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RECOGNITION, TREATMENT AND

PREVENTION OF
ENDOPHTHALMITIS
UPDATED: 2015

Harry W. Flynn, Jr., MD

Bascom Palmer Eye Institute
University of Miami School of Medicine

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RECOGNITION, TREATMENT, AND PREVENTION

OF ENDOPHTHALMITIS: UPDATE 2014
Harry W. Flynn, Jr., M.D.
Bascom Palmer Eye Institute
University of Miami, Miller 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 weeks postop): P.

acnes, coagulase (-) staphylococci, Fungi
c.
Conjunctival filtering bleb-associated endophthalmitis: Streptococcus species,

Hemophilus influenza, staphylococcus species
2.
3.
4.
5.

B.

Post-traumatic: Bacillus species (30-40%), staphylococcus species

Endogenous: Candida species, S. aureus, Gram-negative bacteria
Keratitis-associated: Pseudomonas, staphylococcus
Intravitreal injection-associated: Staphylococcus/Streptococcus

Acute-onset postoperative endophthalmitis at BPEI (Wykoff et al.):

Procedure
CE + IOL
PPV
PK
Secondary IOL
Glaucoma
Totals

1984-1994

1995-2001

2002-2009

#/total Incidence
34/41,654 0.08%
03/6,557
0.05%
05/2,805
0.18%
05/1,367
0.37%
04/3,233
0.12%
51/55,616 0.09%

#/total Incidence
08/21,972 0.04%
02/7,429
0.03%
02/2,362
0.08%
01/485
0.21%
04/1,970
0.20%
17/34,218 0.05%

#/total Incidence
08/28,568 0.03%
02/18,492 0.01%
03/2,788
0.11%
01/1,783
0.06%
00/5,041
0.00%
14/56,672 0.03%

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Acute-onset endophthalmitis after cataract surgery (2002-2013) at BPEI by year:

2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Total

00/2809
03/2883
01/2957
01/3344
01/3544
01/3929
00/4218
01/4884
00/4865
00/5211
03/4861
04/4729
02/4340
17/52574

0.00
0.10
0.03
0.03
0.03
0.03
0.00
0.02
0.00
0.00
0.06
0.08
0.05
0.03*

*Without the use of intracameral antibiotics

2.
Post-traumatic endophthalmitis (incidence)
a.
After penetrating injury (larger studies)
Barr (1982) (3.2%) 04/122
Brinton (1984) (7.4%) 19/257
Thompson (1995) (5.0%) 13/258
b.
With retained intraocular foreign body (IOFB)
Culotta (1983) (8.3%) 08/96
Williams (1988) (13%) 14/105
National Eye Trauma System (1993) (6.9%) 34/492
I. Metallic IOFB (7.2%)
II.
Non-metallic IOFB (7.3%)
III.
Organic IOFB (6.3%)

3.
Endogenous endophthalmitis- associated risk factors:

a.
Elderly or debilitated patients

b.
IV drug abuse
c.
Indwelling catheters

d.
History of abdominal surgery

4.
5.

Keratitis associated- increased in advanced corneal ulcers and keratoprosthesis

Intravitreal injection- 1/2000 to 1/5000

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C.
Diagnostic Features

1.
Postoperative endophthalmitis
a.
Acute-onset endophthalmitis- signs and symptoms:




Marked intraocular inflammation
Hypopyon
Reduced vision (marked)
Pain (75%)
b.
Delayed-onset endophthalmitis- signs:




P. acnes- white intracapsular plaque, granulomatous uveitis, fibrin strands in
anterior chamber. Vitritis.


Coagulase negative staphylococcus- vitritis, hypopyon.




Fungi- vitreous infiltrates, string of pearls lesions.
c.
Bleb-associated endophthalmitis- purulent bleb, hypopyon, marked intraocular



inflammation.

2.
3.
4.
5.

Trauma- hypopyon, periphlebitis, vitreous infiltrates around IOFB

Endogenous- chorioretinal infiltrate, vitritis, history of systemic disease
Keratitis- marked intraocular inflammation
Intravitreal injections- fibrin/marked intraocular inflammation

D.
Clinical Setting for Treatment (usually outpatient)

1.
Needle tap (usually performed in minor OR)
a.
Peribulbar anesthesia
b.
Povidone-iodine prep
c.
23 gauge needle (one inch)- may use butterfly needle
d.
Inject IOABs in separate syringes

2.
Pars plana vitrectomy (PPV)- Transconjunctival PPV 23 or 25 gauge
a.
Peribulbar anesthesia
b.
Povidone-iodine prep
c.
2 instrument approach (when view limited) vs. standard 3 port PPV
d.
Inject IOABs in separate syringes
E.
Clinical Management of Suspected Acute-Onset Bacterial Endophthalmitis

1.
Initial approach (usually outpatient treatment)
a.
Obtain intraocular specimen by needle tap or by vitrectomy (See EVS for general

guidelines) (use peribulbular anesthesia)
b.
Administer intraocular antibiotics (0.1 ml of each)
c.
Administer intraocular steroids (0.1 ml optional)
d.
Consider periocular antibiotics and steroids
e.
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, large hypopyon, no red reflex)

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2.
Follow-up approach
a.
If clinically worsening status at 48-72 hours, consider repeating intraocular cultures

and/or re-injection of intraocular antibiotics (and intraocular steroids). Consider

vitrectomy if not performed initially.
b.
Change topical antibiotics if indicated by results of cultures and/or clinical course

3.
Evaluate Risk Factors
a.
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:


Vancomycin 1 mg/0.1 ml




Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml




Dexamethasone 0. 4 mg/0.1 ml (optional)
b.
Periocular (subconjunctival): Optional
Vancomycin 25 mg




Ceftazidime 100 mg




Dexamethasone 12 to 24 mg
c.

Topical (started on first postoperative day): Optional

Vancomycin 25 mg/ml q 1 hour (during day)

Ceftazidime 50 mg/ml q 1 hour (during day)

Topical steroids and cycloplegics (q.i.d)

d.
Systemic: usually none (when used, it is generally reserved for eyes with more



severe inflammation, LP vision, rapid-onset, glaucoma drainage device,


panophthalmitis)


Vancomycin 1 gram IV q 12 hours




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)


Vancomycin 1.0 mg/0. 1 ml




Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml




Dexamethasone 0.4 mg/0. 1 ml (optional) *(Amphotericin 0.005 mg/0.1 ml




or Voriconazole 0.1mg/0.2ml in suspected fungal cases)

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b.
Periocular (subconjunctival): Optional
Vancomycin 25 mg




Ceftazidime 100 mg




Dexamethasone 12 to 24 mg
c.

Topical (started on first postoperative day): Optional

Vancomycin 25 mg/ml q 1 hour (during day)

Ceftazidime 50 mg/ml q I hour (during day)

Topical steroids and cycloplegics (q.i.d)

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

3.
Conjunctival Filtering Bleb-Associated or Glaucoma Device Endophthalmitis:


a.
Intravitreal:


Vancomycin 1 mg/0.1 ml




Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml




Dexamethasone 0.4 mg/0.1 ml (optional)
b.
Periocular (subconjunctival): Preferred
Vancomycin 25 mg




Ceftazidime 100 mg




Dexamethasone 12 to 24 mg
c.

Topical (started on first postoperative day):

Vancomycin 25 mg/ml q 1 hour (during day)

Ceftazidime 50 mg/ml q 1 hour (during day)

Topical steroids and cycloplegics (q.i.d)

d.

Systemic: usually none but consider oral fluoroquinolone in eyes with marked
inflammation, LP vision, rapid-onset

4.
Post-Traumatic Endophthalmitis


a.
Intravitreal:


Vancomycin 1 mg/0.1 ml




Ceftazidime 2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml)




Dexamethasone 0.4 mg/0.1 ml (optional)
b.
Periocular (subconjunctival): Preferred
Vancomycin 25 mg




Ceftazidime 100 mg




Dexamethasone 12 to 24 mg
c.

Topical (started on first postoperative day):

Vancomycin 25 mg/ml q 1 hour (during day)

Ceftazidime 50 mg/ml q 1 hour (during day)

Topical steroids and cycloplegics (q.i.d)

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d.

5.

Systemic (generally reserved for more severe cases):

Vancomycin 1 gram IV q 12 hours

Ceftazidime 1 gram IV q 12 hours or oral fluoroquinolone

Endogenous Fungal Endophthalmitis

a.
Intravitreal:


Voriconazole 0.1mg/0.2ml or Amphotericin-B 0.005 mg/0.1 ml


Usually do not use Dexamethasone 0.4 mg/0.1 ml

b.

Periocular (subconjunctival): Optional

Vancomycin 25 mg and

Dexamethasone 12 mg to 24 mg (must have anti-fungal coverage)

c.

Topical (started on first postoperative day):

Topical steroids and cycloplegics (q.i.d)

Topical amphotericin-B has poor intraocular penetration and is not used

d.
Systemic antibiotics (selected in consultation with internist):




Voriconazole 200 mg p.o. b.i.d. for 2-4 weeks or




Fluconazole 200 mg p.o. b.i.d. for 2-4 weeks or




Itraconazole 200 mg p.o. b.i.d. for 2-4 weeks or




Ketoconazole 200 mg p.o. b.i.d. for 2-4 weeks or


Amphotericin B 0.25 to 1.0 mg/kg of body weight/IV over 6 hours as

tolerated (only if disseminated disease present)

6.
Endogenous Bacterial Endophthalmitis


a.
Intravitreal:
Vancomycin 1.0 mg/0.1 ml




Ceftazidime
2.25 mg/0.1 ml or Amikacin 0.4 mg/0.1 ml




Dexamethasone
0.4 mg/0.1 ml (optional)
b.
Periocular (subconjunctival): Optional
Vancomycin 25 mg




Ceftazidime
100 mg




Dexamethasone
12 to 24 mg
c.

Topical (started on first postoperative day):

Vancomycin 25 mg/ml q 1 hour (during day)

Ceftazidime 50 mg/ml q 1 hour (during day)

Topical steroids and/or cycloplegics (q.i.d)

d.
Systemic antibiotics (selected in consultation with internist):


Vancomycin 1 gram IV q 12 hours




Ceftazidime 1 gram IV q 12 hours (or Oral fluoroquinolones for
susceptible organisms)

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G.

Preparation of Intravitreal Antibiotics/Antifungals

NOTE: Intraocular antibiotics are prepared in a volume of 10 ml or greater volume and labeled in a
sealed sterile vial. The physician will withdraw the appropriate dose in a tuberculin syringe for injection
into the eye.
Vancomycin (VANCOCIN) 1 mg/0.1 ml

1.
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 #l

3.
Inject 2 ml of solution #2 into a sterile empty vial

4.
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 Vancomycin

5.
Seal the vial containing solution #4.
Ceftazidime (FORTAZ) 2.25 mg/0.1 ml

1.
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 #1

3.
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 ml ceftazidime.

5.
Seal the vial containing solution #4.
Amikacin (AMIKIN) 0.4 mg/0.1 ml

1.
Begin with 500 mg/2 ml vial of amikacin

2.
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 amikacin

4.
Seal the vial containing #3
Amphotericin B (FUNGIZONE) 0.005 mg/0.1 ml

1.
Begin with a vial containing 50 mg of amphotericin B

2.
Add 10 ml of Sterile Water for Injection USP (no preservatives) to vial in # 1

3.
Inject 0.1 ml of solution #2 into a steril empyt vial

4.
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 ml amphotericin B

5.
Seal the vial containing solution #4
Voriconazole (Vfend I.V. powder) 0.050 mg/0.1. ml

1.
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.

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H.

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

sterile water)

Antibiotic
Amikacin
Ampicillin
Clindamycin
Cephalothin
Cefazolin
Ceftazidime
Chloramphenicol
Gentamicin
Methicillin

Tobramycin
Vancomycin

Amt. in Package
100mg/2 ml
1gm
600mg/4ml
1gm
500mg
500mg
1gm
80mg/2ml
1gm

Vol. Added
0
5ml
0
5ml
2.5ml
2.5ml
5ml
0
5ml

Vol. for Inj.

0.5ml
0.5ml
0.33ml
0.5ml
0.5ml
0.5ml
0.5ml
0.5ml
0.5ml

Dose
25mg
100mg
50mg
100mg
100mg
100mg
100mg
20mg
100mg

80mg/2ml
500 mg

0
5ml

0.5ml
0.25ml

20mg
25mg

I.
Preparation of Fortified Topical Antibiotics:

1.
Vancomycin (VANCOCIN) 25 mg/ml
a.
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 a Solution of
25 mg/ml Vancomycin
b.
Refrigerate and shake well before instillation

2.
Ceftazidime (FORTAZ) 50 mg/ml
a.
Add 9.2 ml of Tears Naturale to a vial of Ceftazidime 1gm (powder for injection)
b.
Dissolve. Take 5 ml of this solution and add it to 5 ml of Tears Naturale
c.
Refrigerate and shake well before instillation

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

free water of 15 ml
b.
Refrigerate and shake well before instillation.
J.
Endophthalmitis Vitrectomy Study (EVS)

1.
Purpose:
a.
To determine the role of immediate 3 port pars plana vitrectomy versus immediate
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 IOL
b.
Hypopyon or clouding of AC or vitreous media sufficient to obscure clear



visualization of second-order retinal arterioles


c.
The cornea and AC were clear enough to visualize some part of iris.


d.
The cornea was clear enough to allow the possibility of PPV.


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 PPV vs. tap/biopsy for

patients with hand motion or better vision.


c.
For patients with initial visual acuity of LP only, much better visual results occurred in

the immediate 3 port PPV group (versus tap/biopsy group)


3 times more likely to achieve 20/40 (33% vs. 11%)


2 times more likely to achieve 20/100 (56% vs. 30%)


Less likely to incur <5/200 (20% vs. 47%)

4.

EVS Microbiologic Isolates

Confirmed growth
Coagulase negative micrococci
Staphylococcus aureus
Streptococcus species
Enterococcus species
Gram negative organisms
Miscellaneous gram positive

- 69.3%
- 70.0%
- 9.9%
- 9.0%
- 2.2%
- 5.9%
- 3.1%

(291/420)

5.
EVS Microbiologic Isolates/Antibiotic Sensitivities
a.
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 and ceftazidime and 2/19 were resistant to
both)

6.
Rates of (+) culture from a single source
a.
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 = 187)
(N = 56)
(N = 16)
Visual Acuity (N = 123)
No or
Coag (-)
Other
Gram (-)
Equivocal
micrococci
gram (+)
growth
> 20/40
> 20/100
> 5/200

8.

55%
80%
92%

62%
84%
96%

Microbiology
Results
Total
No. growth/equiv.
Coag. (-) micrococci
Other gram-positive
Gram-negative
Polymicrobial

9.

44%
56%
69%

25%
42%
92%

EVS Media Clarity ( 20/40) Outcomes by Microbiologic Results vs Initial Treatment

N
200
56
94
35
8
7

N = total number of patients

29%
43%
63%

(N = 12)
Mixed
growth

Vitrectomy
n
%
179
90
51
91
94
100
22
63
5
63
7
100

N
191
65
90
23
8
5

Tap / Biopsy
n
159
58
81
10
6
4

%
83
89
90
44
75
80

n = number achieving 20/40 view to retina

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

N = 185
Pigmentary degeneration of the macula
Macular edema
No apparent cause
Macular distortion or preretinal membrane
Presumed optic nerve damage
Corneal opacity or irregularity
Phthisis bulbi or atrophia bulbi
Posterior capsular opacity
Retinal detachment
Macular ischemia
Vitreous opacification
Other miscellaneous
N = total number of patients

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n
33
32
26
15
13
11
13
07
08
06
03
18

%
18
17
14
08
07
06
07
04
04
03
02
10

n = number achieving 20/40 view to retina

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10.
Additional Procedures (ADPROC) (10.5% OR 44/420 EVS Patients)
Early ADPROC= within 7 days
Late ADPROC= 8 days to 1 year


a.

Early ADPROC in each treatment category:

8% in 3 port PPV group versus 13% in tap/biopsy group

12% in IV antibiotics group versus 9% no IV antibiotics group.

86% for worsening ocular inflammation

14% for complications of the initial procedure

b.
Early ADPROC by organisms isolated


Gram (+) coag. negative or no growth
5%
Gram (-) or other gram (+) 30%


c.
Early ADPROC Recultures performed: 82%
Positive growth 39%


Reculture positive by treatment category
(i)
Initial 3 port PPV group 13%
(ii)
Initial tap/biopsy group 71%


Recultures positive by organism isolated

(i)
Gram (+) coag. neg. (e.g. Staph. epi.)
17%
(ii)
Gram (+) other (e.g. Streptococci) 40%
(iii)
Gram (-) organisms (e.g. Serratia) 60%

(36/44)
(14/36)

d.
Visual acuity outcomes > 20/40
ADPROC= Additional Procedures after Initial Rx

ADPROC 15%
NO ADPROC 57%

11.
Factors associated with higher rates of both gram (-) and other gram (+) organisms:
a.
Symptom-onset within 2 days of surgery
b.
Light perception only visual acuity


c.
Afferent pupillary defect


d.
Wound abnormalities


e.
Corneal infiltrate


f.
Hypopyon > 1.5 mm


g.
Loss of red reflex


h.
Eyelid swelling

12.
Other EVS Findings
a.
Diabetes associated with higher yield of coagulase negative staphylococci
b.
If retinal vessel was visible on initial exam (N = 42), isolates were gram (+),


coagulase-negative micrococci or no/equivocal growth
c.
40% (85/211) had prep with povidone-iodine at cataract surgery (when
information was recorded)
d.
Ten patients had received antibiotics in the infusion fluid.

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13.
RD rates: Overall incidence was 8.3%
a.
LP initial vision (15%) vs > LP vision
b.
Initial PPV group (7%) vs. Tap/Biopsy group


c.
Attempted RD repair in 23 of 35


d.
VA > 20/40 - No RD (55%) vs. with RD

(05%)
(09%)
(66%)
(26%)

14.
Diabetes (58/420 had DM)


a.
VA > 20/40 outcomes:
non-diabetic 55%
diabetic 39%


b.
For diabetic patients with better than LP vision at baseline
initial PPV 57%
initial TAP/Biopsy 40%

K.
Endophthalmitis Prevention:

1.
Selective prophylactic systemic therapy for open globe injuries
a.
Vancomycin 1 gram IV q 12 hours
b.
Ceftazidime 1 gram IV q 12 hours (or Gatifloxacin 400 mg IV or po qd)

2.
Identify high risk patients before elective surgery
a.
Chronic Blepharitis
b.
Lacrimal drainage abnormalities


c.
Prosthesis in fellow eye


d.
Active infection elsewhere

3.
Preparation of operative field
a.
Pre-prep in holding room (5% povidone-iodine solution)
b.
Second 10% povidone-iodine prep immediately before surgery


c.
Drape to cover lashes and lid margins

4.
Use of Prophylactic Antibiotics (controversial)
a.
Preoperative topical antibiotics No definitive studies

b.
Subconjunctival antibiotics at the end of surgery


c.
Antibiotics in irrigating solution (ESCRS Cefuroxime Study)


Emergence of resistant organisms


Enormous cost for all procedures




Risk of toxicity
5.

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

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General References:
Brod RD, Flynn HW Jr, Han DP, Miller D. Endophthalmitis: Diagnosis, Clinical Findings and Management. In
Spaeth G. (Ed). Ophthalmic Surgery: Principles and Practice, 4th Edition. Elsevier 2012. Ch. 64. 550-560.
Packer M, Chang DF, Dewey SH, Little BC, Mamalis N, Oetting TA, Talley-Rostov A, Yoo SH for the ASCRS
Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial
endophthalmitis. J Cataract Refract Surg 2011; 37:16991714.
Schwartz SG, Flynn HW Jr., Scott IU. Endophthalmitis: Classification and current management. Expert Rev
Ophthalmol 2 (3), 385-396, 2007.
Scott IU, Flynn HW Jr. Endophthalmitis: categories, management and prevention. In: Tasman W, Jaeger EA Eds:
Duanes Clinical Ophthalmology, Vol 6, Ch 64. Philadelphia: Lippincott Williams & Wilkins; 2012.
Doft BH. Managing infectious endophthalmitis: Results of the Endophthalmitis Vitrectomy Study. American
Academy of Ophthalmology (Focal Points: Clinical Modules). San Francisco. Vol 15; No.3, 1997.
Flynn HW Jr., Scott IU. Legacy of the Endophthalmitis Vitrectomy Study. Arch Ophthalmol 2008: 126: 559-561.
Cataract Surgery:
Avinash Pathengay, Stephen G. Schwartz, Harry W. Flynn Jr. and Darlene Miller (2013). Endophthalmitis
Following Cataract Surgery: Clinical Features, Treatment and Prophylaxis in Cataract Surgery, Dr. Farhan
Zaidi (Ed.), ISBN: 978-953-51-0975-4, InTech, DOI: 10.5772/22751. Available from: http://www.intechopen.
com/books/cataract-surgery/endophthalmitis-following-cataract-surgery-clinical-features-treatment-andprophylaxis.
Shirodkar AR, Pathengay A, Flynn HW Jr, et al. Delayed vs. Acute-Onset Endophthalmitis after Cataract
Surgery. Am J Ophthalmol. 2012 Mar; 153(3):391-398.e2 doi: 10.1016/j.ajo.2011.08.029.
Hung JH, Huang YH, Chang TC, Tseng SH, Shih MH, Wu JJ, Huang FC. A cluster of endophthalmitis caused
by Mycobacterium abscessus after cataract surgery. J Microbiol Immunol Infect. 2014 Mar 20. pii: S16841182(14)00028-0. doi: 10.1016/j.jmii.2014.02.001
Rachitskaya AV, Reddy AK, Miller D, Davis J, Flynn HW Jr, Smiddy W, Lara W, Lin S, Dubovy S, Albini TA. Prolonged
Curvularia Endophthalmitis Due to Organism Sequestration. JAMA Ophthalmol. 2014;132(9):1123-1126.
doi:10.1001/jamaophthalmol.2014.1069
Villegas VM, Emanuelli A, Flynn HW Jr, et al. Endophthalmitis Caused by Achromobacter xylosoxidans after
Cataract Surgery. RETINA 34:583586, 2014 2014.
Scott IU, Flynn HW Jr., Endophthalmitis: Prevention and Management. In: Han Eds: Cataract Surgery and
Retinal Diseases: Optimizing Visual Outcome. bmc, Philadelphia. ISBN: 978-0-615-84030-7, 2013.

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Pathengay A, Flynn HW Jr, Isom RF, Miller D. Endophthalmitis Outbreaks Following Cataract Surgery:
Causative Organisms, Etiologies, and Visual Acuity Outcomes. Journal of Cataract and Refractive Surgery
(0886-3350)2012 Jul. Vol. 38: (7); 1278-82.
Pathengay A, Khera M, Das T, Sharma S, Miller D, Flynn HW Jr. Acute Postoperative Endophthalmitis Following
Cataract Surgery: A Review. Asia Pacific Academy of Ophthalmology 12/2011;1(1):35-42.
Lalwani GA, Flynn HW Jr, Scott IU, et al. Acute-Onset Endophthalmitis after Clear Corneal Cataract Surgery
(1996-2005). Ophthalmology; 115: 473-476, 2008.
Endophthalmitis Incidence:
Yao K, Zhu Y, Zhu Z, Wu J, Liu Y, Lu Y, Hao Y, Bao Y, Ye J, Huang Y, Li Z, Shentu X, Yu Y. The incidence of
postoperative endophthalmitis after cataract surgery in China: a multicenter investigation of 2006-2011. Br J
Ophthalmol. 2013 Oct;97(10):1312-7.
West ES, Behrens A, McDonnell PJ, et al. The incidence of endophthalmitis after cataract surgery among the
U.S. Medicare population increased between 1994 and 2001. Ophthalmology. 2005 Aug; 112(8):1388-94.
Wykoff CC, Parrott MB, Flynn HW Jr., Shi W, Miller D, Alfonso EC. Nosocomial acute-onset postoperative
endophthalmitis at a university teaching hospital (2002-2009). Am J Ophthalmol 2010; 150: 392-398.
Eifrig CW, Scott IU, Flynn HW Jr, Miller D. Acute-onset postoperative endophthalmitis: Review of incidence
and visual outcomes. Ophthalmic Surg. Lasers 33: 373-378, 2002.
Aaberg TM Jr., Flynn HW Jr, Newton J. Nosocomial acute-onset postoperative endophthalmitis survey: a 10year review of incidence and outcomes. Ophthalmology 105: 1004-1010, 1998.
Kattan HM, Flynn HW Jr, Pflugfelder SC, Robertson C, Forster RK. Nosocomial endophthalmitis survery.
Current incidence of infection following intraocular surgery. Ophthalmology 98: 227-238, 1991.
Ravindran RD, Venkatesh R, Chang DF et al. Incidence of post-cataract endophthalmitis at Aravind Eye
Hospital. Outcomes of more than 42000 consecutive 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 nosocomial endophthalmitis after cataract surgery.
Incidence, clinical features, causative organisms, and visual outcomes. J Cataract Refract Surg 2009; 35: 643649.
Miller JJ, Scott IU, Flynn HW Jr. Smiddy WE, Newton J, Miller D. Acute-onset endophthalmitis 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.

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Keay L, Gower EW, Cassard SD et al. Postcataract Surgery Endophthalmitis in the US. Analysis of Complete
2003 to 2004 Medicare Database of Cataract Surgery. Ophthalmology 2012; 119: 914-922.
Endophthalmitis Cultures:
Moloney TP, Park J. Microbiological isolates and antibiotic sensitivities in culture-proven endophthalmitis: a
15- year review. Br J Ophthalmol. 2014 Jun 17. Epub ahead of print.
Gentile RC, Shukla S, Shah M, Ritterband DC, Engelbert M, Davis A, Hu DN. Microbiological Spectrum and
Antibiotic Sensitivity in Endophthalmitis: A 25-Year Review. Ophthalmology. 2014 Aug;121(8):1634-42. doi:
10.1016/j.ophtha.2014.02.001
Schimel AM, Miller D, Flynn HW Jr. Endophthalmitis Isolates and Antibiotic Susceptibilities: A 10-Year Review
of Culture-Proven Cases. Am J Ophthalmol. 2013 Jul;156(1):50-52.e1. doi: 10.1016/j.ajo.2013.01.027
Schimel AM, Miller D, Flynn HW Jr., Evolving Fluoroquinolone Resistance Among Coagulase-Negative
Staphylococcus Isolates Causing Endophthalmitis. Arch Ophthalmol 2012. 130; 12: 1617-1618 DEC.
Benz MS, Scott IU, Flynn HW Jr. Unonius N, Miller D. Endophthalmitis isolates and antibiotic sensitivities: A
6-year review of culture-proven cases. Am J Ophthalmol 137: 38-42, 2004.
Donahue SP, Kowalski RP, Jewart BH, Friberg TR. Vitreous cultures in suspected endophthalmitis - Biopsy or
vitrectomy? Ophthalmology 100: 452-455, 1993.
Speaker MG, Milch FA, Shah MK et al. Role of external bacterial flora in the pathogenesis of acute postoperative
endophthalmitis. Ophthalmology 98: 639-650, 1991.
Joondeph BC, Flynn HW Jr, Miller DA, Joondeph HC. A new culture method for infectious endophthalmitis.
Arch Ophthalmol 107:1334-1337, 1989.
Recchia FM, Busbee BG, Pearlman RB, Carvalho-Recchia CA, Ho AC. Changing trends in the microbiologic
aspects of postoperative endophthalmitis. Arch Ophthalmol 123: 341-346, 2005.
Prophylaxis and Prep for Surgery:
Rahman N, Murphy CC. Impact of intracameral cefuroxime on the incidence of postoperative endophthalmitis
following cataract surgery in Ireland. Ir J Med Sci. doi 10.1007/s11845-014-1127-y.
Rudnisky CJ,Wan D,Weis E. Antibiotic choice for the prophylaxis of post-cataract extraction endophthalmitis.
Ophthalmology. 2014 Apr;121(4):835-41.
Ahmed Y, Scott IU, Pathengay A, Bawdekar A, and Flynn HW Jr., Editorial: Povidone-Iodine for Endophthalmitis
Prophylaxis. Am J Ophthal 2014 Mar; 157(3): 503-4. doi: 10.1016/j.ajo.2013.12.001.
Myneni J, Desai SP, Jayamanne DG. Reduction in postoperative endophthalmitis with intracameral cefuroxime.
J Hosp Infect. 2013 Aug;84(4):326-8.
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Gower EW, Lindsley K, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute
endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2013 Jul 15;7:CD006364.
Wykoff CC, Flynn HW Jr., Han DP. Allergy to Povidone-Iodine and Cephalosporins: The Clinical Dilemma in
Ophthalmic Use. Am J Ophthalmol 2011; 151: 4-6.
Miller D, Flynn PM, Scott IU, Flynn HW Jr. In vitro fluoroquinolone resistance in staphylococcal endophthalmitis
isolates. Arch Ophthalmol 124: 479-483, 2006.
Deramo VA, Lai JC, Fastenberg DM, Udell IJ. Acute endophthalmitis in eyes treated prophylactically with
gatifloxacin and moxifloxacin. Am J. Ophthalmol. 142: 721-725, 2006.
Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery. Ophthalmology
109:13-26, 2002 (See Letters-to-editor, Ophthalmology 110: 1667-1669, 2003).
Berrocal AM, Schuman JS. Subconjunctival cephalosporin anaphylaxis. Ophthalmic Surg Lasers 32: 79-80,
2001.
Starr MB, Lally JM. Antimicrobial prophylaxis for ophthalmic surgery. Surv. Ophthalmol. 39: 485-501, 1995.
Apt L, Isenberg SJ, Yoshimori R, et al: The effect of povidone-iodine solution applied at the conclusion of
ophthalmic surgery. Am J Ophthalmol 119: 701-705, 1995.
Masket S. The role of antibacterial prophylaxis for cataract surgery (consultation section). J. Cataract Refract
Surg. 19: 108-111, 1993.
Meredith TA. Prevention of postoperative infection (Editorial) Arch Ophthalmol 109: 944-945, 1991.
Apt L. Isenberg SJ, Yoshimori R. et al. Outpatient topical use of povidone-iodine in preparing the eye for
surgery. Ophthalmology 96: 289-292, 1989.
Antibiotics in the Irrigating Fluid / Intracameral Injection:
Schimel AM, Alfonso EC, Flynn HW Jr. Endophthalmitis Prophylaxis for Cataract Surgery, Are Intracameral
Antibiotics Necessary? JAMA Ophthalmol online Aug 2014 doi 10.10001/jamaophthalmol.2014.2052.
Rudnisky CJ,Wan D,Weis E. Antibiotic choice for the prophylaxis of post-cataract extraction endophthalmitis.
Ophthalmology. 2014 Apr;121(4):835-41.
Matsuura K, Miyoshi T, Suto C, Akura J, Inoue Y. Efficacy and safety of prophylactic intracameral moxifloxacin
injection in Japan. J Cataract Refract Surg. 2013 Nov;39(11):1702-6.
Myneni J, Desai SP, Jayamanne DG. Reduction in postoperative endophthalmitis with intracameral cefuroxime.
J Hosp Infect. 2013 Aug;84(4):326-8.
Garat M, Moser CL, Martin-Baranera M et al. Prophylactic intracameral cefazolin after cataract surgery.
Endophthalmitis risk reduction and safety results in a 6-year study. J Cataract Refract Surg 2009; 35: 637-642.
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Gupta MS, McKee HDR, Saldaa M, Stewart OG. Macular thickness after cataract surgery with intracameral
cefuroxime. J. Cataract Refract Surg, 31: 1163-1166, 2005.
Gills JP, Rowsey JJ: Bacterial endophthalmitis prophylaxis (letter to the editor) Ophthalmology 110: 16681669, 2003.
Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral cefuroxime efficacy in preventing
endophthalmitis after cataract surgery. J Cataract Refract Surg. 28: 977-981, 2002.
Gordon YJ.Vancomycin prophylaxis and emerging resistance: Are Ophthalmologists the Villains? The Heroes?
Am J Ophthalmol 131: 371-376, 2001.
Mendivil, A, Mendivil MP. The effect of topical povidone-iodine, intraocular vancomycin or both on aqueous
humor cultures at the time of cataract surgery. Am J Ophthalmol 131, 293-300, 2001.
Axel-Siegal R, Stiebel-Kalish H, Rosenblatt I, Stressmann E, Yassur Y, Weinberger D. Cystoid macular edema
after cataract surgery with intraocular vancomycin. Ophthalmology 106: 1660-1664, 1999.
Townsend-PicoWA,Meyers SM,Langston RHS,Costin JA. Coagulase-negative Staphylococcus endophthalmitis
after cataract surgery with intraocular vancomycin. Am J Ophthalmol 121: 318-319, 1996.
Gritz DC, Cevallos AV, Smolin G, Whitcher JP. Antibiotic supplementation of intraocular irrigating solutions.
An in vitro model of antibacterial action. Ophthalmology 103: 1204-1209, 1996.
Alfonso EC, Flynn HW Jr. Controversies in endophthalmitis prevention. The risk for 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.
Packer M, Chang DF, Dewey SH, Little BC, Mamalis N, Oetting TA, Talley-Rostov A, Yoo SH for the ASCRS
Cataract Clinical Committee. Prevention, diagnosis, and management of acute postoperative bacterial
endophthalmitis. Cataract Refract Surg 2011; 37:16991714.
OBrien TP, Arshinoff SA, Mah FS. Perspectives on antibiotics for postoperative endophthalmitis prophylaxis:
Potential role of moxifloxacin. J Cataract Refract Surg 2007; 33: (10)1790-1800.
Nentwich MM, Ta CN, Kreutzer TC et al. Incidence of postoperative endophthalmitis from 1990 to 2009
using povidone-iodine but no intracameral antibiotics at a single academic institution. J Cataract Refract Surg
2015; 41: 58-66.
Tan CS, Goh AG, Ngo WK et al. Safety of intracameral antibiotic use after cataract surgery. J Cataract Refract
Surg. 2014 Nov;40(11):1940-1. doi: 10.1016/j.jcrs.2014.09.028.

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ESCRS:
Barry P. Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery: update
on the ESCRS Endophthalmitis Study. J Cataract Refract Surg. 2014 Jan;40(1):138-42.
Beselga D, Campos A, Castro M, Fernandes C, Carvalheira F, Campos S, Mendes S, Neves A, Campos J,
Violante L, Sousa JC. Postcataract surgery endophthalmitis after introduction of the ESCRS protocol: a 5-year
study. Eur J Ophthalmol. 2014 Jun 23;24(4):516-9.
Behndig A, Cochener B, Gell JL, Kodjikian L, Mencucci R, Nuijts RM, Pleyer U, Rosen P, Szaflik JP, Tassignon
MJ. Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns in 9 European
countries. J Cataract Refract Surg. 2013 Sep;39(9):1421-31.
Garca-Senz MC,Arias-Puente A,Rodrguez-Caravaca G,Bauelos JB.Effectiveness of intracameral cefuroxime
in preventing endophthalmitis after cataract surgery Ten-year comparative study. J Cataract Refract Surg.
2010; 36(2):203-7.
Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M; ASCRS
Cataract Clinical Committee. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of
the 2007 ASCRS member survey. J Cataract Refract Surg. 2008; 34(4): 531-2; author reply 532-3.
Endophthalmitis ESCRS Study Group. Prophylaxis of postoperative endophthalmitis following cataract
surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg.
2007 Jun; 33(6):978-88.
Seal DV, Barry P, Gettinby G, Lees F, Peterson M, Revie CW, Wilhelmus KR, ESCRS Endophthalmitis Study
Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Case for a
European multicenter study. J Cataract Refract Surg. 2006; 32(3): 396-406. Erratum in: J Cataract Refract Surg.
2006; 32(5): 709.
Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, ESCRS Endophthalmitis Study Group. ESCRS
study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal
results from a European multicenter study. J Cataract Refract Surg. 2006; 32(3): 407-10. Erratum in: J Cataract
Refract Surg. 2006; 32(5): 709.
Bohigian,GM, Letter: ESCRS study of endophthalmitis prophylaxis Journal of Cataracts & Refractive Surgery,
2006; 32(9)1406-1407.
Peter Barry. Reply: ESCRS study of endophthalmitis prophylaxis Journal of Cataract & Refractive Surgery,
Volume 32, Issue 9, September 2006;32 (9)1407.
Endophthalmitis Organisms and Outcomes:
Chhablani J,Sudhalkar A,Jindal A,DasTaraprasad,Motukupally SR, Pathengay A,Flynn HW Jr.Stenotrophomonas
maltophilia Endogenous Endophthalmitis: Clinical Presentation,Antibiotic Suceptibility , and Outcomes. Clinical
Ophthalmology 2014:8 1523-1526.

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Kuriyan AE, Sridhar J, Flynn HW JR. et al. Endophthalmitis Caused by Enterococcus Faecalis:Clinical Features,
Antibiotic Sensitivities and Outcomes. Am J Ophthalmol 2014. Doi:10.1016/j.ajo.2014.07.038.
Kuriyan AE, Weiss KD, Flynn HW Jr., Smiddy WE et al. Endophthalmitis Caused by Streptococcal Species:
Clinical Settings, Microbiology, Management and Outcomes. Am J Ophthalmol 2014; 157: 774780.
Gentile RC, Shukla S, Shah M, Ritterband DC, Engelbert M, Davis A, Hu DN. Microbiological Spectrum and
Antibiotic Sensitivity in Endophthalmitis: A 25-Year Review. Ophthalmology. 2014 Aug;121(8):1634-42. doi:
10.1016/j.ophtha.2014.02.001
Khera M, Pathengay A, Jindal A, Jalali S, Mathai A, Reddy Pappuru R, Relhan N, Das S, Sharma S, Flynn HW
Jr. Vancomycin-Resistant Gram-Positive Bacterial Endophthalmitis: Epidemiology, Treatment Options, and
Outcomes. J Ophthalmic Inflamm Infect. 2013 Apr 22;3(1):46. doi: 10.1186/1869-5760-3-46.
Bispo PJ, Alfonso EC, Flynn HW Jr. and Miller D. Emerging 8-Methoxyfluoroquinolone Resistance Among
Methicillin-Susceptible Staphylococcus Epidermidis Isolates Recovered from Patients with Endophthalmitis. J.
Clin. Microbiol. 2013, 51(9): 2959-2963. doi: 10.1128/JCM.00846-13.
Rachitskaya A,Flynn HW Jr., Wong J, et al. A 10-Year Study of Membrane Filter System Versus Blood Culture
Bottles in Culturing Vitrectomy Cassette Vitreous in Infectious Endophthalmitis. Am J Ophthalmol. 2013; 156:
349-354.
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.
Miller DM,Vedula AS, Flynn HW Jr., Miller D, Scott IU, Smiddy WE, MurrayTG,Venkatraman A. Endophthalmitis
caused by Staphylococcus epidermidis. In Vitro Antibiotic Susceptibilities and Clinical Outcomes. Ophthalmic
Surg Lasers Imaging 2007; 38:446-451.
Yoder DM,Scott IU,Flynn HW Jr,Miller D. Endophthalmitis caused by Haemophilus influenzae. Ophthalmology
2004; 11: 2023-2036.
Miller JJ, Scott IU, Flynn HW Jr., et al. Endophthalmitis caused by Streptococcus pneumonia. Am J Ophthalmol
138: 231-236, 2004.
Scott IU, Loo RH, Flynn HW Jr, Miller D. Endophthalmitis caused by Enterococcus faecalis. Ophthalmology
110: 1573-1577, 2003.
Cohen SM, Flynn HW Jr, Miller D. Endophthalmitis caused by Serratia marcescens. Ophthalmic Surgery 28:
195-200, 1997.
Mao LK, Flynn HW Jr, Miller DA, Pflugfelder SC. Endophthalmitis caused by Staphylococcus aureus. Am J
Ophthalmol 116: 584-589, 1993.
Irvine WD, Flynn HW Jr, Miller DA, Pflugfelder SC. Endophthalmitis caused by gram-negative organisms. Arch.
Ophthalmol 110: 1450-1454, 1992.

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Mao LK, Flynn HW Jr, Miller D, Pflugfelder SC. Endophthalmitis caused by Streptococcal species. Arch
Ophthalmol 110: 798-801, 1992.
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.
Davis JL, Koidou A, Pflugfelder SC, Miller D, Flynn HW Jr, Forster RK. Coagulase-negative Staphylococcal
endophthalmitis. Ophthalmology 95: 1404-1410, 1988.
Chang JS, Flynn HW Jr., Miller D. et al. Stenotrophomonas maltophilia Endophthalmitis Following Cataract
Surgery: Clinical and Microbiological Results. Clinical Ophthalmology: 2013:7; 771-777.
Exogenous Fungal Endophthalmitis:
Vilela RC, Vilela L, Vilela P, Vilela R, Motta R, Pssa AP, de Almeida C, Mendoza L. Etiological agents of fungal
endophthalmitis: diagnosis and management. Int Ophthalmol. 2014 Jun;34(3):707-21.
Buchta V, Feuermannov A, Va M, Bakov L, Kutov R, Kubtov A, Vejsov M. Outbreak of fungal
endophthalmitis due to Fusarium oxysporum following cataract surgery. Mycopathologia. 2014 Feb;177(12):115-21.
Schwartz SG, Davis JL, Flynn HW Jr., Exogenous Endophthalmitis. In: Intraocular Inflammation, M Zierhut, S
Ohno, F Orefice, C Pavesio, NA Rao eds. New York: Springer, Avai 10-29-2013.
McMillan BD, Miller GJ, Nguyen J. Rare case of exogenous Candida dubliniensis endophthalmitis: a case report
and brief review of the literature. J Ophthalmic Inflamm Infect. 2014 May 2;4:11.
Wykoff CC, Flynn HW Jr., Scott IU, Alfonso EC. Exogenous Fungal Endophthalmitis: Microbiology and Clinical
Outcomes. Ophthalmology. 2008; 115(9): 1501-1507.
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 Candida endophthalmitis following cataract surgery. Ophthalmic
Surg Lasers Imaging 2007; 38: 278-385.
Callanan D, Scott IU, Murray TG, Oxford KW, Bowman CB, Flynn HW Jr. Early onset endophthalmitis caused
by Aspergillus species following cataract surgery. Am J Ophthalmol 2006; 142:509-511.
Hariprasad SM, Mieler WF, Holz ER, et al. Determination of vitreous, aqueous, and plasma concentration of
orally administered voriconazole in humans. Arch Ophthalmol 122:42-47, 2004.
Gao H, Pennesi ME, Shah K, et al. Intravitreal voriconazole. An electro- retinographic and histologic study. Arch
Ophthalmol 122: 1687-1692, 2004.

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Scott IU, Flynn HW Jr. Miller D, Speights JW, Snip RC, Brod RD. Exogenous endophthalmitis 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 cataract surgery: Clinical presentation,
microbiological spectrum and outcome. Am J Ophthalmol 132: 609-617, 2001.
Reis A, Sundmacher R,Tintelnot K, et al. Successful treatment of ocular invasive mold infection with voriconazole.
Br J Ophthalmol 84: 932-933, 2000.
Pflugfelder SC, Flynn HW Jr, Zwickey TA, et al. Exogenous fungal endophthalmitis. Ophthalmology 95: 1930,
1988.
Endophthalmitis / Trauma:
Jindal A, Pathengay A, Mithal K, Jalali S, Mathai A, Pappuru RR, Narayanan R, Chhablani J, Motukupally SR, Sharma
S, Das T, Flynn HW Jr. Endophthalmitis After Open Globe Injuries: Changes in Microbiological Spectrum and
Isolate Susceptibility Patterns Over 14 Years. Journal of Ophthalmic Inflammation and Infection 2014, 4:5.
http//www.joii-journal.com/content/4/1/5.
Long C, Liu B, Xu C, Jing Y,Yuan Z, Lin X. Causative organisms of post-traumatic endophthalmitis: a 20-year
retrospective study. BMC Ophthalmol. 2014 Mar 25;14:34.
AhmedY, Schimel AM, Pathengay A, Colyer MH, Flynn HW Jr., Endophthalmitis Following Open Globe Injuries.
EYE 2012:Vol 26 (2), 212-7. DOI: 10.1038/eye.2011.313.
Jacobs DJ, Grube TJ, Flynn HW Jr. et al. Inravitreal Moxifloxacin in the Management of Ochrobactrum
intermedium Endophthalmitis due to Metallic Intraocular Foreign Body. Clinical Mol Ophthalmol 2013:7;17271730.
Parke DW III, Pathengay A, Flynn HW Jr, Albini T. Risk factors for endophthalmitis and retinal detachment with
retained intraocular foreign bodies. J Ophthalmol 2012 (2012) 758526. doi:10.1155/2012/758526.
Andreoli MT, Andreoli CM. Surgical rehabilitation of the open globe injury patient Am J Ophthalmol. 2012
May; 153(5):856-60.
Cebulla CM, Flynn HW Jr., Endophthalmitis after Open Globe Injuries. (Editorial). Am J Ophthalmol 2009;
147: 567-568.
Lieb DF, Scott IU, Flynn HW Jr. et al. Open globe injuries with positive intraocular cultures. Factors influencing
final visual acuity outcomes. Ophthalmology 110: 1560-1566, 2003.
Reynolds DG, Flynn HW Jr. Endophthalmitis after penetrating ocular trauma. Current Opinion in Ophthalmology;
8: 32-38, 1997.
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treatment of Bacillus cereus endophthalmitis. Ophthalmology 103: 390-397, 1996.
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Thompson WS, Rubsamen PE, Flynn HW Jr, Schiffman J, Cousins SW. Endophthalmitis following penetrating
trauma: Risk factors and visual acuity outcomes. Ophthalmology 102: 1696-1701, 1995.
Ariyasu RG, Kumar S, La Bree LD, Wagner DG, Smith RE. Microorganisms cultured from the anterior chamber
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ocular injuries with retained intraocular foreign bodies. Ophthalmology 100: 1468-1474, 1993.
Yoshizumi MO, Leinwand MJ, Kim J.Topical and intravenous gentamicin in traumatically lacerated eye. Graefe
Arch Clin Exp Ophthalmol 230: 175-177, 1992.
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110: 683-687,1990.
Mieler WF, Ellis MK, Williams DF, Han DP. Retained intraocular foreign bodies and endophthalmitis.
Ophthalmology 97: 1532-1538, 1990.
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1989.
Williams DR, Mieler WF, Abrams GW, Lewis H. Results and prognostic factors in penetrating ocular injuries
with retained intraocular foreign bodies. Ophthalmology 95: 911-916, 1988.
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from ocular trauma. Ophthalmology 94: 407-413, 1987.
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Arch Ophthalmol 102: 547-550, 1984.
Barr CC. Prognosis factors in corneoscleral lacerations. Arch Ophthalmol 101: 919-924, 1983.
Delayed-onset Pseudophakic Endophthalmitis:
Javey G, Albini TA, Flynn HW Jr. Resolution of Pigmented Keratic Precipitates Following Treatment of
Pseudophakic Endophthalmitis Caused by Propionibacterium Acnes. Ophthalmic Surg Lasers Imaging. 2010
Mar 9:1-3.
Shirodkar AR, Pathengay A, Flynn HW Jr, et al. Delayed vs. Acute-Onset Endophthalmitis after Cataract
Surgery. Am J Ophthalmol. 2012 Mar; 153(3):391-398.e2.
Al-Mezaine HS, Al-Assiri A, Al-Rajhi AA. Incidence, clinical features, causative organisms, and visual outcomes
of delayed-onset pseudophakic endophthalmitis. Eur J Ophthalmol. 2009 Sep-Oct;19(5):804-11.

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

Chaudhry N, Flynn HW Jr, Smiddy WE, Miller D. Xanthomonas maltophilia endophthalmitis after cataract
surgery. Arch Ophthalmol 118: 572-575, 2000.
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P. acnes endophthalmitis. Ophthalmology 106: 1665-1670, 1999.
Aldave AJ. Stein JD, Deramo VA et al. Treatment strategies for postoperative P. acnes endophthalmitis.
Ophthalmology 1999; 106: 2395-401.
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Retina 17: 260-262, 1997.
Winward KE,Pflugfelder SC,Flynn HW Jr,RousellTJ,Davis JL. Postoperative Propionibacterium Endophthalmitis.
Treatment strategies and long-term results. Ophthalmology 100:447-451, 1993.
Owens SL, Lam S, Tessler HH, Deutsch TA: Preliminary study of a new intraocular method in the diagnosis
and treatment of P. acnes endophthalmitis. Ophthalmic Surgery 24: 268-72, 1993.
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parapsilosis endophthalmitis, clinical findings and management of 15 consecutive cases. Ophthalmology 92:
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Delayed-onset Endophthalmitis Associated With Filtering Blebs / Blebitis:
Brillat-Zaratzian E, Bron A, Aptel F, Romanet JP, Cornut PL, Vandenesch F, Boisset S, Maurin M, Chiquet C.
FRIENDS Group: clinical and microbiological characteristics of post-filtering surgery endophthalmitis. Graefes
Arch Clin Exp Ophthalmol. 2014 Jan;252(1):101-7.
Jacobs DJ, Pathengay A, Flynn HW Jr., Leng T, Miller D, and Shi W. Intravitreal Dexamethasone in the Management
of Delayed-Onset Bleb-Associated Endophthalmitis, International Journal of Inflammation, vol. 2012, Article
ID 503912, 5 pages, 2012.
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Outcome by Culture Result. Clinical Ophthalmology 2011; 5: 1-6.

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Leng T, Miller D, Flynn HW Jr, Jacobs DJ, Gedde SJ. Delayed-Onset Bleb-Associated Endophthalmitis (19962008); Causative Organisms and Visual Acuity Outcomes. Retina 31:344-352, 2011.
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109:985-991, 2002.
Kangas TA, Greenfield DS, Flynn HW Jr. Delayed onset endophthalmitis associated with conjunctival filtering
blebs. Ophthalmology 104: 746-752, 1997.
Phillips WB, Wong TP, Berger RL, Friedberg MA, Benson WE. Late-onset endophthalmitis associated with
filtering blebs. Ophthal. Surg 25: 88-91, 1994.
Brown RH, Yang LH, Walker SD et al. Treatment of bleb infection after glaucoma surgery. Arch Ophthalmol
112: 57-61, 1994.
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trabeculectomy with adjunctive 5-fluorouracil. Ophthalmology 98: 1053-1060, 1991.
Mandelbaum S. Forster RK, Gelender H, Culbertson W. Late onset endophthalmitis associated with filtering
blebs. Ophthalmology 92: 964-972, 1985.
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following glaucoma filtering surgery. Ophthlamology 92: 959-963, 1985.
Endophthalmitis Associated with Glaucoma Drainage Devices:
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.
Stewart MW, Bolling JP, Bendel RE. Nocardia brasiliensis endophthalmitis in a patient with an exposed Ahmed
glaucoma drainage implant. Ocul Immunol Inflamm. 2013;21(1):69-70.
Ahmed Y, Pathengay A, Flynn HW Jr, et al. Delayed-Onset Endophthalmitis Associated with Ex-PRESS Mini
Glaucoma Shunt. Ophthalmic Surgery Lasers & Imaging 2012; 43: e62-e63. doi: 10.3928/1542887720120705-01.
Endogenous Endophthalmitis:
Sridhar J, Flynn HW Jr, Kuriyan AE, Dubovy S, Miller D. Endophthalmitis caused by Klebsiella species. Retina.
2014. Epub ahead of print.
Adam CR, Sigler EJ. Multimodal Imaging Findings in Endogenous Aspergillus Endophthalmitis. Retina. 2014 Apr
1. Epub ahead of print.
Wu Z, Huang J, Huynh S, Sadda S. Bilateral endogenous endophthalmitis secondary to group B streptococcal
sepsis. Chin Med J (Engl). 2014 May;127(10):1999.
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Sridhar J, Flynn HW Jr., Kuriyan AE et al. Endogenous Fungal Endophthalmitis: Risk Factors, Clinical Features,
and Treatment Outcomes in Mold and Yeast Infections. Journal of Ophthalmic Inflammation and Infection
2013, 3:60. http://www.joii-journal.con/content/3/1/60.
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Organisms, Management Strategies and Visual Acuity Outcomes. Am J Ophthalmol 2012: 153; 162166.
Schiedler V, Scott IU, Flynn HW Jr et al. Culture-proven endogenous endophthalmitis: clinical features and
visual acuity outcomes. Am J Ophthalmol 137: 725-731, 2004.
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Harris EW, DAmico DJ, Bhisitkul R. et al. Bacterial subretinal abscess: A case report and review of the
literature. Am J. Ophthalmol. 129: 778-785, 2000.
Brod RD, Flynn HW Jr, Miller D. Endogenous fungal endophthalmitis. In Tasman W, Jaeger E. (eds.) Duanes
Clinical Ophthalmology CV Mosby, St. Louis, Chapter 11, Vol 3: 2000, 1-40.
Gupta A, Gupta V, Dogna MR et al. Fungal endophthalmitis after a single intravenous 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: 14831491, 2000.
Weishaar PD, Flynn HW Jr, Murray TG, et. al. Endogenous Aspergillus Endophthalmitis: Clinical Features and
treatment outcomes. Ophthalmology 105: 57-65, 1998.
Essman TF, Flynn HW Jr, Smiddy WE, Brod RD, Murray TG, Davis JL, Rubsamen PE. Endogenous fungal
endophthalmitis: Treatment outcomes in a ten-year study. Ophthalmic Surgery 28: 185-194, 1997.
Okada AA, Johnson RP, Liles C, DAmico DJ, Baker AS. Endogenous bacterial endophthalmitis. Ophthalmol
101: 832-838, 1994.
Menezes AV, Sigesmund DA, Demajo WA, Devenyi RG. Mortality of hospitalized patients with Candida
endophthalmitis. Arch Intern Med. 154: 2093-7, 1994.
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Ophthalmol 31: 81-101, 1986.

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Experimental Endophthalmitis:
Chio S, Hahn TW, Osterhout G, OBrien TP. Comparative intravitreal antibiotic therapy for experimental
Enterococcus faecalis endophthalmitis. Arch Ophthalmol 114: 61-65, 1996.
Alfaro DV, Hudson SJ, Rafanan MM et. al. The effect of trauma on the ocular penetration of intravenous
ciprofloxacin. Am J Ophthalmol 122: 678-683, 1996.
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administration. Am J Ophthalmol 122: 684-689, 1996.
Meredith TA, Aguilar HE, Shaarawy A, et al. Vancomycin levels in the vitreous cavity 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.
Stern GA: Factors affecting the efficacy of antibiotics in the treatment of experimental postoperative
endophthalmitis. Trans Am Ophthalmol Soc. 91: 775, 1993.
Forster, RK. Experimental postoperative endophthalmitis. Tr. Am Ophth Soc.Vol 90, 505-559. 1992.
MeredithTA,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, DAmico DJ,Talamo JH, CaseyVJ, Kenyon KR.The role of vitrectomy in the treatment of postoperative
bacterial endophthalmitis. An experimental study. Arch Ophthalmol 105: 1699-1702;, 1987.
Early Large Clinical Series:
Phillips WB,Tasman WS. Postoperative endophthalmitis in association with diabetes mellitus. Ophthalmology
101: 508-518, 1994.
Stonecipher KG, Ainbinder DI, Maxwell DP, Diamond JG, Caldwell DR. Infectious endophthalmitis: A review
of 100 cases. Ann Ophthalmol Glaucoma 26: 108-115, 1994.
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332-334, 1986.
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1055-1066, 1982.

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Diamond JG. Intraocular management of endophthalmitis. Arch Ophthalmol 99: 96-99, 1981.
Endophthalmitis Treatment with Intravitreal / Periocular / Systemic Steroids:
Roth DB, Modi KK Scott IU, Flynn HW Jr., Update on the Use of Intraocular Steroids for Posterior-Segment
Diseases. More Choices Exist than Ever Before, but Complications Persist as Well. Retinal Physician 2013 Vol
10, No 7; 49-53, 62-63.
Jacobs DJ, Pathengay A, Flynn HW Jr., Intravitreal Dexamethasone in the Management of Delayed-Onset
Bleb-Associated Endophthalmitis, International Journal of Inflammation, vol. 2012 doi:10.1155/2012/503912.
Liu SM, Way T, Rodrigues M, Scott M, Steidl, SM. Effects of Intravitreal corticosteroids in the treatment of
Bacillus cereus endophthalmitis. Ophthalmol 118: 803-806.2011.
Harris MJ. Visual outcome after intravitreal steroid use for postoperative endophthalmitis. Ophthalmology
108: 240-241, 2001.
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following the use of intravitreal steroids in the treatment of postoperative endophthalmitis. Ophthalmology;
107: 486-489. 2000.
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endophthalmitis: results of a prospective randomized study. Br J Ophthalmol 83: 1050-1055, 1999.
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aureus endophthalmitis. Retina 18: 130-135, 1998.
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concentration after dexamethasone disodium phosphate injection. Am J Ophthalmol 123: 358-363, 1997.
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dexamethasone. Arch Ophthalmol. 91: 416-418, 1974.

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Miscellaneous:
Townsend J, Pathengay A, Flynn HW Jr., Miller D. Management of Endophthalmitis While Preserving the
Uninvolved Crystalline Lens. Clinical Ophthalmology 2012: 6; 453-457.
Nguyen JK, Fung AE, Flynn HW Jr, Scott IU. Hypopyon and pseudoendophthalmitis associated with chronic
vitreous hemorrhage. Ophthalmic Surg Lasers Imaging 37: 317-319, 2006.
Sulkes DJ, Flynn HW Jr, Scott IU, Feuer WJ, Christmas J. Evaluating outpatient versus inpatient costs in
endophthalmitis management. Retina 22: 747-751, 2002.
Jones DB. Emerging antibiotic resistance: real and relative. Arch Ophthalmol 114: 91-92, 1996.
Kim JE, Flynn HW Jr, Rubsamen PE, Murray TG, Davis JL, Smiddy WE. Endophthalmitis in patients with
retained lens fragments after phacoemulsification. Ophthalmology 103: 575-578, 1996.
Scott IU, Flynn HW Jr, Feuer W. Endophthalmitis after secondary IOL implantation: a case/control study.
Ophthalmology 102; 1925-1931, 1995.
Foster RE, Rubsamen PE, Joondeph BC, Flynn HW, Smiddy WS: Concurrent endophthalmitis and retinal
detachment. Ophthalmology 101:490-498, 1994.
Ormerod LD, Puklin JE, McHenry JG, McDermott ML. Scleral flap necrosis and infectious endophthalmitis
after cataract surgery with a scleral tunnel incision. Ophthalmology 100: 159-163, 1993.
Monson MC, Mamalis N, Olson RJ,Toxic anterior segment inflammation following cataract surgery. J. Cataract
Refract Surg. 18; 184-189, 1992.
Irvine WD, Flynn HW Jr, Murray TG, Rubsamen PE. Retained lens fragments after
phacoemulsification manifesting as marked intraocular inflammation with hypopyon. Am J Ophthalmol 114:
610-614, 1992.
Huang S, Brod R, Flynn HW Jr. Endophthalmitis management while preserving the uninvolved crystalline lens.
Am J Ophthalmol 112: 695-701, 1991.
Stonecipher KG, Parmley VC, Jensen H, Rowsey JJ. Infectious endophthalmitis following sutureless cataract
surgery. Arch Ophthalmol 109: 1562-1563, 1991.
TASS:
Arslan OS, Tunc Z, Ucar D, Seckin I, Cicik E, Kalem H, Sencan S, Hepokur M. Histologic Findings of Corneal
Buttons in Decompensated Corneas WithToxic Anterior Segment Syndrome After Cataract Surgery. Cornea.
October 2013 - Volume 32 - Issue 10 - p 13871390 doi: 10.1097/ICO.0b013e3182a0d030

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Gottsch JD, Schein OD.Taking TASS to Task. Ophthalmol 2012: 119; 7, 1295-1296.
Eydelman MB, Tarver ME, Calogero D, et al. The Food and Drug Administrations Proactive Toxic Anterior
Segment Syndrome Program. Ophthalmol 2012: 119; 7, 1297-1302.
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American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Registered
Nurses. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract
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Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L.Toxic anterior segment syndrome. J
Cataract Refractive Surg 2006; 32: 324-333.
Mamalis N.Toxic anterior segment syndrome [Editorial]. J Cataract Refract Surg 2006; 32: 181-182.
The Endophthalmitis Vitrectomy Study:
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Ophthalmol 119: 650-656, 2001.
Sternberg P, Martin DF. Management of endophthalmitis in the Post-Endophthalmitis Vitrectomy Study Era.
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patients screened for the EVS. Ophthalmology 107: 1274-1282, 2000.
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Ophthalmol 118: 1661-1665, 2000.
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or tap-biopsy in the EVS. Ophthalmology 105: 707-716, 1998.
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-negative staphylococci in the
Endophthalmitis Vitrectomy Study: A comparison of eyelid and intraocular isolates using pulsed-field gel
electrophoresis. Arch Ophthalmol 115: 357-361, 1997.
Wisniewski SR, Hammer ME, Grizzard WS, et al. An investigation of the hospital charges related to the
treatment of endophthalmitis in the EVS. Ophthalmology 104: 739-745, 1997.
Barza M, Han DP, Doft BH and the EVS Study Group. Microbiological factors and visual outcome in the EVS.
(Letter to Editor). Am J Ophthalmol 124: 127-130, 1997.
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Barza M, Paven PR, Doft BH et al. Evaluation of microbiology diagnostic techniques in postoperative
endophthalmitis in the EVS. Arch Ophthalmol 115: 1142-1150, 1997.
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susceptibilities of microbiologic isolates in the EVS. Am J Ophthalmol 122: 1-17, 1996.
Flynn HW Jr, Meredith TA. Interpreting the results of the EVS (Letter to Editor) Arch Ophthalmol 114: 10278, 1996.
Peyman GA. EVS, a different point of view. (Editorial) Arch de la Sociedad Espanola de Oftalmologia 3: 205207, 1996.
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Doft BH. The Endophthalmitis Vitrectomy Study. Arch Ophthalmol 109: 487-489, 1991.
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118: 939-944, 2000.
Rosenbaum AL (editorial) Endophthalmitis after strabismus surgery. Arch Ophthalmol 118: 982-983, 2000.
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surgery. J. Pediatric Ophthalmol Strabismus 32: 42-49, 1995.
Thomas JW, Hamill MB, Lambert HM, Streptococcus pneumoniae endophthalmitis following strabismus
surgery. Arch Ophthalmol 111: 1170-1171, 1993.
Compatibility of Intraocular Antibiotics:
Jindal A, Pathengay A, Khera M, Jalali S, Mathai Annie, Pappuru RR, Narayanan R, Sharma S, Das T and Flynn
HW Jr., Combined Ceftazidime and Amikacin Resistance Among Gram-Negative Isolates in Acute-Onset
Posoperative Endophthalmitis: Prevalence, Antimicrobial Susceptibilities, and Visual Acuity Outcome. Journal
of Ophthalmic Inflammation and Infection 2013, 3:62. http://www.joii-journal.com/content/3/1/62.

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Eifrig CWG, Scott IU, Flynn HW, Jr, Smiddy WE, Newton J. Endophthalmitis after pars plana vitrectomy:
incidence, causative organisms, and visual acuity outcomes. Am J Ophthalmol 138: 799-802, 2004.
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Endophthalmitis after pars plana vitrectomy. Ophthalmology 102: 705-712, 1995.
Kaiser RS, Prenner J, Scott IU, Brucker AJ, Flynn HW Jr., et al. The Microsurgical Safety Task Force: Evolving
guidelines for minimizing the risk of endophthalmitis associated with microincisional vitrectomy surgery.
Retina 2010 April; 30(4): 692-699.
Foster RE, Rubsamen PE, Joondeph BC, Flynn HW Jr., Smiddy WE. Concurrent Endophthalmitis and Retinal
Detachment. Ophthalmology 1994; 101: 4

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