motility, scleral/orbital extension, or panophthalmitis (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereendogenous_systemic_source
    Endophthalmitis with candidemia / bacteraemia / IVDU / indwelling line / Klebsiella liver abscess / endocarditis — endogenous, systemic-source disease (Chuang Taiwan J Ophthalmol 2025 PMID 40584198; Yang Ophthalmic Res 2020 PMID 31940653)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebleb_associated_virulent
    Late, often delayed, endophthalmitis after glaucoma filtration surgery through a thin/leaking bleb — virulent streptococci/Haemophilus, poor prognosis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefungal_endophthalmitis
    Feathery/atypical course, fungal smear/culture, vegetative trauma, or endogenous Candida — fungal endophthalmitis (Rodríguez-Adrián Medicine 2003 PMID 12792305)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenon_response_repeat_tap_or_vitrectomy
    No improvement or worsening hypopyon/vitritis/acuity at 48-72 h despite empiric intravitreal therapy (EVS microbiologic factors Am J Ophthalmol 1996 PMID 8956638)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSrequiredDrives screening
Loading…

Recommended regimen

Endophthalmitis — immediate tap-and-inject + vitrectomy decision + endogenous systemic arm
axis: endophthalmitis_tap_and_inject_empiricstep 1 - Step 1 — Immediate empiric intravitreal antibiotics AT the tap (do NOT await culture)
Selected step "Step 1 — Immediate empiric intravitreal antibiotics AT the tap (do NOT await culture)" — Any clinically suspected endophthalmitis (post-cataract / post-injection / post-trauma / bleb / endogenous) with hypopyon/vitritis and decreasing vision
  • vancomycin
    first line
    glycopeptide
    1 mg/0.1 mL intravitreal • intravitreal • once; repeat at 48-72 h if no improvement
    triggers: suspected_endophthalmitis, gram_positive_coverage, mrsa_or_bacillus_risk
    EVS Results Arch Ophthalmol 1995 PMID 7487614 / EVS microbiologic factors Am J Ophthalmol 1996 PMID 8956638 — empiric gram-positive cover (coag-neg staph, S. aureus incl. MRSA, streptococci, enterococci, Bacillus) given immediately at the tap, before culture
    rxcui 11124
  • ceftazidime
    first line
    3rd_gen_cephalosporin
    2.25 mg/0.1 mL intravitreal • intravitreal • once; repeat at 48-72 h if no improvement
    triggers: suspected_endophthalmitis, gram_negative_coverage, pseudomonas_risk
    EVS Results PMID 7487614 — empiric gram-negative cover incl. Pseudomonas; preferred over an aminoglycoside (less retinal toxicity) as the standard intravitreal partner to vancomycin
    rxcui 2191
  • amikacin
    contraindication substitute
    aminoglycoside
    0.4 mg/0.1 mL intravitreal • intravitreal • once
    triggers: ceftazidime_unsuitable, severe_beta_lactam_allergy
    EVS used systemic ceftazidime+amikacin; intravitreal amikacin is the gram-negative substitute only when ceftazidime is unsuitable — macular-infarction risk mandates caution (EVS Results PMID 7487614)
    rxcui 641
  • vitreous_aqueous_tap_for_gram_stain_and_culture
    first line
    diagnostic_procedure
    triggers: suspected_endophthalmitis
    EVS microbiologic factors Am J Ophthalmol 1996 PMID 8956638 — diagnostic tap taken AT the injection; empiric therapy is never delayed for the result

ed playbook — drug actions (3)

  1. 1. intravitreal vancomycin (at the tap)
    rxcui 11124
    1 mg/0.1 mL • intravitreal • once (repeat 48-72 h if needed)
    trigger: Suspected endophthalmitis — empiric gram-positive cover before culture (EVS Results PMID 7487614)
    Covers coag-neg staph / S. aureus incl. MRSA / strep / enterococci / Bacillus
  2. 2. intravitreal ceftazidime (at the tap)
    rxcui 2191
    2.25 mg/0.1 mL • intravitreal • once (repeat 48-72 h if needed)
    trigger: Suspected endophthalmitis — empiric gram-negative cover (EVS Results PMID 7487614)
    Gram-negative incl. Pseudomonas; preferred over amikacin (less retinal toxicity)
  3. 3. intravitreal amikacin (only if ceftazidime unsuitable)
    rxcui 641
    0.4 mg/0.1 mL • intravitreal • once
    trigger: Severe β-lactam allergy / ceftazidime unsuitable (EVS Results PMID 7487614)
    Gram-negative substitute — macular-infarction caution

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Pain + rapidly decreasing vision within ~6 weeks of cataract / intraocular surgery — acute postoperative endophthalmitis until excluded (EVS Results Arch Ophthalmol 1995 PMID 7487614); Pain / redness / floaters / vision loss days after an intravitreal anti-VEGF injection — post-injection endophthalmitis (Morioka Sci Rep 2020 PMID 33335269; Bates Ophthalmol Retina 2025 PMID 40158626); Open-globe injury or retained intraocular foreign body with developing pain, hypopyon, vitritis — post-traumatic endophthalmitis; Bacillus cereus fulminant risk (Silpa-Archa Int J Ophthalmol 2020 PMID 33344198; Gupta Eur J Ophthalmol 2007 PMID 17671943).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Endophthalmitis (intraocular infection)** (ophtho.endophthalmitis.core.v1).
Phenotype framing: Terminal differential with pivot findings: endophthalmitis vs sterile post-op inflammation / TASS (latency + pain + vitritis pivot — TASS = early <24-48 h, limbus-to-limbus corneal oedema, AC reaction WITHOUT significant vitritis, painless, steroid-responsive) vs severe anterior uveitis (cell/flare WITHOUT vitritis or red-reflex loss pivot) vs microbial keratitis with hypopyon (sterile reactive hypopyon over a corneal infiltrate, no true vitritis — route reciprocally to ophtho.microbial-keratitis.core.v1) vs retained lens fragment (post-cataract granulomatous reaction, indolent, lens material in AC/vitreous pivot) vs masquerade (intraocular lymphoma / necrotic tumour / old vitreous haemorrhage — indolent, steroid-refractory, no source).
Scope: Frame as a VISION-DESTROYING intraocular-infection EMERGENCY whose prognosis is measured in hours — the EVS tap-and-inject spine, NOT undifferentiated red-eye triage (that is ophtho.acute-red-eye.core.v1, which routes here). Set the five-category partition (post-cataract / post-injection / post-trauma / bleb-associated / endogenous) and the hard rules: empiric intravitreal vancomycin + ceftazidime BEFORE culture; vitrectomy if light-perception-only; no routine systemic abx for post-cataract; systemic therapy + source hunt for endogenous. Orbital/panophthalmitis extension is recognised then routed OUT.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Endophthalmitis — immediate tap-and-inject + vitrectomy decision + endogenous systemic arm** — step "Step 1 — Immediate empiric intravitreal antibiotics AT the tap (do NOT await culture)".
1. vancomycin 1 mg/0.1 mL intravitreal intravitreal once; repeat at 48-72 h if no improvement (glycopeptide, first line) — EVS Results Arch Ophthalmol 1995 PMID 7487614 / EVS microbiologic factors Am J Ophthalmol 1996 PMID 8956638 — empiric gram-positive cover (coag-neg staph, S. aureus incl. MRSA, streptococci, enterococci, Bacillus) given immediately at the tap, before culture
2. ceftazidime 2.25 mg/0.1 mL intravitreal intravitreal once; repeat at 48-72 h if no improvement (3rd_gen_cephalosporin, first line) — EVS Results PMID 7487614 — empiric gram-negative cover incl. Pseudomonas; preferred over an aminoglycoside (less retinal toxicity) as the standard intravitreal partner to vancomycin
3. amikacin 0.4 mg/0.1 mL intravitreal intravitreal once (aminoglycoside, contraindication substitute) — EVS used systemic ceftazidime+amikacin; intravitreal amikacin is the gram-negative substitute only when ceftazidime is unsuitable — macular-infarction risk mandates caution (EVS Results PMID 7487614)
4. vitreous_aqueous_tap_for_gram_stain_and_culture (diagnostic_procedure, first line) — EVS microbiologic factors Am J Ophthalmol 1996 PMID 8956638 — diagnostic tap taken AT the injection; empiric therapy is never delayed for the result

Setting playbook (ed) — Recognise endophthalmitis in minutes, obtain same-hour vitreoretinal ophthalmology, deliver tap-and-inject within hours, and identify the EVS vitrectomy-criterion / endogenous / fulminant subsets (EVS Results Arch Ophthalmol 1995 PMID 7487614)
5. intravitreal vancomycin (at the tap) 1 mg/0.1 mL intravitreal once (repeat 48-72 h if needed) — Suspected endophthalmitis — empiric gram-positive cover before culture (EVS Results PMID 7487614) (Covers coag-neg staph / S. aureus incl. MRSA / strep / enterococci / Bacillus)
6. intravitreal ceftazidime (at the tap) 2.25 mg/0.1 mL intravitreal once (repeat 48-72 h if needed) — Suspected endophthalmitis — empiric gram-negative cover (EVS Results PMID 7487614) (Gram-negative incl. Pseudomonas; preferred over amikacin (less retinal toxicity))
7. intravitreal amikacin (only if ceftazidime unsuitable) 0.4 mg/0.1 mL intravitreal once — Severe β-lactam allergy / ceftazidime unsuitable (EVS Results PMID 7487614) (Gram-negative substitute — macular-infarction caution)

Non-pharmacologic actions:
- Vitreous (± aqueous) tap for Gram/Giemsa/KOH + bacterial & fungal culture AT the injection (EVS microbiologic factors PMID 8956638)
- Emergent pars-plana vitrectomy if presenting vision is light-perception only (EVS Results PMID 7487614)
- Blood cultures + systemic source hunt + echo if endogenous; route systemic arm to id.sepsis.core.v1 (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)
- B-scan if the fundus view is obscured by vitritis (Silpa-Archa Int J Ophthalmol 2020 PMID 33344198)

AVOID / contraindication checks:
- Do not delay tap and inject for culture (EVS Results Arch Ophthalmol 1995 PMID 7487614 — empiric intravitreal vancomycin+ceftazidime within hours)
- Intravitreal amikacin macular infarction caution prefer ceftazidime (EVS Results PMID 7487614)
- No routine systemic antibiotics for postcataract endophthalmitis (EVS Results PMID 7487614 — null for visual outcome; systemic therapy reserved for endogenous/bleb/trauma)
- Intravitreal dexamethasone debated withhold if fungal or atypical (no consistent benefit; harm if fungal)
- Voriconazole teratogenic substitute amphotericinB in pregnancy (Rodríguez Adrián Medicine 2003 PMID 12792305)
- Endogenous needs systemic therapy and source control route to id sepsis (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)

Monitoring

Regimen monitoring:
- re-examine hypopyon vitritis red reflex acuity within 24-48h (EVS Results PMID 7487614)
- repeat tap and reinject or vitrectomy if no improvement 48-72h (EVS microbiologic factors PMID 8956638)
- blood culture clearance and source control for endogenous (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)
- B scan and retinal status for RD membrane macular damage (Silpa-Archa Int J Ophthalmol 2020 PMID 33344198)

Setting (ed) monitoring:
- Re-examine within 24-48 h: hypopyon, vitritis, red reflex, acuity vs baseline (EVS Results PMID 7487614)
- Repeat tap + re-inject / escalate to vitrectomy if no improvement at 48-72 h (EVS microbiologic factors PMID 8956638)

Follow-up plan: Track final visual outcome (EVS prognostic anchors), retinal/vitreous sequelae (RD, epiretinal membrane, macular damage), and silicone-oil/secondary-surgery needs. PREVENTION (a core deliverable): povidone-iodine antisepsis + intracameral cefuroxime for cataract surgery (ESCRS ~5-fold reduction); meticulous injection antisepsis (antibiotic prophylaxis does NOT help); prompt open-globe repair + IOFB removal; bleb-leak surveillance and patient education on the bleb-endophthalmitis lifetime risk; treat the systemic source and screen the fellow eye in endogenous disease.
- Close-out criterion: visual-outcome + sequelae tracked; category-specific prevention plan documented; systemic source treated for endogenous

Monitoring phase: Re-examine within 24-48 h: hypopyon/AC reaction, vitritis density, red reflex, B-scan, and acuity vs the baseline map. Worsening or non-improvement at 48-72 h → repeat tap + re-inject, reconsider fungal/atypical/Bacillus, and escalate to vitrectomy. Endogenous: track blood-culture clearance, source control, and systemic-therapy response with the medicine/ID team.

Disposition

Current setting: ed — Recognise endophthalmitis in minutes, obtain same-hour vitreoretinal ophthalmology, deliver tap-and-inject within hours, and identify the EVS vitrectomy-criterion / endogenous / fulminant subsets (EVS Results Arch Ophthalmol 1995 PMID 7487614)

Disposition criteria:
- Admit / same-hour vitreoretinal ophthalmology with repeat-tap and vitrectomy capability for every endophthalmitis (EVS Results PMID 7487614)
- Endogenous → admit under medicine/ID with the eye co-managed and the systemic arm routed (Chuang 2025 PMID 40584198)
- Confirmed sterile look-alike (TASS / retained lens fragment / masquerade) → off anti-infectives, manage/route accordingly

Escalation triggers (move to higher acuity):
- Light-perception-only vision → emergent vitrectomy (EVS Results PMID 7487614)
- Endogenous / septic / candidemic → route systemic arm to id.sepsis.core.v1, ID + medicine admission (Chuang 2025 PMID 40584198)
- Orbital/panophthalmitis extension → route to ophtho.orbital-cellulitis.core.v1 (Chuang 2025 PMID 40584198)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Presenting visual acuity light-perception only in a suspected endophthalmitis (EVS Results Arch Ophthalmol 1995 PMID 7487614)
- [LIFE_THREATENING] Open-globe / retained-IOFB trauma with fulminant pain, ring infiltrate, fever, hours-to-blindness course — Bacillus cereus until excluded (Gupta Eur J Ophthalmol 2007 PMID 17671943)
- [LIFE_THREATENING] Bilateral endophthalmitis — almost always endogenous (esp. fungal), mandating a systemic work-up and bilateral treatment (Chuang Taiwan J Ophthalmol 2025 PMID 40584198)

Citations

- Endophthalmitis Vitrectomy Study — Results (Endophthalmitis Vitrectomy Study Group, Arch Ophthalmol 1995;113(12):1479-96, PMID 7487614) + EVS microbiologic factors (Am J Ophthalmol 1996;122(6):830-46, PMID 8956638) + EVS diabetes subgroup (Arch Ophthalmol 2001, PMID 11346391) + ESCRS prophylaxis study (Barry et al, J Cataract Refract Surg 2006;32(3):407-10, PMID 16631047) + post-intravitreal-injection endophthalmitis registries (Morioka Sci Rep 2020 PMID 33335269; Bates/Storey Ophthalmol Retina 2025 PMID 40158626) + endogenous endophthalmitis series (Chuang Taiwan J Ophthalmol 2025 PMID 40584198; Yang Ophthalmic Res 2020 PMID 31940653; Rodríguez-Adrián Medicine 2003 PMID 12792305) + post-traumatic series (Silpa-Archa Int J Ophthalmol 2020 PMID 33344198; Gupta Eur J Ophthalmol 2007 PMID 17671943) — AAO Preferred Practice Pattern doctrine (tap-and-inject within hours, empiric intravitreal vancomycin + ceftazidime, vitrectomy by the EVS vision criterion) [PMID:7487614](https://pubmed.ncbi.nlm.nih.gov/7487614/)
- Cited evidence (PMID 8956638) [PMID:8956638](https://pubmed.ncbi.nlm.nih.gov/8956638/)
- Cited evidence (PMID 11346391) [PMID:11346391](https://pubmed.ncbi.nlm.nih.gov/11346391/)
- Cited evidence (PMID 9160017) [PMID:9160017](https://pubmed.ncbi.nlm.nih.gov/9160017/)
- Cited evidence (PMID 7817022) [PMID:7817022](https://pubmed.ncbi.nlm.nih.gov/7817022/)

Last reconciled with current guidelines: 2026-05-17.
References
  • Endophthalmitis Vitrectomy Study — Results (Endophthalmitis Vitrectomy Study Group, Arch Ophthalmol 1995;113(12):1479-96, PMID 7487614) + EVS microbiologic factors (Am J Ophthalmol 1996;122(6):830-46, PMID 8956638) + EVS diabetes subgroup (Arch Ophthalmol 2001, PMID 11346391) + ESCRS prophylaxis study (Barry et al, J Cataract Refract Surg 2006;32(3):407-10, PMID 16631047) + post-intravitreal-injection endophthalmitis registries (Morioka Sci Rep 2020 PMID 33335269; Bates/Storey Ophthalmol Retina 2025 PMID 40158626) + endogenous endophthalmitis series (Chuang Taiwan J Ophthalmol 2025 PMID 40584198; Yang Ophthalmic Res 2020 PMID 31940653; Rodríguez-Adrián Medicine 2003 PMID 12792305) + post-traumatic series (Silpa-Archa Int J Ophthalmol 2020 PMID 33344198; Gupta Eur J Ophthalmol 2007 PMID 17671943) — AAO Preferred Practice Pattern doctrine (tap-and-inject within hours, empiric intravitreal vancomycin + ceftazidime, vitrectomy by the EVS vision criterion) — PMID:7487614
  • Cited evidence (PMID 8956638) — PMID:8956638
  • Cited evidence (PMID 11346391) — PMID:11346391
  • Cited evidence (PMID 9160017) — PMID:9160017
  • Cited evidence (PMID 7817022) — PMID:7817022