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[Conditions](https://durgical.com/en/conditions/) · [Ophthalmology and ENT](https://durgical.com/en/conditions/)

# Endophthalmitis

A severe infection inside the eye, usually after eye surgery, an injection or a penetrating injury. It is an emergency that can cause blindness within hours.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Vitreous](https://durgical.com/en/anatomy/vitreous-body/)
- [Retina](https://durgical.com/en/anatomy/retina/)
- [Lens](https://durgical.com/en/anatomy/lens/)
- [Cornea](https://durgical.com/en/anatomy/cornea/)
- [Iris](https://durgical.com/en/anatomy/iris/)
- [Ciliary body](https://durgical.com/en/anatomy/ciliary-body/)
- [Choroid](https://durgical.com/en/anatomy/choroid/)
- [Sclera](https://durgical.com/en/anatomy/sclera/)
- [Optic nerve](https://durgical.com/en/anatomy/optic-nerve/)
- [Eyelids](https://durgical.com/en/anatomy/superior-tarsus/)

## Why it happens

- [Patterns of acute inflammation: serous, fibrinous, purulent, abscess, ulcer](https://durgical.com/en/general-pathology/patterns-of-acute-inflammation-serous-fibrinous-purulent-abscess-ulcer/)
- [The eye wall: cornea, sclera, uvea and lens](https://durgical.com/en/histology/the-eye-wall-cornea-sclera-uvea-and-lens/)

## What it is

Inflammation, almost always infectious, of the internal cavities of the eye: the vitreous and the aqueous humour, often spreading to the retina and uvea. Exogenous endophthalmitis follows entry of organisms from outside (surgery, intravitreal injection, trauma, corneal ulcer); endogenous endophthalmitis is seeded through the bloodstream from an infection elsewhere.

## Who gets it

Rare but feared. Acute postoperative endophthalmitis follows roughly one in a thousand cataract operations or fewer, and post-injection cases are rarer still; because cataract surgery and intravitreal injections are very common, these are the main sources. Open-globe injuries, frequent in agricultural and work-related trauma in Latin America, carry a much higher risk, especially with retained foreign bodies or soil contamination. Endogenous cases are a small minority and occur in seriously ill or immunocompromised patients.

## Causes

- Acute postoperative (days after surgery): mainly coagulase-negative staphylococci, also Staphylococcus aureus and streptococci
- Chronic postoperative (weeks to months): low-virulence organisms such as Cutibacterium (Propionibacterium) acnes, or fungi
- Post-traumatic: Bacillus cereus (rapid and destructive), staphylococci and fungi after injuries with soil or plant matter
- Bleb-related after glaucoma surgery: streptococci and Haemophilus
- Endogenous: Candida and other fungi, or bacteria such as Klebsiella, S. aureus and streptococci from a distant focus

## Risk factors

- Recent intraocular surgery, especially with a posterior capsule rupture or a leaking wound
- Intravitreal injection
- Penetrating eye injury, particularly with a retained intraocular foreign body or rural setting
- Glaucoma filtering bleb
- Endogenous: diabetes, intravenous drug use, central venous catheters, total parenteral nutrition, immunosuppression, endocarditis and [liver](https://durgical.com/en/anatomy/liver/) abscess

## Pathophysiology

Organisms reach the normally sterile vitreous, a gel that offers little defence and is easily colonised. Bacterial toxins and the host's neutrophilic response produce pus in the [anterior chamber](https://durgical.com/en/anatomy/anterior-chamber-of-eyeball/) (hypopyon) and vitreous, and inflammatory mediators damage the retina within hours. The retina does not regenerate, so delay translates directly into permanent vision loss; severe cases spread to all coats of the eye (panophthalmitis) and the orbit.

## Classification

- Exogenous: acute postoperative, chronic (delayed) postoperative, post-injection, bleb-related, post-traumatic, keratitis-related
- Endogenous (haematogenous): bacterial or fungal
- Panophthalmitis: infection extending through the [sclera](https://durgical.com/en/anatomy/sclera/) into orbital tissue

## Symptoms and signs

- Decreased vision, often marked, in an eye operated or injected days earlier
- Eye pain that worsens instead of improving after surgery
- Red eye with eyelid swelling and conjunctival oedema
- Hypopyon (layer of pus in the anterior chamber) and cells in the anterior chamber and vitreous
- Loss of the red reflex and a hazy view of the fundus
- Endogenous: often a fever and a systemic infection, sometimes in both eyes

## Red flags

- Pain and falling vision in the first week after cataract surgery or an injection: same-day ophthalmology review
- Hypopyon after any intraocular procedure
- Vision reduced to light perception only
- Penetrating injury with a contaminated or retained foreign body
- Eye symptoms in a septic, candidaemic or intravenous drug-using patient

## Diagnosis

**Clinical**
Mainly clinical: inflammation out of proportion to the expected postoperative course, with hypopyon, vitritis and reduced red reflex. Visual acuity at presentation is recorded because it guides treatment and prognosis.

**Tests**
Samples of [vitreous](https://durgical.com/en/anatomy/vitreous-body/) (preferred) and aqueous humour for Gram stain, culture and, where available, PCR before or at the moment of intravitreal treatment. In endogenous cases, blood cultures, echocardiography and a search for the source.

**Imaging**
B-scan ultrasound when the view of the [retina](https://durgical.com/en/anatomy/retina/) is blocked, to show vitreous opacities, retinal detachment or a foreign body. CT of the orbit after trauma to locate a metallic foreign body (MRI is avoided if metal is suspected).

## Differential diagnosis

- Toxic anterior segment syndrome (sterile inflammation within 24 hours of surgery, no vitreous involvement)
- Retained [lens](https://durgical.com/en/anatomy/lens/) fragments with postoperative uveitis
- Non-infectious uveitis
- Infectious keratitis with a sterile hypopyon
- Orbital cellulitis (proptosis and limited eye movements rather than intraocular pus)

## Goal of treatment

Sterilise the inside of the eye as quickly as possible to save vision and the eye, and treat any systemic source.

## Treatment

**Acute**
Emergency referral to ophthalmology; intraocular samples are taken and broad-spectrum intravitreal antibiotics covering gram-positive and gram-negative bacteria are injected the same day.

**Surgical**
Pars plana vitrectomy removes infected vitreous and is favoured when vision is light perception only, in severe or post-traumatic cases, or when the eye does not improve.

**Medical**
Intravitreal antifungals plus systemic antifungals when fungi are suspected; systemic antibiotics as an adjunct in post-traumatic and endogenous cases; steroids are debated and avoided when fungal infection is possible.

**Medical**
Endogenous disease: treat the primary infection (endocarditis, abscess, candidaemia) and remove infected catheters.

**Follow-up**
Daily review of pain, acuity and hypopyon in the first days, with repeat injection if there is no improvement in about 48 hours; nursing care includes eye protection, pain control and teaching the patient to report worsening at once.

## Complications

- Permanent vision loss or blindness
- Retinal detachment
- Panophthalmitis and orbital spread
- Phthisis bulbi (shrunken, non-functional eye) or need for evisceration
- Spread of infection in endogenous disease

## Prognosis

Depends on the organism and on vision at presentation. Low-virulence staphylococcal infections treated promptly often recover useful vision; streptococci, Bacillus and late treatment carry a poor outlook, and many endogenous cases end with severe loss.

## Prevention

- Antiseptic preparation of the eye surface with povidone-iodine before surgery and injections
- Intracameral antibiotic at the end of cataract surgery, as used in many centres
- Watertight wound closure and prompt repair of open-globe injuries with early antibiotics
- Protective eyewear for agricultural and industrial work
- Routine eye examination in candidaemia

## Test yourself

Think of the answer, then tap the question to see it.

## A patient has pain, decreased vision and hypopyon 4 days after cataract surgery. Most likely diagnosis?

Acute postoperative endophthalmitis.

## Most common organisms in acute postoperative endophthalmitis?

Coagulase-negative staphylococci.

## What sample is preferred to identify the organism?

Vitreous, for Gram stain, culture and PCR.

## Which organism causes a fulminant endophthalmitis after penetrating trauma with soil contamination?

Bacillus cereus.

## In a patient with candidaemia, why is a fundus examination done?

To detect endogenous Candida endophthalmitis, which changes treatment.

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## Related conditions

- [Cataract](https://durgical.com/en/conditions/cataract/)
- [Keratitis and corneal ulcer](https://durgical.com/en/conditions/keratitis-and-corneal-ulcer/)
- [Ocular trauma: hyphema and open globe injury](https://durgical.com/en/conditions/ocular-trauma-hyphema-and-open-globe-injury/)
- [Uveitis](https://durgical.com/en/conditions/uveitis/)
- [Candidiasis: oral, oesophageal and invasive](https://durgical.com/en/conditions/candidiasis-oral-oesophageal-and-invasive/)
- [Infective endocarditis](https://durgical.com/en/conditions/infective-endocarditis/)
- [Orbital cellulitis](https://durgical.com/en/conditions/orbital-cellulitis/)
- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- [Conjunctivitis](https://durgical.com/en/conditions/conjunctivitis/)
- [Diabetic retinopathy](https://durgical.com/en/conditions/diabetic-retinopathy/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [What is Endophthalmitis?](https://www.aao.org/eye-health/diseases/what-is-endophthalmitis) (American Academy of Ophthalmology, 2026); [Endophthalmitis](https://eyewiki.org/Endophthalmitis) (EyeWiki, American Academy of Ophthalmology, 2026).

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Source: https://durgical.com/en/conditions/endophthalmitis/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/endophthalmitis/