Endophthalmitis Primer

8/3/2019 Endophthalmitis Primer

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RECOGNITION, TREATMENT AND PREVENTIONOF ENDOPHTHALMITIS: UPDATE 2010

Harry W. Flynn, Jr., M.D.Bascom Palmer Eye Institute Eye Institute

University of Miami School of Medicine

A. Classification (most frequent organisms in various clinical settings):1. Postoperative:

a. Acute-onset postoperative endophthalmitis: Coagulase (-)staphylococci, Staphylococcus aureus, Streptococcus species,Gram negative bacteria

b. Delayed-onset (chronic) pseudophakic endophthalmitis (> 6 weekspostop): P. acnes, coagulase (-) staphylococci, Fungi

c. Conjunctival filtering bleb-associated endophthalmitis:Streptococcus species, Hemophilus influenza, staphylococcusspecies

2. Post-traumatic: Bacillus species (30-40%), staphylococcus species3. Endogenous: Candida species, S. aureus, Gram-negative bacteria4. Keratitis-associated: Pseudomonas, staphylococcus5. Intravitreal injection-associated: Staphylococcus

B. Acute-onset postoperative endophthalmitis at BPEI

1984-1994 1995-2001 2002-2009Procedure #/total Incidence #/total Incidence #/total Incidence

CE + IOL 34/41,654 0.08% 8/21,972 0.04% 8/28,568 0.03%PPV 3/6,557 0.05% 2/7,429 0.03% 2/18,492 0.01%

PK 5/2,805 0.18% 2/2,362 0.08% 3/2,788 0.11%Secondary IOL 5/1,367 0.37% 1/485 0.21% 1/1,783 0.06%Glaucoma 4/3,233 0.12% 4/1,970 0.20% 0/5,041 0.00%

Total 51/55,616 0.09% 17/34,218 0.05% 14/56,672 0.03%

Acute-onset endophthalmitis after cataract surgery (2000-2008) at BPEI by year

2000 2/2949 0.072001 1/3162 0.032002 0/2809 0.002003 3/2883 0.10

2004 1/2957 0.032005 1/3344 0.032006 1/3544 0.032007 1/3929 0.032008 0/4218 0.002009 1/4884 0.02Total 11/34,679 0.03



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2. Post-traumatic endophthalmitis (incidence)a. After penetrating injury (larger studies)

- Barr (1982) - (3.2%) 4/122- Brinton (1984) - (7.4%) 19/257- Thompson (1995) - (5.0%) 13/258

b. With retained intraocular foreign body (IOFB)

- Culotta (1983) - (8.3%) 8/96- Williams (1988) - (13%) 14/105- National Eye Trauma System (1993) - (6.9%) 34/4921. Metallic IOFB (7.2%)2. Non-metallic IOFB (7.3%)3. Organic IOFB (6.3%)

3. Endogenous endophthalmitis - associated risk factors:a. Elderly or debilitated patientb. IV drug abusec. Indwelling cathetersd. History of abdominal surgery

4. Keratitis associated - rare5. Intravitreal injection – 1/1000 or less

C. Diagnosis1. Postoperative endophthalmitis

a. Acute-onset endophthalmitis - signs and symptoms:1. Marked intraocular inflammation2. Hypopyon3. Reduced vision (marked)4. Pain (75%)

b. Delayed-onset endophthalmitis - signs:1. P. acnes - white intracapsular plaque, granulomatous uveitis,

fibrin strands in anterior chamber. vitritis2. Coagulase negative staphylococcus - vitritis, hypopyon.3. Fungi - vitreous infiltrates, "string of pearls" lesions

c. Bleb-associated endophthalmitis - purulent bleb, hypopyon, markedintraocular inflammation.

2. Trauma - hypopyon, periphlebitis, vitreous infiltrates around IOFB3. Endogenous - chorioretinal infiltrate, vitritis, history of systemic disease4. Keratitis – marked intraocular inflammation5. Intravitreal injections – fibrin/marked intraocular inflammation

D. Clinical Setting for Treatment (usually outpatient)1. Needle tap (usually performed in minor OR)

a. Peribulbar anesthesiab. Betadine prepc. 23 gauge needle (one inch)d. Inject IOABs in separate syringes

2. Pars plana vitrectomy (PPV) – Transconjunctival PPV 23 or 25 gaugea. Peribulbar anesthesiab. Betadine prepc. 2 instrument approach (when view limited) vs. 3 port PPVd. Inject IOABs in separate syringes



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E. Clinical Management of Suspected Endophthalmitis

Initial approach (usually outpatient treatment)a. Obtain intraocular specimen by needle tap or by vitrectomy

(See EVS for general guidelines)b. Administer intraocular antibiotics (0.1 ml of each)

c. Administer intraocular steroids (0.1 ml – optional)d. Administer periocular antibiotics and steroidse. Postoperative topical antibiotics, steroids, and cycloplegics (started on

the first morning after initial treatment)f. Postoperative systemic antibiotics (generally not used; can be

considered for the more severe cases: rapid onset, LP vision, largehypopyon, no red reflex)

2. Follow-up approacha. If clinically worsening status at 48-72 hours,consider repeating

intraocular cultures and/or re-injection of intraocular antibiotics (andintraocular steroids). Consider vitrectomy if not performed initially.

b. Change topical antibiotics if indicated by results of cultures and/orclinical course

3. Risk Factorsa. Systemic immunosuppression (DM, PR)b. Operative preparation (Xylocaine jelly before Povidone-iodine prep)c. Intraoperative complications (vitreous loss)d. Perioperative factors (surface bacteria)e. Wound construction (wound leak; inferior wound placement)f. Chronic blepharitis

F. Recommended Initial Antibiotic and Drug Therapy

1. Acute-onset Postoperative Bacterial Endophthalmitis:a. Intravitreal:

1. Vancomycin 1 mg/0.1 ml2. Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml3. Dexamethasone 0. 4 mg/0.1 ml (optional)

b. Periocular (subconjunctival): Optional1. Vancomycin 25 mg2. Ceftazidime 100 mg3. Dexamethasone 12 to 24 mg

c. Topical (started on first postoperative day):1. Vancomycin 25 mg/ml q 1 hour2. Ceftazidime 50 mg/ml q 1 hour3. Topical steroids and cycloplegics



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d. Systemic: usually none (when used, it is generally reserved for eyeswith more severe inflammation, LP vision, rapid-onset,panophthalmitis)1. Vancomycin 1 gram IV q 12 hours2. Ceftazidime 1 gram IV q 12 hours(or oral fluoroquinolone for susceptible organisms)

2. Delayed-Onset (Chronic) Postoperative Endophthalmitis(Clinical Diagnosis: Bacterial vs. Fungal* Etiology Necessary):

a. Intravitreal: (bacterial cases)1. Vancomycin 1.0 mg/0. 1 ml2. Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml3. Dexamethasone 0.4 mg/0. 1 ml (optional)*(Fungal: Amphotericin 0.005 mg/0.1 ml or Voriconazole 0.1mg/0.2ml


c. Topical (started on first postoperative day):1. Vancomycin 25 mg/ml q 1 hour2. Ceftazidime 50 mg/ml q I hour3. Topical steroids and cycloplegics

d. Systemic: (usually none but consider in more severe cases)( bacterial vs fungal etiology)

3. Conjunctival Filtering Bleb-Associated Endophthalmitis:

a. Intravitreal:1. Vancomycin 1 mg/0.1 ml2. Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml3. Dexamethasone 0.4 mg/0.1 ml (optional)

b. Periocular (subconjunctival): Preferred1. Vancomycin 25 mg2. Ceftazidime 100 mg3. Dexamethasone 12 to 24 mg


d. Systemic: usually none but consider oral fluoroquinolone in eyeswith marked inflammation, LP vision, rapid-onset



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4. Post-Traumatic Endophthalmitis

a. Intravitreal:

1. Vancomycin 1 mg/0.1 ml2. Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml)3. Dexamethasone 0.4 mg/0.1 ml (optional)

b. Periocular (subconjunctival): Preferred1. Vancomycin 25 mg2. Ceftazidime 100 mg3. Dexamethasone 12 to 24 mg


d. Systemic (generally reserved for more severe cases):1. Vancomycin 1 gram IV q 12 hours2. Ceftazidime 1 gram IV q 12 hours or oral fluoroquinolone

5. Endogenous Fungal Endophthalmitis

a. Intravitreal:1. Amphotericin-B 0.005 mg/0.1 ml or Voriconazole 0.1mg/0.2ml(in amphotericin B resistant fungi)2. Dexamethasone 0.4 mg/0.1 ml (optional)

b. Periocular (subconjunctival): Optional1. Vancomycin 25 mg and2. Dexamethasone 12 mg to 24 mg

c. Topical (started on first postoperative day):1. Topical steroids and cycloplegics2. Topical amphotericin-B has poor intraocular

penetration and is not used

d. Systemic antibiotics (selected in consultation with internist):1. Voriconazole 200 mg po. b.i.d. for 2-4 weeks2. Fluconazole 200 mg p.o. b.i.d. day for 2-4 weeks or3. Itraconazole 200 mg p.o. b.i.d. for 2-4 weeks or4. Ketoconazole 200 mg p.o. b.i.d. for 2-4 weeks or5. Amphotericin B 0.25 to 1.0 mg/kg of body weight/IV

over 6 hours as tolerated (only if disseminated disease present)



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6. Endogenous Bacterial Endophthalmitis

a. Intravitreal:

1. Vancomycin 1.0 mg/0.1 ml2. Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml3. Dexamethasone 0.4 mg/0.1 ml (optional)


c. Topical (started on first postoperative day):1. Vancomycin 25 mg/ml q 1 hour2. Ceftazidime 50 mg/ml q 1 hour3. Topical steroids and/or cycloplegics

d. Systemic antibiotics (selected in consultation with internist):1. Vancomycin 1 gram IV q 12 hours2. Ceftazidime 1 gram IV q 12 hours(or Ciprofloxacin 750 mg p.o. q 12 h for susceptible organisms)

Preparation of Intravitreal Antibiotics/Antifungals

NOTE: Intraocular antibiotics are prepared in a volume of 10 ml or greater volumeand labelled in a sealed sterile vial. The physician will withdraw the appropriatedose in a tuberculin syringe for injection into the eye.

Vancomycin (VANCOCIN) 1 mg/0.1 ml1. Begin with 500 mg vial of Vancomycin (this is a powder)2. Add 10 ml of 0.9% Sodium Chloride for Injection, USP (no preservatives)

(or BSS) to 500 mg vial in #l3. Inject 2 ml of solution #2 into a sterile empty vial4. Add 8 ml of 0.9% Sodium Chloride for Injection, USP (no preservative)(or

BSS) to produce a solution containing 1 mg/0.1 ml Vancomycin5. Seal the vial containing solution #4.

Ceftazidime ( FORTAZ) 2.25 mg/0.1 ml1. Begin with 500 mg vial of Ceftazidime (this is a powder)2. Add 10 ml of 0.9% Sodium Chloride for Injection, USP (no

preservatives) (or BSS) to 500 mg vial in #13. Inject 1 ml of the solution #2 into an empty sterile vial.4. Add 1.2 ml of Sodium Chloride for Injection, USP (no preservatives)

into the vial #2 to produce a solution containing 2.25 mg/0.1 mlceftazidime.

5. Seal the vial containing solution #4.



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Amikacin (AMIKIN) 0.4 mg/0.1 ml1. Begin with 500 mg/2 ml vial of amikacin2. Inject 0.16 ml of solution #1 (40 mg) into sterile empty vial

3. Add 9.84 ml of 0.9% Sodium Chloride Injection, USP (no preservatives)to produce a solution of 0.4mg/0.1 ml amikacin4. Seal the vial containing #3.

Amphotericin B (FUNGIZONE) 0.005 mg/0.1 ml1. Begin with a vial containing 50 mg of amphotericin B2. Add 10 ml of Sterile Water for Injection USP (no preservatives)

to vial in # 13. Inject 0.1 ml of solution #2 into a steril empyt vial4. Add 9.9 ml of Sterile Water for Injection, USP (no preservatives)

to vial in #3 to produce a solution containing 0.0005 mg/0.1 mlamphotericin B

5. Seal the vial containing solution #4

Voriconazole (Vfend I.V. powder) 0.050 mg/0.1. ml1. Reconstitute a 200mg vial of voriconazole (Vfend I.V. ® ) powder

with 19 mL of Preservative-Free Sterile Water for Injection.2. Withdraw 1 mL of voriconazole solution from step 1 and q.s. to

make 20 mL with Preservative-Free Sterile Water for Injection.3. Transfer the solution from step 2 in 10 mL aliquots to each of

2 sterile empty vials. Seal the vial.

Preparation of Subconjunctival Antibiotics(Dilutions should be made with non-bacteriostatic sterile water)

Antibiotic Amt. in Package Vol. Added Vol. for Inj. DoseAmikacin 100mg/2 ml 0 0.5ml 25mgAmpicillin 1 gm 5ml 0.5ml 100mgBacitracin 50,000 U 5ml 0.5ml 5000 UClindamycin 600mg/4ml 0 0.33ml 50mgCarbenicillin 1gm 5ml 0.5ml 100mgCephalothin 1gm 5ml 0.5ml 100mgCefazolin 500mg 2.5ml 0.5ml 100mgCeftazidime 500 mg 2.5ml 0.5ml 100mgChloramphenicol 1gm 5 ml 0.5ml 100mgColistin 150mg 2ml 0.3ml 25mgGentamicin 80mg/2ml 0 0.5ml 20mgMethicillin 1gm 5ml 0.5ml 100mgNeomycin 500mg 1ml 0.5ml 250mgPenicillin 5,000,000U 3ml 0.5ml 500,000 UTobramycin 80mg/2ml 0 0.5ml 20mgVancomycin 500 mg 5ml 0.25ml 25mg



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I. Preparation of Fortified Topical Antibiotics:

1. Vancomycin (VANCOMYCIN) 25 mg/mla. Add 20 ml of 0.9% Sodium Chloride Injection, USP (no preservatives) or

Tears Naturale artificial tears to a 500 mg vial of Vancomycin to produce aSolution of 25 mg/ml Vancomycinb. Refrigerate and shake well before instillation

2. Ceftazidime (FORTAZ) 50 mg/mla. Add 9.2 ml of Tears Naturale to a vial of Ceftazidime 1 gm (powder for

injection)b. Dissolve. Take 5 ml of this solution and add it to 5 ml of Tears Naturalec. Refrigerate and shake well before instillation

3. Amikacin 8 mg/mla. Add 0.48 ml of Amikacin (500 mg/2 ml) to make a volume with sterile

preservative free water of 15 mlb. Refrigerate and shake well before instillation.

J. Outcomes for endophthalmitis after Clear Corneal Cataract Surgery

1. BPEI Study (1996-2005) Lalwani et al –2. a. 73 treated patients in 2 groups

1) PPV and IOAB – N = 212) TAP amd IOAB – N = 59

b. Outcomes by Groups> 20/40 <5/200

1) PPV 33% 16%2) TAP 50% 24%

3. Organisms – Coagulase Negative Staph 66% (N=37)63% > 20/40

4. Time to diagnosis: 13 days

K. Endophthalmitis Vitrectomy Study (EVS)1. Purpose:

a. To determine the role of immediate 3 port pars plana vitrectomy versusimmediate tap/biopsy

b. To determine the role of IV antibiotics versus no IV antibiotics



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2. EVS Entry Criteria:a. Clinical diagnosis within 6 weeks of CE or secondary IOLb. Hypopyon or clouding of AC or vitreous media sufficient to obscure

clear visualization of second-order retinal arteriolesc. The cornea and AC were clear enough to visualize some part of iris.

d. The cornea was clear enough to allow the possibility of pars planavitrectomy.e. Visual acuity: worse than 20/50 but at least light perception.

3. EVS Results:a. No difference in final VA or media clarity whether or not systemic

antibiotics were employed.b. No difference in outcomes between immediate 3 port pars plana

vitrectomy versus tap/biopsy for patients with hand motion orbetter vision.

c. For patients with initial visual acuity of LP only, much bettervisual results occurred in the immediate 3 port pars plana vitrectomygroup (versus tap/biopsy group)a. 3 times more likely to achieve ≥ 20/40 (33% vs 11%)b. 2 times more likely to achieve ≥ 20/100 (56% vs 30%)c. Less likely to incur <5/200 (20% vs. 47%)

4. EVS Microbiologic Isolates"Confirmed growth" - 69.3% (291/420)Coagulase negative micrococci - 70.0%Staphylococcus aureus - 9.9%Streptococcus species - 9.0%

Enterococcus species - 2.2%Gram negative organisms - 5.9%Miscellaneous gram positive - 3.1%

5. EVS Microbiologic Isolates/Antibiotic Sensitivitiesa. Gram positive organisms - 94.2% (274/291)

(all sensitive to vancomycin)b. Gram negative organisms - 6.5% ( 19/291)

(17/19 were sensitive to both amikacin andceftazidime and 2/19 were resistant to both)

6. Rates of (+) culture from a single sourcea. aqueous alone 4%b. undiluted vitreous 21%c. vitrectomy cassette 8.9%



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7. EVS Visual Acuity (> 20/40) Outcomes versus Microbiology Results(N = 123) (N = 187) (N = 56) (N = 16) (N = 12)

Visual Acuity No or Coag (-) Other Gram (-) Mixed growthEquivocal micrococci gram (+)

growth

> 20/40 55% 62% 29% 44% 25%

> 20/100 80% 84% 43% 56% 42%

> 5/200 92% 96% 63% 69% 92%

8. EVS Media Clarity (≥ 20/40) Outcomes by Microbiologic Results vsInitial Treatment

Microbiology Vitrectomy Tap/BiopsyResults N n % N n %

Total 200 179 90 191 159 83

No. growth/equiv. 56 51 91 65 58 89

Coag. (-) micrococci 94 94 100 90 81 90

Other gram-positive 35 22 63 23 10 44

Gram-negative 8 5 63 8 6 75

Polymicrobial 7 7 100 5 4 80

N = total number of patientsN = number achieving > 20/40 view to retina

9. EVS Outcomes: Causes of VA < 20/40 at Final Follow-up

N = 185 n %

Pigmentary degeneration of the macula 33 18Macular edema 32 17No apparent cause 26 14Macular distortion or preretinal membrane 15 8Presumed optic nerve damage 13 7Corneal opacity or irregularity 11 6Phthisis bulbi or atrophia bulbi 13 7Posterior capsular opacity 7 4Retinal detachment 8 4Macular ischemia 6 3Vitreous opacification 3 2Other miscellaneous 18 10





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12. Other EVS Findings1. Diabetes associated with higher yield of coagulase negative

staphylococci2. If retinal vessel was visible on initial exam (N = 42),

isolates were gram (+), coagulase-negative micrococci or no/equivocalgrowth

3. 40% (85/211) had previous prep with povidone-iodine at cataractsurgery (when information was recorded)4. Ten patients had received antibiotics in the infusion fluid.

13. RD rates: Overall incidence was 8.3%1. LP initial vision (15%) vs > LP vision (5%)2. Initial PPV group (7%) vs. Tap/Biopsy group (9%)3. Attempted RD repair in 23 of 35 (66%)4. VA > 20/40 - No RD (55%) vs. with RD (26%)

14. Diabetes (58/420 had DM)VA > 20/40 outcomes:

- non-diabetic 55%- diabetic 39%For diabetic patients with better than LP vision at baseline- initial PPV 57%- initial TAP/Biopsy 40%

L. Endophthalmitis Prevention:1. Selective prophylactic systemic therapy for penetrating ocular trauma

a. Vancomycin 1 gram IV q 12 hoursb. Ceftazidime 1 gram IV q 12 hours

(or Gatifloxacin 400 mg IV or po qd)

2. Identify high risk patients before elective surgerya. Chronic blepharitisb. Lacrimal drainage abnormalitiesc. Prosthesis in fellow eyed. Active infection elsewhere

3. Preparation of operative fielda. Pre-prep in holding room (5% povidone-iodine solution)b. Second 10% povidone-iodine prep immediately before surgeryc. Drape to cover lashes and lid margins

4. Use of Prophylactic Antibiotics (controversial)a. Preoperative topical antibiotics – No definitive studiesb. Subconjunctival antibiotics at the end of surgeryc. Antibiotics in irrigating solution ( ESCRS Cefuroxime Study)

1. Emergence of resistant organisms2. Enormous cost for all procedures3. Risk of toxicity

5. Discard old topical medications (esp. glaucoma drops used prior to surgery)



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General References:

Lalwani GA, Flynn HW Jr, Scott IU, et al. Acute-Onset Endophthalmitis after Clear

Corneal Cataract Surgery (1996-2005). Ophthalmology; 115: 473-476, 2008.

Flynn HW Jr, Brod RD, Han D, Miller D. Endophthalmitis management. In SpaethG. (Ed). Ophthalmic Surgery: Principles and Practice. Lippincott, Philadelphia2002.

Schwartz SG, Flynn HW Jr., Scott IU. Endophthalmitis: Classification and currentmanagement. Expert Rev Ophthalmol 2 (3), 385-396, 2007

Doft BH. Managing infectious endophthalmitis: Results of the EndophthalmitisVitrectomy Study. American Academy of Ophthalmology (Focal Points: ClinicalModules). San Francisco. Vol 15;No.3, 1997.

Endophthalmitis Incidence:

Wykoff CC, Parrott MB, Flynn HW Jr., Shi W, Miller D, Alfonso EC. Nosocomialacute-onset postoperative endophthalmitis at a university teaching hospital (2002-2009). Am J Ophthalmol. 2010 7 [Epub ahead of print].

Kattan HM, Flynn HW Jr, Pflugfelder SC, Robertson C, Forster RK. Nosocomialendophthalmitis survery. Current incidence of infection following intraocularsurgery. Ophthalmology 98: 227-238, 1991.

Aaberg TM Jr., Flynn HW Jr, Newton J. Nosocomial acute-onset postoperativeendophthalmitis survey: a 10-year review of incidence and outcomes.Ophthalmology 105: 1004-1010, 1998.

Eifrig CW, Scott IU, Flynn HW Jr, Miller D. Acute-onset postoperativeendophthalmitis: Review of incidence and visual outcomes. Ophthalmic Surg.Lasers 33: 373-378, 2002.

Miller JJ, Scott IU, Flynn HW Jr. Smiddy WE, Newton J, Miller D. Acute-onsetendophthalmitis after cataract surgery (2000-2004): Incidence, clinical settings,and visual acuity outcomes after treatment. Am J Ophthalmol 139:983-987, 2005.

Javitt JC, Street DA, Tielsch JM et al. National outcomes of cataract extraction.Retinal detachment and endophthalmitis after outpatient cataract surgery.Ophthalmology 101: 100-106, 1994.

Kohnen T. Post-cataract endophthalmitis: Can we do better? J Cataract & Refract Surg , 35:4 , 609, April 2009 ,



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Ravindran RD, Venkatesh R, Chang DF et al. Incidence of post-cataractendophthalmitis at Aravind Eye Hospital. Outcomes of more than 42000consecutive cases using standardized sterilization and prophylaxis protocols. J

Cataract Refract Surg 2009; 35:629-636

Al-Mezaine HS, Kangave D, Al-Assiri A et al. Acute-onset nosocomialendophthalmitis after cataract surgery. Incidence, clinical features, causativeorganisms, and visual outcomes. J Cataract Refract Surg 2009; 35: 643-649

Endophthalmitis Cultures:

Joondeph BC, Flynn HW Jr, Miller DA, Joondeph HC. A new culture method forinfectious endophthalmitis. Arch Ophthalmol 107:1334-1337, 1989.

Donahue SP, Kowalski RP, Jewart BH, Friberg TR. Vitreous cultures in suspectedendophthalmitis - Biopsy or vitrectomy? Ophthalmology 100: 452-455, 1993.

Speaker MG, Milch FA, Shah MK et al. Role of external bacterial flora in thepathogenesis of acute postoperative endophthalmitis. Ophthalmology 98: 639-650, 1991.

Benz MS, Scott IU, Flynn HW Jr. Unonius N, Miller D. Endophthalmitis isolatesand antibiotic sensitivities: A 6-year review of culture-proven cases. Am JOphthalmol 137: 38-42, 2004.

Recchia FM, Busbee BG, Pearlman RB, Carvalho-Recchia CA, Ho AC. Changingtrends in the microbiologic aspects of postoperative endophthalmitis. ArchOphthalmol 123: 341-346, 2005.

Prophylaxis and Prep for Surgery:

Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataractsurgery. Ophthalmology 109:13-26, 2002 (See Letters-to-editor, Ophthalmology110: 1667-1669, 2003)

Starr MB, Lally JM. Antimicrobial prophylaxis for ophthalmic surgery. Surv.Ophthalmol. 39: 485-501, 1995.

Masket S. The role of antibacterial prophylaxis for cataract surgery (consultationsection). J. Cataract Refract Surg. 19: 108-111, 1993.



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Apt L. Isenberg SJ, Yoshimori R. et al. Outpatient topical use of povidone-iodinein preparing the eye for surgery. Ophthalmology 96: 289-292, 1989.

Meredith TA. Prevention of postoperative infection (Editorial) Arch Ophthalmol109: 944-945, 1991.

Apt L, Isenberg SJ, Yoshimori R, et al: The effect of povidone-iodine solutionapplied at the conclusion of ophthalmic surgery. Am J Ophthalmol 119: 701-705,1995.

Berrocal AM, Schuman JS. Subconjunctival cephalosporin anaphylaxis.Ophthalmic Surg Lasers 32: 79-80, 2001.

Miller D, Flynn PM, Scott IU, Flynn HW Jr. In vitro fluoroquinolone resistance instaphylococcal endophthalmitis isolates. Arch Ophthalmol 124: 479-483, 2006.

Deramo VA, Lai JC, Fastenberg DM, Udell IJ. Acute endophthalmitis in eyestreated prophylactically with gatifloxacin and moxifloxacin. Am J. Ophthalmol.142: 721-725, 2006.

Antibiotics in the Irrigating Fluid

Alfonso EC, Flynn HW Jr. Controversies in endophthalmitis prevention. The riskfor emerging resistance to vancomycin. Arch Ophthalmol 113: 1369-1370, 1995.

Gills JP: Filters and antibiotics in irrigating solution for cataract surgery. J.Cataract Refract Surg 17: 385-390, 1991.

Gills JP, Rowsey JJ: Bacterial endophthalmitis prophylaxis (letter to the editor)Ophthalmology 110: 1668-1669, 2003.

Townsend-Pico WA, Meyers SM, Langston RHS, Costin JA. Coagulase-negativeStaphylococcus endophthalmitis after cataract surgery with intraocularvancomycin. Am J Ophthalmol 121: 318-319, 1996.

Gritz DC, Cevallos AV, Smolin G, Whitcher JP. Antibiotic supplementation ofintraocular irrigating solutions. An in vitro model of antibacterial action.Ophthalmology 103: 1204-1209, 1996.

Axel-Siegal R, Stiebel-Kalish H, Rosenblatt I, Stressmann E, Yassur Y, WeinbergerD. Cystoid macular edema after cataract surgery with intraocular vancomycin.Ophthalmology 106: 1660-1664, 1999.

Gordon YJ. Vancomycin prophylaxis and emerging resistance: AreOphthalmologists the Villains? The Heroes? Am J Ophthalmol 131: 371-376, 2001.



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Mendivil, A, Mendivil MP. The effect of topical povidone-iodine, intraocularvancomycin or both on aqueous humor cultures at the time of cataract surgery.Am J Ophthalmol 131, 293-300, 2001.

Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameralcefuroxime efficacy in preventing endophthalmitis after cataract surgery. J

Cataract Refract Surg. 28: 977-981, 2002.

Barry P, Seal DV, Gettinby G, Lees F, Peterson M et al. ESCRS study ofprophylaxis of postoperative endophthalmitis after cataract surgery. J. CataractRefract Surg 32:407-410, 2006.

Gupta MS, McKee HDR, Saldaa M, Stewart OG. Macular thickness after cataractsurgery with intracameral cefuroxime. J. Cataract Refract Surg, 31: 1163-1166,2005.

Garat M, Moser CL, Martin-Baranera M et al. Phophylactic intracameral cefazolinafter cataract surgery. Endophthalmitis risk reduction and safety results in a 6-year study. J Cataract Refract Surg 2009; 35: 637-642

ESCRS

Seal DV, Barry P, Gettinby G, Lees F, Peterson M, Revie CW, Wilhelmus KR,ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis ofpostoperative endophthalmitis after cataract surgery: Case for a Europeanmulticenter study. J Cataract Refract Surg. 2006; 32(3): 396-406. Erratum in: JCataract Refract Surg. 2006; 32(5): 709.

Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, ESCRSEndophthalmitis Study Group. ESCRS study of prophylaxis of postoperativeendophthalmitis after cataract surgery: Preliminary report of principal results froma European multicenter study. J Cataract Refract Surg. 2006; 32(3): 407-10.Erratum in: J Cataract Refract Surg. 2006; 32(5): 709.

Endophthalmitis ESCRS Study Group. Prophylaxis of postoperativeendophthalmitis following cataract surgery: results of the ESCRS multicenterstudy and identification of risk factors. J Cataract Refract Surg. 2007 Jun;33(6):978-88.

Bohigian,GM, Letter: ESCRS study of endophthalmitis prophylaxisJournal of Cataracts & Refractive Surgery, 2006;32(9)1406-1407



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Peter Barry. Reply: ESCRS study of endophthalmitis prophylaxisJournal of Cataract & Refractive Surgery, Volume 32, Issue 9, September2006;32(9)1407.

Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard

RB, Packer M; ASCRS Cataract Clinical Committee. Prophylaxis of postoperativeendophthalmitis after cataract surgery: results of the 2007 ASCRS membersurvey. J Cataract Refract Surg. 2008; 34(4): 531-2; author reply 532-3.

García-Sáenz MC, Arias-Puente A, Rodríguez-Caravaca G, Bañuelos JB.Effectiveness of intracameral cefuroxime in preventing endophthalmitis aftercataract surgery Ten-year comparative study. J Cataract Refract Surg.2010;36(2):203-7.

Endophthalmitis Organisms and Outcomes:

Davis JL, Koidou A, Pflugfelder SC, Miller D, Flynn HW Jr, Forster RK. Coagulase-negative staphylococcal endophthalmitis. Ophthalmology 95: 1404-1410, 1988.

Mao LK, Flynn HW Jr, Miller DA, Pflugfelder SC. Endophthalmitis caused byStaphylococcus aureus . Am J Ophthalmol 116: 584-589, 1993.

Irvine WD, Flynn HW Jr, Miller DA, Pflugfelder SC. Endophthalmitis caused bygram-negative organisms. Arch. Ophthalmol 110: 1450-1454, 1992.

Scott IU, Loo RH, Flynn HW Jr, Miller D. Endophthalmitis caused by Enterococcus faecalis . Ophthalmology 110: 1573-1577, 2003.

Mao LK, Flynn HW Jr, Miller D, Pflugfelder SC. Endophthalmitis caused bystreptococcal species. Arch Ophthalmol 110: 798-801, 1992.

Miller JJ, Scott IU, Flynn HW Jr., et al. Endophthalmitis caused by Streptococcus pneumonia . Am J Ophthalmol 138: 231-236, 2004

Miller DM,Vedula AS, Flynn HW Jr., Miller D, Scott IU, Smiddy WE, MurrayTG, Venkatraman A. Endophthalmitis caused by Staphylococcus epidermidis . InVitro Antibiotic Susceptibilities and Clinical Outcomes. Ophthalmic Surg LasersImaging 2007; 38:446-451.

Vahey J, Flynn HW Jr: Bacillus endophthalmitis. Ophthalmic Surgery 22(11): 681-686, 1991.

Brod RD, Flynn HW Jr, Clarkson JG, Pflugfelder SC, Culbertson WW, Miller DA.Endogenous candida endophthalmitis. Ophthalmology 97: 666-674, 1990.

Cohen SM, Flynn HW Jr, Miller D. Endophthalmitis caused by Serratia marcescens . Ophthalmic Surgery 28: 195-200, 1997.



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Yoder DM, Scott IU, Flynn HW Jr, Miller D. Endophthalmitis caused byHaemophilus influenzae . Ophthalmology 2004; 11: 2023-2036.

Exogenous Fungal Endophthalmitis:

Gregori NZ, Flynn HW Jr., Miller D, Scott IU, Davis JL, Murray TG, Williams B Jr.,Clinical features, management strategies and visual acuity outcomes of Candidaendophthalmitis following cataract surgery. Ophthalmic Surg Lasers Imaging2007; 38: 278-385

Pflugfelder SC, Flynn HW Jr, Zwickey TA, et al. Exogenous fungalendophthalmitis. Ophthalmology 95: 1930, 1988.

Scott IU, Flynn HW Jr. Miller D, Speights JW, Snip RC, Brod RD. Exogenousendophthalmitis caused by amphotericin B-resistant Paecilomyces lilacinus :Treatment options and visual outcomes. Arch Ophthalmol 119: 916-919, 2001.

Narang S, Gupta A, Gupta V et al. Fungal endophthalmitis following cataractsurgery: Clinical presentation, microbiologial spectrum and outcome. Am JOphthalmol 132: 609-617, 2001.

Hariprasad SM, Mieler WF, Holz ER, et al. Determination of vitreous, aqueous, andplasma concentration of orally administered voriconazole in humans. ArchOphthalmol 122:42-47, 2004

Reis A, Sundmacher R, Tintelnot K, et al. Successful treatment of ocular invasivemold infection with voriconazole. Br J Ophthalmol 84: 932-933, 2000.

Gao H, Pennesi ME, Shah K, et al. Intravitreal voriconazole. An electro-retinographic and histologic study. Arch Ophthalmol 122: 1687-1692, 2004

Callanan D, Scott IU, Murray TG, Oxford KW, Bowman CB, Flynn HW Jr. Earlyonset endophthalmitis caused by Aspergillus species following cataract surgery.Am J Ophthalmol 2006; 142:509-511.

Wykoff CC, Flynn HW Jr., Scott IU, Alfonso EC. Exogenous FungalEndophthalmitis: Microbiology and Clinical Outcomes. Ophthalmology. 2008;115(9): 1501-1507.

Endophthalmitis/Trauma:

Cebulla CM, Flynn HW Jr., Endophthalmitis after Open Globe Injuries. Editorial.Am J Ophthalmol 2009; 147: 567-568.



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Reynolds DG, Flynn HW Jr. Endophthalmitis after penetrating ocular trauma.Current Opinion in Ophthalmology, 8: 32-38, 1997

Barr CC. Prognosis factors in corneoscleral lacerations. Arch Ophthalmol 101:919-924, 1983.

Boldt HC, Pulido JS, Blodi CF, Folk JC, Weingeist TA. Rural endophthalmitis.Ophthalmology 967: 1722-1726, 1989.

Affeldt JC, Flynn HW Jr, Forster RK, Mandelbaum S, Clarkson JG, Jarus GD.Microbial endophthalmitis resulting from ocular trauma. Ophthalmology 94: 407-413, 1987.

Mieler WF, Ellis MK, Williams DF, Han DP. Retained intraocular foreign bodies andendophthalmitis. Ophthalmology 97: 1532-1538, 1990.

Lieb DF, Scott IU, Flynn HW Jr. et al. Open globe injuries with positive intraocularcultures. Factors influencing final visual acuity outcomes. Ophthalmology 110:1560-1566, 2003.

Brinton GS, Topping TM, Hyndiuk RA, Aaberg TM, Reeser FH, Abrams GW. Post-traumatic endophthalmitis. Arch Ophthalmol 102: 547-550, 1984.

Williams DR, Mieler WF, Abrams GW, Lewis H. Results and prognostic factors inpenetrating ocular injuries with retained intraocular foreign bodies.Ophthalmology 95: 911-916, 1988.

Thompson JT, Parver LM, Enger C, Mieler WF, Liggett PE and the NETS.Endophthalmitis after penetrating ocular injuries with retained intraocular foreignbodies. Ophthalmology 100: 1468-1474, 1993.

Ariyasu RG, Kumar S, La Bree LD, Wagner DG, Smith RE. Microorganismscultured from the anterior chamber of ruptured globes at the time or repair. Am JOphthalmol 119: 181-188, 1995.

Verbraeken H, Rysselaere M: Post-traumatic endophthalmitis. Eur J Ophthalmol 4:1-5, 1994.

Kervick GN, Flynn HW Jr, Alfonso E, Miller D. Antibiotic therapy for Bacillusspecies infections. Am J Ophthalmol 110: 683-687, 1990

Yoshizumi MO, Leinwand MJ, Kim J. Topical and intravenous gentamicin intraumatically lacerated eye. Graefe Arch Clin Exp Ophthalmol 230: 175-177, 1992.



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Thompson WS, Rubsamen PE, Flynn HW Jr, Schiffman J, Cousins SW.Endophthalmitis following penetrating trauma: Risk factors and visual acuityoutcomes. Ophthalmology 102: 1696-1701, 1995.

Foster RE, Martinez JA, Murray TG, Rubsamen PE, Flynn HW Jr, Forster RK.

Useful visual outcomes after treatment of Bacillus cereus endophthalmitis.Ophthalmology 103: 390-397, 1996.

Delayed-onset Pseudophakic Endophthalmitis

Ficker L, Meredith TA, Wilson LA, Kaplan HJ, Kozarsky AM. Chronic bacterialendophthalmitis. Am J Ophthalmol. 103: 745-749, 1987.

Clark WL, Kaiser PK, Flynn HW Jr et al. Treatment strategies and visual acuityoutcomes in chronic postoperative P. acnes endophthalmitis. Ophthalmology106: 1665-1670, 1999

Winward KE, Pflugfelder SC, Flynn HW Jr, Rousell TJ, Davis JL. PostoperativePropionibacterium Endophthalmitis. Treatment strategies and long-term results.Ophthalmology 100:447-451, 1993.

Fox GM, Joondeph BC, Flynn HW Jr, Pflugfelder SC, Roussel TJ. Delayed-onsetpseudophakic endophthalmitis. Am J Ophthalmol 1991; 111: 163-173.

Meisler DM, Palestine AG, Vastine DW, Demartini DR, Murphy BF, Reinhart WJ,Zakov ZN, McMahon JT, Cliffel TP. Chronic Propionibacterium endophthalmitisafter extracapsular cataract extraction and intraocular lens implantation. Am J.Ophthalmol 102: 733, 1986.

Stern WH, Tamura E. Jacobs RA, Pons VG, Stone RD, O'Day, Irvine AR. Epidemicpostsurgical Candida parapsilosis endophthalmitis, clinical findings andmanagement of 15 consecutive cases. Ophthalmology 92: 1701, 1985.

Aaberg TM Jr, Rubsamen PE, Joondeph BC, Flynn HW Jr. Chronic postoperativegram negative endophthalmitis. Retina 17: 260-262, 1997.

Chaudhry N, Flynn HW Jr, Smiddy WE, Miller D. Xanthomonas maltophilia endophthalmitis after cataract surgery. Arch Ophthalmol 118: 572-575, 2000.

Aldave AJ. Stein JD, Deramo VA et al. Treatment strategies for postoperative P.acnes endophthalmitis. Ophthalmology 1999; 106: 2395-401.

Owens SL, Lam S, Tessler HH, Deutsch TA: Preliminary study of a new intraocularmethod in the diagnosis and treatment of P. acnes endophthalmitis. OphthalmicSurgery 24: 268-72, 1993.



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Jones JB. Postoperative P. acnes endophthalmitis. Ophthalmology 108: 633,2001.

Delayed-onset Endophthalmitis Associated With Filtering Blebs/Blebitis:

Mandelbaum S. Forster RK, Gelender H, Culbertson W. Late onsetendophthalmitis associated with filtering blebs. Ophthalmology 92: 964-972, 1985.

Wolner B, Liebmann JM, Sassani JW, Ritch R, Speaker M, Mamor M. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5-fluorouracil.Ophthalmology 98: 1053-1060, 1991.

Brown RH, Yang LH, Walker SD et al. Treatment of bleb infection after glaucomasurgery. Arch Ophthalmol 112: 57-61, 1994.

Katz LJ, Cantor LB, Spaeth GL, Complications of surgery in glaucoma. Early andlater bacterial endophthalmitis following glaucoma filtering surgery.Ophthlamology 92: 959-963, 1985.

Phillips WB, Wong TP, Berger RL, Friedberg MA, Benson WE. Late-onsetendophthalmitis associated with filtering blebs. Ophthal. Surg 25: 88-91, 1994.

Kangas TA, Greenfield DS, Flynn HW Jr. Delayed onset endophthalmitisassociated with conjunctival filtering blebs. Ophthalmology 104: 746-752, 1997.

Gedde SJ, Scott IU, Homayoun T, Kevin K, Luu M, Budenz DL, Greenfield DS,Flynn HW Jr. Late endophthalmitis associated with glaucoma drainage implants.Arch Ophthalmology 108: 1-5, 2001.

Song AA, Scott IU, Flynn HW Jr, et al. Delayed-onset bleb-associatedendophthalmitis. Ophthalmology 109:985-991, 2002

Endogenous Endophthalmitis:

Flynn HW Jr. The clinical challenge of endogenous endophthalmitis. Retina 21:572-574, 2001

Greenwald MJ, Wohl LG, Sell CH. Metastatic bacterial endophthalmitis. Acontemporary reappraisal. Surv Ophthalmol 31: 81-101, 1986.

Okada AA, Johnson RP, Liles C, D'Amico DJ, Baker AS. Endogenous bacterialendophthalmitis. Ophthalmol 101: 832-838, 1994.



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Harris EW, D'Amico DJ, Bhisitkul R. et al. Bacterial subretinal abscess: A casereport and review of the literature. Am J. Ophthalmol. 129: 778-785, 2000.

Brod RD, Flynn HW Jr, Miller D. Endogenous fungal endophthalmitis. In TasmanW, Jaeger E. (eds) Duane's Clinical Ophthalmology CV Mosby, St. Louis, Chapter

11, Vol 3: 2000, 1-40.

Menezes AV, Sigesmund DA, Demajo WA, Devenyi RG. Mortality of hospitalizedpatients with Candida endophthalmitis. Arch Intern Med. 154: 2093-7, 1994.

Weishaar PD, Flynn HW Jr, Murray TG, et. al. Endogenous AspergillusEndophthalmitis: Clinical Features and treatment outcomes. Ophthalmology 105:57-65, 1998.

Essman TF, Flynn HW Jr, Smiddy WE, Brod RD, Murray TG, Davis JL, RubsamenPE. Endogenous fungal endophthalmitis: Treatment outcomes in a ten-year study.Ophthalmic Surgery 28: 185-194, 1997.

Gupta A, Gupta V, Dogna MR et al. Fungal endophthalmitis after a singleintravenous administration of presumably contaminated dextrose infusion fluid.Retina 20: 262-268, 2000.

LaKasha H, Pavlin CJ, Lipton J. Subretinal abscess due to Nocardia farcinica infection. Retina 20: 269-274, 2000.

Wong JS, Chan TK, Lee HM, Chee SP. Endogenous bacterial endophthalmitis.Ophthalmology 107: 1483-1491, 2000.

Schiedler V, Scott IU, Flynn HW Jr et al. Culture-proven endogenousendophthalmitis: clinical features and visual acuity outcomes. Am J Ophthalmol137: 725-731, 2004.

Experimental Endophthalmitis:

Forster, RK. Experimental postoperative endophthalmitis. Tr. Am Ophth Soc. Vol90, 505-559. 1992.

Meredith TA, Aguilar HE, Shaarawy A, et al. Vancomycin levels in the vitreouscavity after intravenous administration. Am J Ophthalmol 119: 774-778, 1995.

Meredith TA: Antimicrobial pharmacokinetics in endophthalmitis treatment.Studies of ceftazidime. Trans Am Ophthalmol Soc 91: 653, 1993.



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Stern GA: Factors affecting the efficacy of antibiotics in the treatment ofexperimental postoperative endophthalmitis. Trans Am Ophthalmol Soc. 91: 775,1993.

Meredith TA, Aguilar HE, Miller MJ, Gardner SK, Trabelski A, Wilson LA.

Comparative treatment of experimental Staphylococcus epidermidis endophthalmitis. Arch Ophthalmol 108: 857-860, 1990.

Talley AR, D'Amico DJ, Talamo JH, Casey VJ, Kenyon KR. The role of vitrectomyin the treatment of postoperative bacterial endophthalmitis. An experimentalstudy. Arch Ophthalmol 105: 1699-1702;, 1987.

Chio S, Hahn TW, Osterhout G, O'Brien TP. Comparative intravitreal antibiotictherapy for experimental Enterococcus faecalis endophthalmitis. Arch Ophthalmol114: 61-65, 1996.

Alfaro DV, Hudson SJ, Rafanan MM et. al. The effect of trauma on the ocularpenetration of intravenous ciprofloxacin. Am J Ophthalmol 122: 678-683, 1996.

El-Massry A, Meredith TA, Aguilar HE, et. al. Aminoglycoside levels in the rabbitvitreous cavity after intravenous administration. Am J Ophthalmol 122: 684-689,1996.

Large Clinical Series:

Bohigian GM, Olk RJ. Factors associated with a poor visual result inendophthalmitis. Am J Ophthalmol 101: 332-334, 1986.

Diamond JG. Intraocular management of endophthalmitis. Arch Ophthalmol 99:96-99, 1981.

Driebe WT Jr, Mandelbaum S, Forster RK, et al. Pseudophakic endophthalmitis:Diagnosis and management. Ophthalmology 93: 442-448, 1986.

Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthalmitis.Ophthalmology 89: 921-929, 1982.

Rowsey JJ, Newson DL, Sexton DJ, Harms WK. Endophthalmitis: Currentapproaches. Ophthalmology 89: 1055-1066, 1982.

Phillips WB, Tasman WS. Postoperative endophthalmitis in association withdiabetes mellitus. Ophthalmology 101: 508-518, 1994.

Stonecipher KG, Ainbinder DI, Maxwell DP, Diamond JG, Caldwell DR. Infectiousendophthalmitis: A review of 100 cases. Ann Ophthalmol Glaucoma 26: 108-115,1994.





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Miscellaneous:

Huang S, Brod R, Flynn HW Jr. Endophthalmitis management while preservingthe uninvolved crystalline lens. Am J Ophthalmol 112: 695-701, 1991.

Irvine WD, Flynn HW Jr, Murray TG, Rubsamen PE. Retained lens fragments after

phacoemulsification manifesting as marked intraocular inflammation withhypopyon. Am J Ophthalmol 114: 610-614, 1992.

Kim JE, Flynn HW Jr, Rubsamen PE, Murray TG, Davis JL, Smiddy WE.Endophthalmitis in patients with retained lens fragments afterphacoemulsification. Ophthalmology 103: 575-578, 1996.

Stonecipher KG, Parmley VC, Jensen H, Rowsey JJ. Infectious endophthalmitisfollowing sutureless cataract surgery. Arch Ophthalmol 109: 1562-1563, 1991.

Ormerod LD, Puklin JE, McHenry JG, McDermott ML. Scleral flap necrosis andinfectious endophthalmitis after cataract surgery with a scleral tunnel incision.Ophthalmology 100: 159-163, 1993.

Scott IU, Flynn HW Jr, Feuer W. Endophthalmitis after secondary IOLimplantation: a case/control study. Ophthalmology 102; 1925-1931, 1995.

Jones DB. Emerging antibiotic resistance: real and relative. Arch Ophthalmol 114:91-92, 1996.

Monson MC, Mamalis N, Olson RJ, Toxic anterior segment inflammation followingcataract surgery. J. Cataract Refract Surg. 18; 184-189, 1992.

Sulkes DJ, Flynn HW Jr, Scott IU, Feuer WJ, Christmas J. Evaluating outpatientversus inpatient costs in endophthalmitis management. Retina 22: 747-751, 2002.

Foster RE, Rubsamen PE, Joondeph BC, Flynn HW, Smiddy WS: Concurrentendophthalmitis and retinal detachment. Ophthalmology 101:490-498, 1994.

Nguyen JK, Fung AE, Flynn HW Jr, Scott IU. Hypopyon andpseudoendophthalmitis associated with chronic vitreous hemorrhage. OphthalmicSurg Lasers Imaging 37: 317-319, 2006.

TASS

Mamalis N. Toxic anterior segment update [Editorial]. J Cataract Refract Surg

2010; 36: 1067-1068

Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxicanterior segment syndrome. J Cataract Refractive Surg 2006; 32: 324-333

Mamalis N. Toxic anterior segment syndrome [Editorial]. J Cataract Refract Surg2006; 32: 181-182



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American Society of Cataract and Refractive Surgery and the American Society ofOphthalmic Registered Nurses. Recommended practices for cleaning andsterilizing intraocular surgical instruments. J Cataract Refract Surg 2007; 33:1095-1100.

The Endophthalmitis Vitrectomy Study

Flynn HW Jr., Scott IU. Legacy of the Endophthalmitis Vitrectomy Study. ArchOphthalmol 2008: 126: 559-561

Miller JJ, Scott IU, Flynn HW Jr., Smiddy WE, Murray TG, Berrocal A, Miller D.Endophthalmitis Caused by Bacillus Species. Am J Ophthalmol 2008; 145: 883-888

Doft BH. The Endophthalmitis Vitrectomy Study. Arch Ophthalmol 109: 487-489,1991.

Endophthalmitis Vitrectomy Study Group. Results of the EndophthalmitisVitrectomy Study. A randomized trial of immediate vitrectomy and of intravenousantibiotics for the treatment of postoperative bacterial endophthalmitis. ArchOphthalmol 113: 1479-1496, 1995.

Han DP, Wisniewski SR, Wilson LA, Barza M, Vine AK, Doft BH, Kelsey SF, and theEVS Group. Spectrum and susceptibilities of microbiologic isolates in the EVS.Am J Ophthalmol 122: 1-17, 1996.

Endophthalmitis Vitrectomy Study Group: Microbiologic factors and visualoutcomes in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol 122: 830-846, 1996.

Johnson MW, Doft BH, Kelsey SF, et. al. The Endophthalmitis Vitrectomy Study.Relationship between clinical presentation and microbiologic spectrum.Ophthalmology 104: 261-272, 1997.

Bannerman TL, Rhoden DL, McAllister, et. al. The source of coagulase-negativestaphylococci in the Endophthalmitis Vitrectomy Study: A comparison of eyelidand intraocular isolates using pulsed-field gel electrophoresis. Arch Ophthalmol115: 357-361, 1997.

Wisniewski SR, Hammer ME, Grizzard WS, et al. An investigation of the hospitalcharges related to the treatment of endophthalmitis in the EVS. Ophthalmology104: 739-745, 1997.

Flynn HW Jr, Meredith TA. Interpreting the results of the EVS (Letter to Editor)Arch Ophthalmol 114: 1027-8, 1996

Peyman GA. EVS, a different point of view. (Editorial) Arch de la SociedadEspanola de Oftalmologia 3: 205-207, 1996

Davis JL (Editorial) Intravenous antibiotics for endophthalmitis. Am JOphthalmol. 122: 724-726, 1996.



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Barza M, Han DP, Doft BH and the EVS Study Group. Microbiological factors andvisual outcome in the EVS. (Letter to Editor). Am J Ophthalmol 124: 127-130, 1997.

Barza M, Paven PR, Doft BH et al. Evaluation of microbiology diagnostictechniques in postoperative endophthalmitis in the EVS. Arch Ophthalmol 115:

1142-1150, 1997.

Doft BH, Kelsey SF, Wisniewski SR, and the EVS Study Group. Additionalprocedures after the initial vitrectomy or tap-biopsy in the EVS. Ophthalmology105: 707-716, 1998.

Wisniewski SR, Capone A, Kelsey SF, et al. Characteristics after cataractextraction or secondary IOL among patients screened for the EVS.Ophthalmology 107: 1274-1282, 2000.

Doft BM, Kelsey SF, Wisniewski SR. Retinal detachment in the EndophthalmitisVitrectomy Study. Arch Ophthalmol 118: 1661-1665, 2000.

Doft BD, Wisniewski SR, Kelsey SF, et al. Diabetes and postoperativeendophthalmitis in the EVS. Arch Ophthalmol 119: 650-656, 2001

Sternberg P, Martin DF. Management of endophthalmitis in the Post-Endophthalmitis Vitrectomy Study Era. Arch Ophthalmol 119: 754-755, 2001

Endophthalmitis after Strabismus Surgery:

Reccia FM, Baumal CR, Sivalingan A, et al. Endophthalmitis after pediatricstrabismus surgery. Arch Ophthalmol 118: 939-944, 2000.

Thomas JW, Hamill MB, Lambert HM, Streptococcus pneumoniae endophthalmitisfollowing strabismus surgery. Arch Ophthalmol 111: 1170-1171, 1993.

Kivlin JD, Wilson ME Jr., and the Periocular Infection Study Group. Periocularinfection after strabismus surgery. J. Pediatric Ophthalmol Strabismus 32: 42-49,1995.

Rosenbaum AL (editorial) Endophthalmitis after strabismus surgery. ArchOphthalmol 118: 982-983, 2000.

Compatibility of Intraocular Antibiotics:

Fiscella RG. Physical incompatibility of vancomycin and ceftazidime forintravitreal injection. Arch Ophthalmol 111: 730, 1993



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Lifshitz T, Lapid-Gortzak R, Finkelman Y, Klemperer I. Vancomycin andceftazidime incompatibility upon intravitreal injection. Br J Ophthalmol 84: 117-8,2000.

Kwok AK, Hui M, Pang CP, et al. An in vitro study of ceftazidime and vancomycinconcentrations in various fluid media: implications for use in treating

endophthalmitis. Invest Ophthalmol Vis Sci. 43: 1182-8, 2002.

Endophthalmitis Associated with Microbial Keratitis:

Scott IU, Flynn HW Jr, Pflugfelder SC, Alfonso EC, Forster PK. Endophthalmitisassociated with microbial keratitis. Ophthalmology 103: 1864-1870, 1996.

Nouri M, Terada H, Alfonso EC, Foster CS, Durand ML, Dohlman CH.Endophthalmitis after keratoprosthesis. Arch Ophthalmol 119: 484-489, 2001.

Rosenberg K, Flynn HW Jr, Alfonso EC, Miller D. Fusarium endophthalmitisfollowing keratitis associated with contact lenses. Ophthalmic Surg LaserImaging 37: 310-313, 2006.

Endophthalmitis/Vitritis Caused by Intravitreal Injections:

Scott IU, Flynn HW Jr., Endophthalmitis Prophylaxis for Intravitreal Injections.Retinal Physician 2008; 5(4): 26, 27,48

Roth DB, Flynn HW Jr., Distinguishing Between Infectious and Noninfectious

Endophthalmitis After Intravitreal Triamcinolone Injection. Am J Ophthalmol 2008;146: 346-347

Sutter FKP, Gillies MC. Pseudo-endophthalmitis after intravitreal injection oftriamcinolone. Br J Ophthalmol 87: 972-974, 2003.

Benz M, Murray TG, Dubovy S, et al. Endophthalmitis caused by M . chelonae (abcessus ) after intravitreal triamcinolone. Arch Ophthalmol 121: 271-273, 2003.

Roth DB, Chieh J, Spirn MJ, et al. Non infectious endophthalmitis associated withintravitreal triamcinolone injection. Arch Ophthalmol 121: 1279-1282, 2003

Nelson ML, Tennant MTS, Sivalingam A, et al. Infectious and presumednoninfectious endophthalmitis after intravitreal triamcinolone acetonide injection.Retina 23: 686-691, 2003.

Moshfeghi DM, Kaiser PK, Scott IU, et al. Acute endophthalmitis followingintravitreal triamcinolone acaetonide injection. Am J Ophthalmol 136: 791-796,2003.



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Parke DW, II. Intravitreal triamcinolone and endophthalmitis. Am J Ophthalmol136: 791-796, 2003.

Aiello LP, Brucker AJ, Chang S, et al. Evolving guidelines for intravitreousinjections. Retina 24 (S): 1-19, 2004.

Jager RD, Aiello LP, Patel SC, Cunningham ET. Jr. Risk of intravitreous injection:a comprehensive review. Retina 24: 676-698, 2004.

Ta CN, Minimizing the risk of endophthalmitis following intravitreous injection.Retina 24: 699-705, 2004.

Vote BJ, Buttery R, Polkinghorne PJ. Endophthalmitis after intravitreal injectionof frozen pre-prepared TPA for pneumatic displacement of submacularhemorrhage. Retina 24: 808-809, 2004.

Scott IU, Flynn HW Jr. Reducing the risk of endophthalmitis following intravitrealinjections. Retina 2007, 27: 10-12.

Scott IU, Flynn HW Jr., Endophthalmitis Prophylaxis for Intravitreal Injections.Retinal Physician 2008; 5(4): 26, 27, 48.

Roth DB, Flynn HW J., Distinguishing Between Infectious and NoninfectiousEndophthalmitis after Intravitreal Triamcinolone Injection. Am J Ophthalmol 2008;146: 346-347

Fintak DR, Shah GK, Blinder KJ et al. Incidence of endophthalmitis related tointravitreal injection of Bevacizumab and Ranibizumab. Retina 2008; 28: 1395-9.

Pilli S, Kotsolis A, Spaide RF et al. Endophthalmitis associated with intravitrealanti-VEGF therapy injections in an office setting. Am J Ophthalmol 2008; 145: 879-82.

Klein KS, Walsh MK, Hassan TS, et al. Endophthalmitis after anti VEGF injections.Ophthalmology. 2009; 116: 1225

Endophthalmitis Management Using Silicone Oil

Ozdamar A, Aras C, Ozturk R, et al. In vitro antimicrobial activity of silicone oilagainst endophthalmitis causing agents. Retina 19: 122-126, 1999.

Kaynak S, Oner FH, Kocak N, Cingil G. Surgical management of postoperativeendophthalmitis: Comparison of 2 techniques. J. Cataract Refract Surg 29: 966-969, 2003.



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Endophthalmitis After Pars Plana Vitrectomy

Eifrig CWG, Scott IU, Flynn HW, Jr, Smiddy WE, Newton J. Endophthalmitis afterpars plana vitrectomy: incidence, causative organisms, and visual acuityoutcomes. Am J Ophthalmol 138: 799-802, 2004.

Cohen SM, Flynn HW Jr, Murray TG, Smiddy WE and the PostvitrectomyEndophthalmitis Study Group. Endophthalmitis after pars plana vitrectomy.Ophthalmology 102: 705-712, 1995.

Scott IU, Flynn HW Jr. Endophthalmitis after pars plana vitrectomy. RetinalPhysician 2006: 3: 61-64.

Kunimoto DY, Kaiser RS. Incidence of endophthalmitis after 20 and 25 gaugevitrectomy. Ophthalmology 2007;114:2133-2137

Scott IU, Flynn HW Jr, Dev S, et al. Endophthalmitis after 25-gauge and 20-gaugepars plana vitrectomy. Incidence and Outcomes. Retina 28:138-142, 2008.

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Endophthalmitis Primer