**10. Conclusion**

Endogenous endophthalmitis can be a result of a systemic infection from a myriad of infectious agents including bacteria, viruses, fungi, protozoa, and helminthic organisms. Systemic infection should be suspected when there is no history of surgical intervention or trauma. Unlike exogenous endophthalmitis, the onset of clinical manifestations may be insidious and difficult to diagnose. This is particularly true in nonverbal patients.



#### **Table 1.**

*Preparation of intravitreal pharmaceuticals.*


Pearl 1: If 25-gauge needle is unsuccessful in obtaining a sample, then a 23-gauge needle can be used after making a small sclerotomy but a safer way is to use a 25 gauge vitrector through the sclerotomy site to obtain vitreous samples.

Pearl 2: Avoid attaching antibiotics to the original vitreous biopsy needle while in the eye due to increased risk of retinal injury. It is preferred to withdraw the biopsy needle and re-enter the eye with a new needle for antibiotic delivery.

Pearl 3: Injection of drugs should be limited to the smallest possible volume and the bevel of the needle

should be placed toward the lens, not toward the retina w.

Pearl 4: Do not combine dexamethasone and vancomycin in the syringe due to precipitation, but aminoglycosides and dexamethasone can be used in the same syringe. Of note, hemorrhagic occlusive retinal vasculitis has been reported with intravitreal gentamicin treatment

#### **Table 2.**

*Vitreous tap technique [265].*


#### **Table 3.**

*Pars Plana vitrectomy role Endophthalmitis [265].*


Pearl 1: Ensure avoidance of the retina in cases where the view is impaired, such as in eyes with a dense cataract.

Pearl 2: Vitrector can be safely placed behind the IOL in pseudophakic eyes.

Pearl 3: We recommend intravitreal and systemic therapy in endogenous endophthalmitis cases, especially in mycotic cases.

Pearl 4: Fluconazole 200 *μ* g/ml can be safely used in the infusion fluid during vitrectomy of eyes with endogenous fungal endophthalmitis.

Pearl 5: *(Silicone filled eyes)*





Pearl 6: We recommend the reduced antibiotic dosage (25%) for retreatment in all vitrectomized eyes.

#### **Table 4.**

*Pars Plana vitrectomy technique [265].*

1. Perform a core pars plana vitrectomy

2. Perform endolaser around the desired biopsy site


6.Close the sclera and conjunctiva appropriately with suture if needed.

Pearl 1: Ensure that infusion bottle is raised during biopsy procedure to reduce the risk of intraocular hemorrhage. The infusion can then be turned off once hemostasis is achieved. Pearl 2: Place the tissue specimen in the culture or fixation solution of choice and then promptly send it for microbiology and histology.

Pearl 3: Minimize any trauma to the biopsy during the procedure and transport.

Pearl 4: Often no further laser treatment or cryotherapy is required at the biopsy site.

Pearl 5: Instruct the patient to lay on the appropriate side to tamponade the site with gas during sleep. Pearl 6: Closely follow up patients for any signs of retinal detachment.

#### **Table 5.**

*Chorioretinal biopsy technique.*



#### **Table 6.**

*Antibiotics in the infusion fluid for pars Plana vitrectomy.*


*Endogenous Endophthalmitis: Etiology and Treatment DOI: http://dx.doi.org/10.5772/intechopen.96766*


#### **Table 7.**

*Causative agents of endogenous endophthalmitis discussed in this chapter.*

Clinical presentations may be bilateral or unilateral. Vitreous and retinal involvement are potentially sight threatening and appropriate investigations should be performed to find the distal infection focus or systemic source(s) of the endogenous endophthalmitis and treatment usually involves systemic agents aimed at the offending organism as well as intravitreal pharmacotherapy and/or pars plana vitrectomy (PPV) to both obtain a microbiological sample both to identify the organism and to therapeutically debride the vitreous cavity of the organism, inflammatory cells, and destructive cytokines. Occasionally a chorioretinal biopsy may be required to identify the organism. Despite aggressive treatment, the eye (s) may lose vision, and some may require enucleation.

Addendum Treatment (**Tables 1**–**7**) [281].

Citation: Gholam A. Peyman, Stephen A. Meffert, Mandi D. Conway. Vitreoretinal Surgical Techniques, Second Edition, 2007.
