**9. Conclusion**

ocular fluid barrier, enhancing penetration of systemic antibiotics into the vitreous cavity [61]. Another reason for poor systemic antibiotic effect in endophthalmitis is poor penetration through the blood flow because of the inflammation and necrosis of blood vessels. Because of variable penetration into the vitreous cavity of aminoglycosides, vancomycin and cephalo‐ sporins, the EVS evaluated their clinical efficacy in a post-cataract surgery endophthalmitis controlled trial and found that systemic antibiotics did not enhance visual outcomes in these patients. However, this recommendation does not hold true following other types of ocular surgery, trauma or suspected endogenous endophthalmitis [62]. Systemic antibiotics are important for therapeutic management of endogenous endophthalmitis where there is concomitant bacteremia, while intravitreal antibiotic is a key component for clinical manage‐ ment of exogenous bacterial endophthalmitis. Fluoroquinolones are currently used by many clinicians in combination with intravitreal antibiotics like vancomycin, amikacin and ceftazi‐ dime for severe endophthalmitis cases. The two drug regimens commonly used by clinicians include vancomycin (1 mg/0.1 ml) to cover Gram-positive organisms and a third-generation cephalosporin (ceftazidime 2 mg /0.1 ml) or amikacin (0.4 mg/0.1 ml) to cover Gram-negative organisms [63]. Repeated intravitreal injections of antibiotics may be necessary if there is no

Fungal endophthalmitis carries a poor prognosis and there is no standard management available for treating this condition. In fungal endophthalmitis cases, systemic antifungal agents namely amphotericin with or without flucytosine or fluconazole are used. In flucona‐ zole-resistant strains voriconazole may be helpful; however, information on new antifungal agents for endophthalmitis is limited. It is seen that chorioretinitis infections can be more readily cured with systemic antifungal agents, whereas more aggressive treatment including pars plana vitrectomy with intravitreal amphotericin (5–10mg/0.1mL) or voriconazole and systemic antifungal is required for patients with vitritis. Topical antifungal agents (natamycin

The use of corticosteroids is controversial. In endophthalmitis, ocular inflammation is induced by growing bacteria and also due to breakdown of cell wall or other components due to use of antibiotics. This overt inflammatory response can damage sensitive neurologic tissues. They should not be administered without proper coverage of all infective microorganisms and when the infection is not controlled. Intravitreal dexamethosone in the concentration of 400 micro‐

Although intravitreal antibiotic therapy can provide effective bacterial killing during endoph‐ thalmitis, vitrectomy is an appealing adjunct to management. Vitrectomy (surgical cutting and aspiration of vitreous contents and replacement with balanced salt solution) (Figure 6) debrides the vitreous cavity of bacteria, inflammatory cells and other toxic debris; promotes better diffusion of antibiotics; helps in obtaining adequate sampling for microanalysis and helps in speedy recovery of vision [66, 67]. Timing of vitrectomy is controversial, and inves‐ tigators advocate aggressive early treatment with early vitrectomy in suspected bacterial metastatic endophthalmitis, and more conservative approach in suspected fungal cases. Also,

gram in 0.1 ml has been used, but is contraindicated in fungal endophthalmitis [65].

5%) are also included, especially in cases of corneal involvement [64].

response to the initial therapy.

34 Advances in Common Eye Infections

**8.3. Pars plana vitrectomy**

Endophthalmitis may cause severe visual loss and detailed understanding of the offending organisms and the intra-ocular host response and its early recognition is necessary for effective treatment of endophthalmitis and improving visual outcome. The key to successful therapy for endophthalmitis is rapid sterilization of the posterior segment by antibiotics and arrest of potentially harmful inflammation, while concurrently limiting risks associated with penetra‐ tion of the eye by injections or surgery.
