POSTTRAUMATIC ENDOPHTHALMITIS

An 18-Year Case Series

XINTONG LI, MD, MARCO A. ZARBIN, MD, PHD, PAUL D. LANGER, MD,
NEELAKSHI BHAGAT, MD

Purpose: To describe the demographics, characteristics, management, and visual

outcomes of eyes diagnosed with endophthalmitis after open globe injury.
Methods: Retrospective cohort analysis of all patients diagnosed with endophthalmitis
after open globe injury from 1997 to 2015 at University Hospital, Newark, NJ.
Results: Twenty-six eyes were identied (all male patients; mean age: 37 15 years).
Cultures were positive in 16 eyes (62%), with Staphylococcus species (7 eyes, 44%) being
the most common organism. Twelve eyes (46%) presented with open globe injury and
concurrent endophthalmitis; 14 eyes (54%) developed endophthalmitis a mean of 14 days
after open globe repair (OGR; 1 outlier of 98 days excluded). All eyes were managed with
systemic and intravitreal antibiotics. The presence of intraocular foreign body (P , 0.05)
and delayed primary OGR (P , 0.03) were signicantly more common with concurrent
versus post-OGR endophthalmitis. Four (29%) eyes in the post-OGR endophthalmitis
group had corneal wound leak after OGR. Four (15%) eyes with no light perception vision
were enucleated. Ten (40%) of 25 eyes with documented best-corrected visual acuity had
nal best-corrected visual acuity $20/200; nal best-corrected visual acuity ranged from
no light perception to 20/20.
Conclusion: The presence of intraocular foreign body and delayed presentation were
signicantly more common with concurrent endophthalmitis. Twenty-nine percent of eyes
that presented with endophthalmitis after OGR had a wound leak. Final best-corrected
visual acuity $20/200 was achieved in 40% of cases.
RETINA 0:112, 2017

P osttraumatic endophthalmitis accounts one-fth to

one-third of all cases of endophthalmitis14 and has
been observed in 2% to 7% of open globe injuries
microbiology of cultured organisms, as well as surgi-
cal complications and prognosis of these eyes.

(OGIs) worldwide in recent years.58 The present

study was conducted to elucidate characteristics of
eyes diagnosed with endophthalmitis either at presen-
tation concurrently with OGI or after primary globe
closure in our urban teaching hospital. We describe
patient demographics and the initial OGI characteris-
tics at presentation, risk factors of endophthalmitis,
From the Department of Ophthalmology, Institute of Ophthalmol-
ogy and Visual Science, Rutgers New Jersey Medical School,
Newark, New Jersey.
Selections from this material have been presented at the Macula
Society Annual Meeting in Fort Lauderdale, FL, February 26, 2016
and at the Association for Research in Vision and Ophthalmology
Annual Meeting in Seattle, WA, May 3, 2016.
None of the authors has any nancial/conicting interests to
disclose.
Reprint requests: Neelakshi Bhagat, MD, Department of Oph-
thalmology, Doctors Ofce Center, Suite 6100, 90 Bergen Street,
Newark, NJ 07103; e-mail: bhagatne@njms.rutgers.edu
Methods
The medical records of 26 eyes of 26 consecutive
patients diagnosed with endophthalmitis after open
globe trauma between July 1997 and April 2015
at University Hospital, a Level I trauma center in
Newark, NJ, United States, were retrospectively
reviewed, including eyes that underwent open globe
repair (OGR) at our institution or elsewhere. Eyes with
a suspected nontraumatic etiology of endophthalmitis,
such as postoperative or endogenous, were excluded.
An OGI was dened based on the clinical or intra-
operative observation of a full-thickness defect of the
globe, and was classied according to standardized
terminology developed by the Ocular Trauma Classi-
cation System.9 Briey, Zone 1 is classied as full
thickness defect restricted to the cornea including the

Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
2 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2017  VOLUME 0  NUMBER 0
limbus, Zone 2 as involving the anterior 5 mm of
sclera, and Zone 3 as involving any structure posterior
to Zone 2. The ocular trauma score10 was devised as
a visual prognostic tool, with initial vision and pres-
ence of rupture, endophthalmitis, perforating injury,
retinal detachment (RD), and/or afferent pupillary
defect contributing to a raw points sum that is then
scored as 1 to 5 on the visual acuity severity scale.
Eyes scoring a 5 have the best visual prognosis,
whereas eyes scoring a 1 have a high chance of NLP
and extremely poor nal visual acuities.10
In our series, cases were classied into endophthal-
mitis diagnosed at presentation concurrently with an
open globe (trauma-induced; termed concurrent en-
dophthalmitis) and eyes diagnosed with endophthal-
mitis at some point after OGR (termed post-OGR
endophthalmitis). Variables assessed clinically and
intraoperatively included age, race, gender, injury date,
injury mechanism, trauma classication, visual acuity
at presentation and immediately after OGR, date of
endophthalmitis diagnosis and symptom onset, duration
of hospitalization, ocular examination, antibiotic
administration, dates and types of surgeries performed,
surgical complications, culture results, and initial and
postmanagement visual acuity. Ocular examination
variables included afferent pupillary defect, lens status,
uveal prolapse, retinal detachment, vitreous hemor-
rhage, choroidal detachment, injury zone, wound size,
intraocular foreign body (IOFB), endophthalmitis, and
sympathetic ophthalmia.
Statistical analysis was performed using Microsoft
Excel and SPSS version 21.0 (IBM Corp, Armonk,
NY). Tests used included z-ratios to compare inde-
pendent proportions, Fishers exact test, and the
students t-test. P values less than 0.05 were consid-
ered signicant. For eyes with visual acuity better
than or equal to 20/800, logarithm of the minimal
angle of resolution units were used for statistical anal-
ysis. If visual acuity was worse than 20/800, loga-
rithm of the minimal angle of resolution units were
designated as follows: counting ngers (CF) = 1.6,
hand motion = 2.0, light perception = 2.5, and NLP =
3.0.11 Outcomes are reported in Snellen equivalents
of the logarithm of the minimal angle of resolution
values. Initial visual acuity was dened as visual acu-
ity at presentation with endophthalmitis, whereas nal
best-corrected visual acuity (BCVA) was measured at
the last follow-up visit. Final BCVA $ 20/200 is
termed good visual outcome, and BCVA , 20/200
is termed poor. Cases with missing variables were
excluded from analysis of that variable.
Approval was obtained from the Rutgers Health
Sciences Newark Campus Institutional Review Board
before data collection and analysis.
Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
Results
Twenty-six eyes of 26 patients were diagnosed
with posttraumatic endophthalmitis at University
Hospital during the specied period (Table 1), all
secondary to OGIs. All patients were male, and the
average age at diagnosis was 37 15 years. At
presentation, the mean ocular trauma score was
1.94 0.68 (range: 13). All patients underwent
either B-scan testing or computerized tomography
imaging to evaluate for IOFB. Intraocular foreign
body was noted in 10 of 26 eyes (38%). All patients
were treated with intravenous antibiotics at presen-
tation. The most common combination used was
vancomycin and ceftazidime. Antifungals (amphoter-
icin or voriconazole) were added in three suspicious
cases.
Specic data on injury characteristics of eyes with
concurrent (n = 12 eyes) versus post-OGR endophthal-
mitis (n = 14 eyes) are reported in Table 1 and sum-
marized in Table 2. The results of the two groups are
described separately below.
Endophthalmitis Concurrent With Open
Globe Injury
Twelve eyes (46%) presented with endophthalmi-
tis and OGI concurrently, and their characteristics
are detailed in Table 1. Detailed injury character-
istics were available for 11 of 12 eyes. Delayed
presentation after 24 hours of injury was seen in
67% of eyes, ranging from 1 day to 6 days, with
a mean of 2.6 days. Seventeen percent of patients
gave a history of wound contamination with organic
matter.
Primary OGR was performed within 24 hours of
presentation at our institution in all cases (Figure 1).
Seven of 11 (64%) eyes for whom we had records for
type of injury were diagnosed with an IOFB (Figures 2
and 3 and Table 3) and included 7 metal, 1 glass-like,
1 wood, and 1 unknown; all except 3 (plus 1
unknown) were in the posterior segment. All 7 eyes
underwent pars plana vitrectomy (PPV) and IOFB
removal or attempted removal emergently within 24
hours of presentation. Four of 7 eyes had IOFB re-
tained for more than 48 hours before presenting to
our institution. In one eye, the IOFB could not be
removed from the vitreous cavity due to extreme poor
visualization of the posterior segment secondary to
intense vitritis and vitreous membranes associated
with endophthalmitis.
Nine of 10 eyes presented with visual acuity of CF or
worse; the remaining eye had a visual acuity of 20/40.
Pars plana vitrectomy and intravitreal antibiotic
Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.

Table 1. Management and Characteristics of Initial Injury and Endophthalmitis by Case

Injury Endophthalmitis
Days:
Injury to Length of IV
Primary Antibiotics, Presenting # Re- # Re-
Case# Age Race Sex Mechanism OGI Type Zone Repair Days BCVA Cultures operations injections Final BCVA
1* 24 B M Wood piece ew IOFB 1 Unknown 5 HM Bacillus sp., Escherichia 1 HM
into eye from vulneris
grass-cutting
machinery
2 50 B M Cornea lacerated by Penetrating 1 5 5 HM Staphylococcus aureus; LP
light bulb cornea: Aspergillus
fragments fuminatum
Metal ew into eye

POSTTRAUMATIC ENDOPHTHALMITIS  LI ET AL
3* 41 W M IOFB 1 2 6 CF 29 Negative 1 20/50
at work
4 36 H M Fragment ew into IOFB 1 1 5 20/40 Negative 20/50
eye while cutting
metal; removed
by patient with
a magnet
5 40 H M Metal ew into eye IOFB 1 5 6 CF 39 Negative 1 1 20/400
at work
6 57 H M Nail bounced from IOFB 1 0 7 CF 19 Negative 20/200
nail gun
7 28 W M Assault with glass Penetrating 1 4 3 CF Streptococcus morbillum 20/150
bottle
8 36 W M Penetrating 1 Unknown 6 Negative 20/100
9 43 B M Metal ew into eye IOFB 1 6 3 CF Negative 1 CF 39
while hammering
toilet
10 24 W M Motor vehicle IOFB 3 0 8 HM Staphylococcus HM
accident: struck epidermidis
face on
windshield
11* 9 W M Hit rock with IOFB 1 0 19 NLP Bacillus sp. 3 (Enucleated)
hammer while
playing in
sandbox; piece of
rock ew into eye
12 10 W M Penetrating 1 Unknown Unknown Bacillus cereus 1 20/80
13 54 H M Unspecied foreign IOFB 2 Unknown 11 LP Streptococcus 1 3 NLP
body pneumoniae,
Streptococcus
lugdunensis, Aspergillus
fuminatus
14 36 H M Nail went in eye Penetrating 1 4 9 HM Staphylococcus 2 2 HM
while hammering epidermidis

(continued on next page)

3
Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.

Table 1. (Continued )

4
Injury Endophthalmitis
Days:

RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2017  VOLUME 0  NUMBER 0
Injury to Length of IV
Primary Antibiotics, Presenting # Re- # Re-
Case# Age Race Sex Mechanism OGI Type Zone Repair Days BCVA Cultures operations injections Final BCVA
15 27 W M Wire went into eye Penetrating 1,2 0 2 CF 69 Staphylococcus hominis, Unknown
while shaking Propionibacterium acnes
a wire over pipe
16 60 W M Foreign body while Rupture 2 0 8 LP Staphylococcus 1 2 20/20
operating staple epidermidis
gun
17 48 H M Nail from nail gun Penetrating 1 0 6 HM Negative 20/20
ew into eye
18 26 W M Foreign body while Penetrating 2 0 8 HM Negative 20/80
hammering a nail
on a tree stump
19 28 H M Injury from broken Unknown 1 Unknown 6 HM Streptococcus sanguinis, CF
windshield wiper Streptococcus viridans
20 47 B M Struck with Penetrating 1,2 0 7 Candida sp. 2 CF
unknown object
that fell from
garbage truck
21 60 W M Twig poked eye IOFB 1 0 11 LP Rhodotorula mucilaginosa HM
22 59 W M Nail from nail gun IOFB 1 0 5 CF 39 Staphylococcus 2 CF
ew into eye epidermidis
23 20 A M Wires penetrated Penetrating 1 0 10 NLP Negative Primarily
eye at work enucleated
24* 39 H M Nail went into eye Penetrating 1 0 10 LP Bacillus sp., fungal hyphae 1 Enucleated
while hammering on silver stain
25 20 H M Nail injury Penetrating 1 None 1 CF 39 None 1 20/100
26 40 H M Nail ricocheted and Penetrating 2 0 7 Coagulase-negative 1 2 Enucleated
ew into eye Staphylococcus sp.
Cases 1-12 are cases of concurrent endophthalmitis (in which case the management of the initial injury and endophthalmitis occurred during the same admission), whereas cases
13-26 represent post-OGR endophthalmitis. All cultures were taken from the vitreous unless noted. Reoperation and reinjection indicate the number of operations or intravitreous
injections required after the initial operation or injection after diagnosis of endophthalmitis.
*Eye presented with retinal detachment when seen for the initial injury.
Wound contaminated with organic matter.
Eye developed retinal detachment after the initial injury.
Wound leak seen after primary globe repair.
A, Asian; B, black; BCVA, best-corrected visual acuity; CF, count ngers; H, Hispanic; HM, hand motion; IOFB, intraocular foreign body; IV, intravenous; M, male; NLP, no light
perception; OGI, open globe injury; OGR, open globe repair; W, white.
 POSTTRAUMATIC ENDOPHTHALMITIS  LI ET AL 5

Table 2. Summary of Characteristics of Eyes With Concurrent or Post-OGR Endophthalmitis After Open Globe Injury
Concurrent Endophthalmitis Post-OGR Endophthalmitis
Number of eyes (%) 12 (46.2) 14 (53.8)
Injury characteristics
Mean duration: injury to primary 2.6 days (n = 9,* range: 06) ,1 day (n = 10,* range: 04)
repair
Organic wound contamination, n (%) 2/11 (18.2) 2/12 (16.7)
Wound location Zone 1: 11/12 (91.7%); Zone 3: 1/12 Zone 1: 8/14 (57.1%); Zone 2: 6/14
(8.3%) (42.9%)
Mechanism of injury Machinery/mechanical work: 7/10 Machinery/mechanical work: 10/13
(70.0%) (76.9%)
Type of injury IOFB: 7/11 (63.6%) Penetrating: 4/11 (36.4%)
Penetrating: 9/13 (69.2%) IOFB: 3/13 (23.1%)
Rupture: 1/13 (7.7%)
Mean duration: injury to IOFB 3.0 days (n = 7, range: 06) 2.5 days (n = 2, range: 05)
removal
Tissue prolapse 5/11 (45.5%) 7/12 (58.3%)
Aphakic 1/11 (9.1%) 2/12 (16.7%)
Mean wound length, mm 3.5 (n = 10, range: 19) 2.3 (n = 6, range: 110)
Endophthalmitis characteristics
Visual acuity at presentation 20/1,074 (n = 10) 20/2,825 (n = 12)
Mean duration: OGI repair to 22.5 days (n = 10, range: 198)
endophthalmitis diagnosis
Mean duration: symptom onset to 2.5 days (n = 13, range: 07)
presentation
Presenting complaint, n (%) Increased pain: 9/14 (64.3);
Decreased vision: 9/14 (64.3)
Predominant organism of culture- Bacillus sp.: 3/6 (50.0) Staphylococcus sp.: 6/10 (60.0)
positive cases, n (%)
Mean duration of intravenous 4.0 3.1 7.0 3.7
antibiotics, Days
PPV, n (%) 12 (100) 12 (85.7)
Intravitreal antibiotics 12 (100%); 1 eye with re-injection(s) 13 (92.8%); 4 eyes with re-injection
(8.3%) (s) (30.8%)
Enucleated, n (%) 1 (8.3) 3 (21.4)
Final BCVA 20/463 20/1,003 (n = 13)
*Not all eyes had data for each cell. Thus, the denominator is not always equal to 12 (concurrent endophthalmitis) or 14 (post-OGR
endophthalmitis).
BCVA, best corrected visual acuity; IOFB, intraocular foreign body; OGR, open globe repair; PPV, pars plana vitrectomy.

injections were done within 24 hours in 11 of 12 eyes vitritis but minimal hypopyon on presentation post-
with concurrent endophthalmitis. The one eye that did OGI, was diagnosed as early subclinical endophthal-
not receive intravitreal antibiotics had no obvious mitis, and was treated with intravenous and fortied

Fig. 1. Delay from injury to primary repair in eyes with concurrent Fig. 2. Presence of intraocular foreign body in eyes with concurrent
versus post-OGR endophthalmitis; OGR, open globe repair. versus post-OGR endophthalmitis; OGR, open globe repair.

Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
6 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2017  VOLUME 0  NUMBER 0

Fig. 3. A. B-scan ultrasound of

an eye with posttraumatic en-
dophthalmitis; A-scan shows an
intraocular foreign body as
a hyperintense area with high
reectivity (arrow). B. A
metallic nail measuring a total of
6.5 mm was later removed from
this eye.

topical antibiotics along with PPV and posterior IOFB comycin and ceftazidime. All eyes that underwent con-
removal (Case #6). No eyes in this group were primar- rmed intravitreal injection received vancomycin and
ily enucleated. All eyes, with and without IOFB, ceftazidime; one received amphotericin B for organic
received intravenous antibiotics; 8 (33%) received van- wound contamination and fungal coverage.

Table 3. Details of Eyes That Presented With or Without an IOFB

Injury Endophthalmitis
Days: Injury
Presence IOFB IOFB to Primary Days: Injury
Case# of IOFB Material Location Repair to Removal Cultures
1* Yes Glass Posterior Unknown Unknown Bacillus sp., Escherichia vulneris
3 Yes Metal Posterior 2 3 Negative
4* Yes Metal Anterior 5 5 Negative
5* Yes Metal Anterior 1 1 Negative
6 Yes Metal Posterior 0 1 Negative
9* Yes Metal Posterior 6 6 Negative
11* Yes Metal Anterior 0 5 Bacillus sp.
2* No 5 Staphylococcus aureus from
vitreous, Aspergillus fuminatum
from cornea
7* No 4 Streptococcus morbillum
8* No Unknown Unknown Negative
10 No 0 0 Streptococcus epidermidis
12* Unknown Unknown Unknown Bacillus cereus
13 Yes Unknown Anterior Unknown Unknown Streptococcus pneumoniae,
Streptococcus lugdunensis,
Aspergillus fuminatus
21 Yes Wood Anterior 0 5 Rhodotorula mucilaginosa
22 Yes Metal Unknown 0 0 Staphylococcus epidermidis
14* No 4 Staphylococcus epidermidis
15* No 0 Staphylococcus hominis,
Propionibacterium acnes
16* No 0 Staphylococcus epidermidis
17* No 0 Negative
18* No 0 Negative
20* No 0 Candida
23* No 0 Negative
24* No 0 Bacillus sp., fungal hyphae on silver
stain
25 No None None
26* No 0 Coagulase-negative
Staphylococcus sp.
19* Unknown Unknown Unknown Streptococcus sanguinis,
Streptococcus viridans
Cases 1-12 are 12 cases of concurrent endophthalmitis; represent 14 cases of post-OGR endophthalmitis.
*Eye was underwent intravitreal antibiotic injection.
It was unknown whether the eye was injected with intravitreous antibiotics at initial presentation after trauma.
IOFB, intraocular foreign body.

Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
 POSTTRAUMATIC ENDOPHTHALMITIS  LI ET AL 7

Endophthalmitis Post-Open Globe Repair (23%) eyes had conrmed IOFB. One patient with
OGI repaired elsewhere reported an IOFB removal but
Fourteen (54%) of 26 eyes constituted the post-
no details could be conrmed.
OGR endophthalmitis group. All 12 patients with
Twelve of 14 (86%) eyes underwent PPV with
available initial visual acuity presented with CF or
intravitreal antibiotics (vancomycin and ceftazidime,
worse (range: NLP to CF). One eye that presented with
along with clindamycin in 2 cases of organic wound
NLP vision was primarily enucleated (Case #23). All
contamination and cefazolin in 1 case that grew
eyes in this group were hospitalized for intravenous
coagulase-negative Streptococcus). Two of the four
antibiotics.
eyes with wound contamination with organic material
Nine eyes of 14 eyes in this group had undergone
received additional antifungal therapy (amphotericin
OGR at our institution. Detailed injury data were
B). One patient (Case #25) refused invasive proce-
available in 8 of 9 eyes; all underwent primary
dures but permitted treatment solely with intravenous
globe closure less than 24 hours after the initial
and topical antibiotics. This eye presented with vision
injury. Twenty-three percent (3 of 13 with injury
of CF at three feet at presentation. The other eye was
type data) had IOFBs which were removed at the
primarily enucleated on presentation with NLP vision
initial globe repair. All received prophylactic intra-
and severe endophthalmitis post-OGR. Four (36%) of
venous (IV) antibiotics after the original open globe
11 eyes that underwent PPV underwent repeat injec-
injury. Vancomycin and cefazidime were the most
tions of intravitreal antibiotics.
common antibiotics given, including for the one eye
Four of nine eyes were reported to have wound leak
with IOFB. Mean duration of systemic antibiotics
(recorded as Seidel positive) after OGR. All 4 were
was 3.8 days. The one eye with IOFB did not
Zone 1 corneal wounds and were treated with topical
receive intravitreal antibiotics at the original OGR;
antibiotics and bandage contact lens. Endophthalmitis
this wood IOFB was not initially visualized on
was diagnosed at a mean duration of 3.0 days after the
B-scan or computerized tomography. Wound con-
wound leak was documented. Wound leak was con-
tamination was reported in one eye.
sidered minimal.
Mean duration of time to presentation of endoph-
thalmitis after OGR was 14 days, excluding 1
Overall
outlier of 98 days. All eyes presented with hypo-
pyon, vitritis, and worsening of visual acuity. In terms of microbiology, 16 (62%) of the 26 eyes
Ultrasonography was used to diagnose vitritis in were culture-positive, with Staphylococcus species
four eyes when media opacity precluded view to the being the most common organism isolated (7 eyes,
vitreous cavity. Although no eyes in this group were 44%) followed by Bacillus (4 eyes, 25%) and Strep-
pseudophakic, 3 (25%) eyes had cataracts at pre- tococcus (3 eyes, 19%) species. Fungal infection, de-
sentation (plus 1 with retained lens fragments in the tails of which are shown in Table 4, was present in 5
vitreous), and 5 (42%) eyes later developed trau- (31%) eyes, whereas 3 (19%) eyes demonstrated both
matic cataract, all within 3 weeks of OGI. Three bacteria and fungus. Four (80%) of 5 fungal cases

Table 4. Microbiology Findings in Cases of Fungal Endophthalmitis

Inpatient Outpatient
Systemic Intravitreal Systemic
Case# Organism Antifungal Antifungal Antifungal Clinical Exam Labs
2 Aspergillus None None None No suspicion Culture-positive
fuminatum after PPV
13 Aspergillus IV voriconazole Voriconazole Oral Corneal inltrate Culture-positive
fuminatus voriconazole after PPV
20 Candida sp. IV voriconazole Amphotericin IV voriconazole Not documented Culture-positive
after PPV
21 Rhodotorula IV amphotericin Amphotericin IV voriconazole Corneal inltrate Culture-positive
mucilaginosa after PPV
24 Fungal hyphae None* None None* Corneal inltrate, GMS-positive
on GMS prurulent after
discharge* enucleation
Case 2 was diagnosed with concurrent endophthalmitis; cases 13, 20, 21, and 24 represent post-OGR endophthalmitis.
*Eye was enucleated during admission for endophthalmitis and cultures were positive for Bacillus.
AC, anterior chamber; GMS, Giemsa silver stain; IV, intravenous; PPV, pars plana vitrectomy.

Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
8 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2017  VOLUME 0  NUMBER 0

were from the post-OGR group, whereas 1 (#2, 20%)

was from the concurrent group. This patient presented
5 days after being injured from light bulb fragments
after 3 days of blurry vision.
Table 5 summarizes ndings of eyes with OGI and
concurrent endophthalmitis versus post-OGR endoph-
thalmitis. Signicantly more eyes with concurrent ver-
sus post-OGR endophthalmitis had an IOFB (Figure 2,
P , 0.05). The delay from injury to primary OGR was
signicantly longer in eyes with concurrent versus
post-OGR endophthalmitis (2.6 vs. 0.44 days, P ,
0.03; Figure 1).
Presenting visual acuity in eyes with concurrent
endophthalmitis was 20/1,074 versus 20/2,825 in
eyes with post-OGR endophthalmitis (P = 0.05;
excluding enucleated eyes, 20/776 vs. 20/2,118).
Mean follow-up after endophthalmitis treatment was
47 weeks (range: 1278; concurrent endophthalmitis
mean: 29; post-OGR endophthalmitis mean: 63; Fig-
ure 4). Final BCVA ranged from NLP to 20/20. Eyes
with concurrent endophthalmitis had a better average
BCVA of 20/463 than the eyes with post-OGR en-
dophthalmitis (20/1,003), though this difference was
not statistically signicant (P = 0.4; excluding enu-
cleated eyes, 20/439 vs. 20/231). Figure 5 plots initial
and nal logarithm of the minimal angle of resolution
visual acuity for each case. Ten (40%) of 25 patients
(one patient had no documented BCVA) with an
average of 54.5 weeks of follow-up achieved good
visual outcome in the affected eye.
Four (40%) of 10 eyes in the concurrent endoph-
thalmitis group and 6 (55%) of 11 eyes in the late-
onset group had documented improvement in visual
acuity. Good visual outcome was achieved in 10
(53%) of 19 eyes with documented initial and nal
visual acuity that were not enucleated.
One eye presented with NLP in each of the two
endophthalmitis groups (Table 1). The NLP eye in the
Table 5. Frequency of Independent Variables Among
Patients With Concurrent Versus Post-OGR Post-
traumatic Endophthalmitis
Characteristic P posttraumatic endophthalmitis.
Concurrent Endophthalmitis
IOFB ,0.05*
Delayed primary repair ,0.03*
Better presenting visual acuity 0.05
Cataract at OGI presentation 0.06
Post-OGR Endophthalmitis
Fungal 0.2
Improved visual acuity after 0.2
treatment
*Indicates statistically signicant difference using Fishers
exact test.
Fig. 4. Follow-up time in weeks for eyes in this case series.
concurrent endophthalmitis cohort remained NLP after
OGR and was enucleated thereafter; the NLP eye was in
the post-OGR cohort was enucleated primarily. Two
eyes in the post-OGR endophthalmitis group became
NLP after PPV and antibiotic treatment and were enu-
cleated secondarily. All 4 (15%) eyes enucleated under-
went orbital implants.
Potential visual prognostic factors with odds ratios
and P values are summarized in Table 6. Notably,
negative cultures were associated with good visual
outcome (P , 0.03). A high ocular trauma score also
signicantly correlated with poor visual outcomes
(Figure 6). Bacillus species growth in culture (data
not shown), delayed primary OGR for more than 48
hours after injury, and IOFB were not signicantly
associated with poor visual outcome.
Discussion
We believe that this study represents the largest
retrospective case series of traumatic endophthalmitis
in the United States68,1233 since standardization of
trauma terminology in 199634 and is the rst study
to separately analyze concurrent versus post-OGR
Eleven of the 14 cases in the post-OGR endoph-
thalmitis group presented with increased pain and/or
blurry vision. In our case series, medical or surgical
management was initiated immediately as endoph-
thalmitis was diagnosed. Patients were hospitalized
for an average of 7.2 3.1 days for intravenous anti-
biotics, and vancomycin plus ceftazidime was the
most common combination used. Nearly all patients
who received intravitreal antibiotics received vancomycin
1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL.31,32,3537

Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
 POSTTRAUMATIC ENDOPHTHALMITIS  LI ET AL
Clindamycin (1 mg/0.1 mL) was added as an intravitreal
injection when additional anaerobic coverage was
required. Systemic vancomycin and ceftazidime were
the intravenous drugs of choice given their high intraoc-
ular penetration and broad-spectrum coverage that in-
cludes Bacillus and Pseudomonas. Oral levooxacin
(500 mg daily for 7 days) was the most commonly pre-
scribed oral antibiotic at discharge from the hospital.
Intravitreal amphotericin B 5 mg/0.1 mL was the most
commonly used antifungal agent in cases of fungal en-
dophthalmitis either suspected clinically (Case #26 pre-
sented with white creamy membranous material in the
anterior chamber that later showed negative cultures) or
diagnosed through positive cultures (Table 4). Two (one
from each group) of the four eyes with a history of
organic-contaminated wounds received intravitreal anti-
fungal (amphotericin B) injections. Fungal vitreous cul-
tures were positive in one of these eyes (Case #21).
Systemic antifungal therapy (either amphotericin B or
voriconazole) was administered in all three cases in
which cultures were positive for fungal species.
Previous studies have demonstrated positive cul-
tures in 17% to 81% of eyes clinically diagnosed
Table 6. Potential Prognostic Factors in Eyes With
Posttraumatic Endophthalmitis
Association Odds
Factor With? Ratio (CI)
Culture-negative Good 8.7* (1.356.2)
prognosis
Delayed presentation Poor prognosis 3.2 (0.424.4)
of endophthalmitis
Intraocular foreign body Poor prognosis 3.1 (0.617)
Poor prognosis is dened as nal best corrected visual acuity
,20/200, and good prognosis as $20/200.
*Indicates statistically signicant odds ratio using Fishers
exact test.
More than 48 hours after symptom onset.
CI, 95% condence interval.
Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
9
Fig. 5. Initial versus nal visual
acuity in eyes with concurrent or
post-open globe repair endoph-
thalmitis after open globe injury.
*Indicates statistically signi-
cant correlation using linear
regression testing; BCVA, best
corrected visual acuity; VA,
visual acuity.
with posttraumatic endophthalmitis12,28,3844; cul-
tures were positive in 63% of eyes in this series, all
were taken from the vitreous (plus cornea in Case
#2). Staphyloccocus species was the most common
organism cultured in the present study, which cor-
roborates previous reports.3032,45
Intraocular foreign body was seen in 67% of 18 cases
of Bacillus-positive posttraumatic endophthalmitis in
the study by Miller et al.46 In our series, 2 (50%) of
4 eyes that were culture-positive for Bacillus had IOFB.
Many studies suggest a positive association between
IOFB and endophthalmitis.1,6,10,14,22,33,38,44,47,48 In this
present case series, of 24 eyes with known injury type,
42% had IOFBs (7/11, 64% of concurrent endophthal-
mitis cases; 3/13, 23% of post-OGR endophthalmitis).
Two of the 3 post-OGR endophthalmitis cases with
IOFB had undergone prompt globe closure within 24
hours of injury. Intraocular foreign body comprises 4%
to 9% of all OGIs based on studies published within the
last 5 years.49,50 Our study reveals that 41.7% of OGIs
with endophthalmitis had IOFBs, an incidence that is 4
to 10 times higher than what is reported in the literature
overall with OGIs.
Fig. 6. Ocular trauma score versus nal visual acuity. *Indicates sta-
tistically signicant correlation using linear regression testing; BCVA,
best corrected visual acuity.
10 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2017  VOLUME 0  NUMBER 0
Lens capsule disruption has also been associated with
posttraumatic endophthalmitis in many studies,5,15,18,38
and we found that cataract at presentation (most likely
due to lens disruption) was noted more frequently with
concurrent endophthalmitis (P = 0.06), whereas delayed
traumatic cataract was more likely in the post-OGR
eyes (P = 0.09). Leakage of lens particles through a pos-
sibly disrupted capsule may cause severe sterile inam-
mation that may be construed as infectious
endophthalmitis; furthermore, histopathologic studies
are needed to clarify this strength of this association.
Except for one case, all fungal infections were seen
in post-OGR, which accords with the typical subacute
presentation of fungal endophthalmitis. The eye with
fungal endophthalmitis that presented concurrently
with OGI involved a 5-day delay in presentation after
OGI (Case #2).
Various prognostic indicators have been consid-
ered for eyes diagnosed with posttraumatic endoph-
thalmitis. In this series, negative cultures were
signicantly associated with good visual outcome,
whereas all cases of fungal endophthalmitis and
wound leak resulted in poor outcomes. Figure 6 also
illustrates that the ocular trauma score, intended for
use as a prognostic indicator for uncomplicated ocu-
lar trauma, may be used to accurately gauge posten-
dophthalmitis prognosis. In our study, eyes with
IOFB had a nal BCVA of 20/853 compared with
the overall nal visual acuity of 20/692. Prompt
removal of IOFB may play a role in rapidly decreas-
ing microbial load and subsequent resolution of
infection.
Delayed presentation of endophthalmitis (dened as
greater than 48 hours after symptom onset) augured
poor visual outcome, though this nding was not
statistically signicant (Table 6). In this series, a large
proportion (26.9%) of total cases had delayed presen-
tation after the initial OGI. The review of records for
reasons of delay in seeking medical attention inclu-
dedthe following: 1) some patients did not immedi-
ately realize there was anatomical injury to the globe
until after symptoms became more severe or, 2) lack of
medical insurance made them wait until the symptoms
worsened drastically before seeking medical assis-
tance. Delayed presentation may lead to a higher
microbial load and thus greater anatomical and func-
tional cellular damage before treatment. Thus, it is
crucial to ensure that the patient understands signs
and symptoms of early endophthalmitis, as well as
the generally dismal prognosis of delayed presenta-
tion; they should be advised of prompt follow-up if
these signs or symptoms develop.
Other investigators have reported delayed treat-
ment33 and the presence of retinal detachment28,33 as
Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
associated with poor visual outcome, whereas negative
cultures may be associated with better nal visual acu-
ity.19,28 Negative cultures may indicate a subthreshold
microbial load and thus lower severity of infection
resulting in better nal BCVA. The three cases of
retinal detachment in the post-OGR endophthalmitis
group had poor visual outcome (Table 1, *), with nal
VAs of hand motion.
Corneal wound leak after open globe repair
occurred in 29% of posttraumatic endophthalmitis
cases in our series (Table 7). A recent retrospective
study of 267 eyes that sustained OGI reported 44 eyes
(16%) with wound leak after primary repair, and the
authors found that delayed presentation increased the
risk of postrepair wound leak and endophthalmitis,
whether concurrent with the injury or after OGR.5 In
our series, four eyes in the post-OGR endophthalmitis
group had wound leaks after the primary wound repair
and were diagnosed with endophthalmitis an average
of 3.0 days after primary OGR. The eyes with wound
leaks had poor visual outcomes with nal BCVA of
CF or worse. The cited series and the present data
indicate that wound leak, a potential source of micro-
bial entry, may be a risk factor of developing endoph-
thalmitis; one should consider revision of the wound if
a wound leak occurs. This nding also underscores the
importance of complete wound closure at the time of
primary repair, even in the case of injuries with tissue
loss or other complex anatomic features.
Use of temporary keratoprosthesis for PPV for
corneal opacities in eyes with active severe endoph-
thalmitis may be limited. With active endophthalmitis,
the scleral and corneal tissue is often times so friable in
the acute setting that a temporary keratoprosthesis
cannot be placed and the rst priority is to close the
globe.
Limitations of this study include observer bias and
difculty in obtaining complete data sets on all
patients, issues inherent to retrospective studies, plus
Table 7. Details of Eyes With Wound Leak After Open
Globe Repair
Days: Leak Repair
Relative to
Days: OGR to Leak Endophthalmitis
Case# Repair Diagnosis
19 2 14 days before
21 4 Same day
23 1213 days (exact OGR Not repaired; primarily
date unknown) enucleated after
receiving intravitreal
antibiotics
24 3 Same day
OGR, open globe repair.
 POSTTRAUMATIC ENDOPHTHALMITIS  LI ET AL
possible selection bias for more severe cases given that
our institution is a tertiary referral center. The rarity of
posttraumatic endophthalmitis limits the sample size.
Prospective large-scale and/or multi-institutional stud-
ies of this condition may further conrm our ndings.
Final visual outcome in this case series, despite
prompt medical and surgical management, was
extremely guarded, with a mean BCVA of 20/692
(20/324 excluding enucleated eyes). Four eyes (15%)
were NLP and thus enucleated.
Prompt treatment after open globe injury is advisable.
During the study time period, 933 OGIs were repaired
at our institution; the incidence of concurrent endoph-
thalmitis and post-OGR endophthalmitis was 1.3% and
0.96%, respectively. The 9 eyes in the post-OGR that
were repaired initially at our institution, underwent
prophylactic systemic antibiotic treatment for a mean
duration of 7 days (range 310 days); intravenous lev-
ooxacin was given in most cases of open globes
without IOFBs. In the presence of IOFB and no en-
dophthalmitis, a combination of intravenous vancomy-
cin and ceftazidime for 3 to 5 days followed by an oral
quinolone for at least 1 week was used in most cases.
Intravitreal injections of vancomycin and ceftazidime
may be considered in some cases of IOFBs. We con-
tinue to advocate for systemic antibiotic prophylaxis
for posttraumatic endophthalmitis. The visual outcome
after infection, despite aggressive management, is
extremely poor. One should give clear instructions to
the OGR patients to present emergently in case of
increased pain or decreased vision.
Key words: endophthalmitis, open globe injury,
ocular trauma, wound leak, management, demograph-
ics, outcomes, prognosis, microbiology, intraocular
foreign body.
References
1. Brinton GS, Topping TM, Hyndiuk RA, et al. Posttraumatic
endophthalmitis. Arch Ophthalmol 1984;102:547550.
2. Azad R, Ravi K, Talwar D, et al. Pars plana vitrectomy with
or without silicone oil endotamponade in post-traumatic en-
dophthalmitis. Graefes Arch Clin Exp Ophthalmol 2003;
241:478483.
3. Fisch A, Salvanet A, Prazuck T, et al. Epidemiology of infective
endophthalmitis in France. The French Collaborative Study
Group on Endophthalmitis. Lancet 1991;338:13731376.
4. Meredith TA. Posttraumatic endophthalmitis. Arch Ophthalmol
1999;117:520521.
5. Kong GY, Henderson RH, Sandhu SS, et al. Wound-related
complications and clinical outcomes following open globe
injury repair. Clin Exp Ophthalmol 2015;43:508513.
6. Dehghani AR, Rezaei L, Salam H, et al. Post traumatic en-
dophthalmitis: incidence and risk factors. Glob J Health Sci
2014;6:36634.
Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
11
7. Parke DW III, Pathengay A, Flynn HW Jr, et al. Risk factors
for endophthalmitis and retinal detachment with retained intra-
ocular foreign bodies. J Ophthalmol 2012;2012:758526.
8. Faghihi H, Hajizadeh F, Esfahani MR, et al. Posttraumatic
endophthalmitis: report no. 2. Retina 2012;32:146151.
9. Pieramici DJ, Sternberg P Jr, Aaberg TM Sr, et al. A system
for classifying mechanical injuries of the eye (globe). The
Ocular Trauma Classication Group. Am J Ophthalmol
1997;123:820831.
10. Kuhn F, Maisiak R, Mann L, et al. The Ocular Trauma Score
(OTS). Ophthalmol Clin North Am 2002;15:163165, vi.
11. Arroyo JG, Postel EA, Stone T, et al. A matched study of
primary scleral buckle placement during repair of posterior
segment open globe injuries. Br J Ophthalmol 2003;87:7578.
12. Duch-Samper AM, Menezo JL, Hurtado-Sarrio M. Endoph-
thalmitis following penetrating eye injuries. Acta Ophthalmol
Scand 1997;75:104106.
13. Schmidseder E, Mino de Kaspar H, Klauss V, Kampik A. Post-
traumatic endophthalmitis after penetrating eye injuries. Risk
factors, microbiological diagnosis and functional outcome [in
German]. Ophthalmologe 1998;95:153157.
14. Jonas JB, Knorr HL, Budde WM. Prognostic factors in ocular
injuries caused by intraocular or retrobulbar foreign bodies.
Ophthalmology 2000;107:823828.
15. Sabaci G, Bayer A, Mutlu FM, et al. Endophthalmitis after
deadly-weapon-related open-globe injuries: risk factors, value
of prophylactic antibiotics, and visual outcomes. Am J
Ophthalmol 2002;133:6269.
16. Hooi SH, Hooi ST. Open-globe injuries: the experience at
Hospital Sultanah Aminah, Johor Bahru. Med J Malaysia
2003;58:405412.
17. Tran TP, Le TM, Bui HT, et al. Posttraumatische Endoph-
thalmitis nach perforierender Verletzung in Vietnam: Ris-
ikofaktoren, mikrobiologische Aspekte und funktionelle
ErgebnisseEine retrospektive Analyse. Klin Monatsbl
Augenheilkd 2003;220:481485.
18. Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic en-
dophthalmitis. Ophthalmology 2004;111:20152022.
19. Vedantham V, Nirmalan PK, Ramasamy K, et al. Clinico-
microbiological prole and visual outcomes of post-traumatic
endophthalmitis at a tertiary eye care center in South India.
Indian J Ophthalmol 2006;54:510.
20. Gupta A, Srinivasan R, Gulnar D, et al. Risk factors for post-
traumatic endophthalmitis in patients with positive intraocular
cultures. Eur J Ophthalmol 2007;17:642647.
21. Chaudhry IA, Shamsi FA, Al-Harthi E, et al. Incidence and
visual outcome of endophthalmitis associated with intraocular
foreign bodies. Graefes Arch Clin Exp Ophthalmol 2008;246:
181186.
22. Andreoli CM, Andreoli MT, Kloek CE, et al. Low rate of
endophthalmitis in a large series of open globe injuries. Am
J Ophthalmol 2009;147:601608.e2.
23. Al-Mezaine HS, Osman EA, Kangave D, Abu El-Asrar AM.
Risk factors for culture-positive endophthalmitis after repair of
open globe injuries. Eur J Ophthalmol 2010;20:201208.
24. Soylu M, Sizmaz S, Cayli S. Eye injury (ocular trauma) in
southern Turkey: epidemiology, ocular survival, and visual
outcome. Int Ophthalmol 2010;30:143148.
25. Yang CS, Lu CK, Lee FL, et al. Treatment and outcome of
traumatic endophthalmitis in open globe injury with retained
intraocular foreign body. Ophthalmologica 2010;224:7985.
26. Zhang Y, Zhang MN, Jiang CH, et al. Endophthalmitis follow-
ing open globe injury. Br J Ophthalmol 2010;94:111114.
12 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2017  VOLUME 0  NUMBER 0
27. Bauza AM, Emami P, Son JH, et al. Work-related open-globe
injuries: demographics and clinical characteristics. Eur J
Ophthalmol 2013;23:242248.
28. Cornut PL, Youssef el B, Bron A, et al. A multicentre pro-
spective study of post-traumatic endophthalmitis. Acta
Ophthalmol 2013;91:475482.
29. George J, Ali N, Rahman NA, Joshi N. Spectrum of intra-
ocular foreign bodies and the outcome of their management
in Brunei Darussalam. Int Ophthalmol 2013;33:277284.
30. Asencio MA, Huertas M, Carranza R, et al. Microbiologi-
cal study of infectious endophthalmitis with positive cul-
ture within a 13 year-period [in Spanish]. Rev Esp
Quimioter 2014;27:2227.
31. Jindal A, Pathengay A, Mithal K, et al. Endophthalmitis after
open globe injuries: changes in microbiological spectrum and
isolate susceptibility patterns over 14 years. J Ophthalmic
Inamm Infect 2014;4:5.
32. Long C, Liu B, Xu C, et al. Causative organisms of post-
traumatic endophthalmitis: a 20-year retrospective study.
BMC Ophthalmol 2014;14:34.
33. Nicoara SD, Irimescu I, Calinici T, Cristian C. Outcome and
prognostic factors for traumatic endophthalmitis over a 5-year
period. J Ophthalmol 2014;2014:747015.
34. Kuhn F, Morris R, Witherspoon CD, et al. A standardized
classication of ocular trauma. Ophthalmology 1996;103:
240243.
35. Fernandez Mdel P, Villegas VM, Armando LO. Vitreous cul-
tures and antibiotic analysis in Puerto Rican endophthalmitis
patients. P R Health Sci J 2011;30:198202.
36. Ahmed S, Kuruvilla O, Yee DC, et al. Intraocular penetration
of systemic antibiotics in eyes with penetrating ocular injury. J
Ocul Pharmacol Ther 2014;30:823830.
37. Zimmer-Galler IE, Santos A, Haller JA, Campochiaro PA.
Management of endophthalmitis in a silicone oil-lled eye.
Retina 1997;17:507509.
38. Thompson JT, Parver LM, Enger CL, et al. Infectious endoph-
thalmitis after penetrating injuries with retained intraocular
Copyright by Ophthalmic Communications Society, Inc. Unauthorized reproduction of this article is prohibited.
foreign bodies. National Eye Trauma System. Ophthalmology
1993;100:14681474.
39. Williams DF, Mieler WF, Abrams GW, Lewis H. Results and
prognostic factors in penetrating ocular injuries with retained
intraocular foreign bodies. Ophthalmology 1988;95:911916.
40. Alfaro DV, Roth D, Liggett PE. Posttraumatic endophthalmi-
tis. Causative organisms, treatment, and prevention. Retina
1994;14:206211.
41. Verbraeken H, Rysselaere M. Post-traumatic endophthalmitis.
Eur J Ophthalmol 1994;4:15.
42. Rubsamen PE, Cousins SW, Martinez JA. Impact of cultures
on management decisions following surgical repair of penetrat-
ing ocular trauma. Ophthalmic Surg Lasers 1997;28:4349.
43. Kunimoto DY, Das T, Sharma S, et al. Microbiologic spectrum
and susceptibility of isolates: part II. Posttraumatic endophthal-
mitis. Am J Ophthalmol 1999;128:242244.
44. Das T, Kunimoto DY, Sharma S, et al. Relationship between
clinical presentation and visual outcome in postoperative and
posttraumatic endophthalmitis in south central India. Indian J
Ophthalmol 2005;53:516.
45. Chhabra S, Kunimoto DY, Kazi L, et al. Endophthalmitis after
open globe injury: microbiologic spectrum and susceptibilities
of isolates. Am J Ophthalmol 2006;142:852854.
46. Miller JJ, Scott IU, Flynn HW Jr, et al. Endophthalmitis caused
by Bacillus species. Am J Ophthalmol 2008;145:883888.
47. Boldt HC, Pulido JS, Blodi CF, et al. Rural endophthalmitis.
Ophthalmology 1989;96:17221726.
48. Kuhn F, Morris R. Posterior segment intraocular foreign bod-
ies: management in the vitrectomy era. Ophthalmology 2000;
107:821822.
49. Babaa A, Zbiba W, Korbi M. Epidemiology of open globe in-
juries in cap bon: about 100 cases. Tunis Med 2015;93:618622.
50. Madhusudhan ALP, Evelyn-Tai LM, Zamri N, et al. Open
globe injury in Hospital Universiti Sains Malaysiaa 10-year
review. Int J Ophthalmol 2014;7:486490.