**28. Endophthalmitis after intra-vitreal injections**

(a)

(b)

(c)

**Figure 18.** Fundus photographs of a 35-years-old immuno-compromised male patient who presented with bilateral decreased vision. He was found to have evidence of bilateral fungal endophthalmitis (a). Initially the patient was treat‐ ed by intra-vitreal antifungal agents (b). Because of worsening of infection, bilateral pars-plana vitrectomy along-with systemic antifungal therapy resulted in clearance o f his eye infection (c). (Photographs: Curtsy of Essam Al-Harthi,

Orbital and peri-orbital cellulitis have been reported as causes of endogenous endophthal‐ mitis. [8, 37] Facial cellulitis is rarely reported as a focus of infection leading to endogenous endophthalmitis. Facial cellulitis usually appears more rapidly than other deep infections, so treatment is required early on. However, facial cellulitis can be a direct or indirect causa‐

**27. Orbital and peri-orbital cellulitis as a cause of endogenous**

MD).

200 Common Eye Infections

**endophthalmitis**

In recent years, increasing number of iatrogenic cases of endophthalmitis have been report‐ ed as a result of increased used of intra-vitreal injections for various retinal conditions. [103-108] Studies have suggested that coagulase-negative Staphylococci, like postoperative endophthalmitis, appear to be the predominant organism in the pathogenesis in the devel‐ opment of endophthalmitis after intra-vitreal injection. Variety of other organisms have been implicated in the development of endophthalmitis following intra-vitreal injections of anti-VEGF agents as well as intra-vitreal Triamcinolone injections (Figure 19). Alkuraya et al, [106] reported a case of culture-positive endophthalmitis after intra-vitreal injection of bevacizumab (Avastin) in a 51-year-old diabetic women. In their case, the patient presented with decreased vision, redness, and mild pain in her eye 3 days after intra-vitreal injection of Avastin for macular edema due to a branch retinal vein occlusion. A clinical diagnosis of en‐ dophthalmitis was made, a vitreous tap was performed and intra-vitreal antibiotics were ad‐ ministered. Because of worsening of the endophthalmitis, PPV was undertaken followed by repeat intra-vitreal antibiotic injection. The patient's ocular condition improved dramatical‐ ly; however, her VA did not improve. The cultures from vitreous taps revealed Staphylococ‐ cus lugdunesis. An up-to-date overview of all patients reported in the literature with

**Figure 19.** External (a) and slit-lamp (b,c) photographs of a patient's eye who developed endopthalmitis after intraviteal Triamcinolone injection to treat post-operative macular edema.

suspected bacterial endophthalmitis along-with specific symptoms and signs which could differentiate between infectious and non-infectious causes following anti-VEGF injection has been reported by Hoevenaars et al. [108] These authors reviewed case series of 118 patients from the PubMed data along with records of their own 15 patients from the Rotterdam Eye Hospital with suspected bacterial endophthalmitis after anti-VEGF injection. Their study re‐ vealed that patients presenting with a VA of 20/200 (logMAR 1.0) or less and later than 24 hours after injection were more likely to have bacterial endophthalmitis and suggested that in order to prevent under-treatment in these patients, the threshold to proceed to vitreous biopsy and empirical intra-vitreous antibiotics should be low.
