Post-Injection Endophthalmitis

Post-Injection Endophthalmitis is a severe infection inside the eye that happens after a needle injection into the eye (for example, an intravitreal anti-VEGF, steroid, or antibiotic injection). In this condition, germs get into the eye and trigger a very strong inflammatory reaction in the eye’s fluid and gel (the aqueous and the vitreous). This inflammation makes the eye painful, red, and cloudy, and it can quickly damage delicate retinal tissue. Without fast treatment, vision can be permanently harmed. Doctors treat it as an eye emergency. EyeWiki

PIE is uncommon, but the risk is never zero. Large studies and clinical statements suggest the risk after an intravitreal injection is roughly a few hundredths of a percent per injection (on the order of 0.02%–0.06%). This means most patients never get it, but because injections are so common, doctors see cases regularly. American Academy of OphthalmologyNatureBioMed Central

Most infections are caused by common skin or mouth bacteria that accidentally enter the eye during the injection. Coagulase-negative staphylococci (often skin bacteria) are frequent; viridans streptococci (often oral bacteria) are also important and can present very quickly and severely. Fungal infections are rare but possible. EyeWikiPubMed

Symptoms usually begin within a few days after the injection. Many reports describe onset around 2–7 days on average, though it can be earlier or later. Pain, rapidly worsening vision, and eye redness are typical. PMC+1

Not all post-injection inflammation is infection. “Sterile” inflammation (a non-infectious immune reaction to a drug or its additives) can mimic infection but usually behaves differently and needs a different treatment plan. Distinguishing infectious endophthalmitis from non-infectious post-injection inflammation is a key early step. PMCSpringerLink

Types

You may see doctors describe PIE in a few simple ways:

1. By cause (microbe type).
   Bacterial PIE is most common (often skin flora like coagulase-negative Staphylococcus or oral flora like viridans Streptococcus). Fungal PIE is uncommon but possible, especially in special circumstances (e.g., immunosuppression, contaminated product). EyeWiki

2. By time of onset after the injection.
   Many clinicians use practical time-based labels because timing can hint at the likely bug and severity:

   • Fulminant: within <4 days; often very aggressive, sometimes associated with oral flora streptococci.

   • Acute: about 5–7 days.

   • Chronic: after >4 weeks; occasionally due to slower organisms or indolent infections. EyeWiki

3. By culture status.
   Culture-positive cases have a microbe grown or detected. Culture-negative cases show classic signs of infection but standard cultures are negative; molecular tests can still find microbial DNA. Nature

4. Infectious vs non-infectious.
   Infectious PIE needs urgent intravitreal antibiotics (and sometimes vitrectomy). Non-infectious post-injection inflammation (sterile) needs anti-inflammatory treatment and close monitoring; it is not caused by live microbes. PMC

Causes

These “causes” are really pathways and risk factors that let germs reach the eye or make infection more likely after an injection. Each item describes how the risk happens in plain English.

1. Touching the lashes or lid margin with the needle or syringe.
   Lids and lashes have bacteria. If the needle or tip touches them and then enters the eye, germs can be carried inside. EyeWiki

2. Inadequate povidone-iodine (PI) antisepsis.
   PI on the ocular surface just before injection is the single most evidence-based step to cut infection risk. Skipping it or using too little allows surface bacteria to persist. Nature

3. Speaking, coughing, or heavy breathing over the sterile field.
   Oral droplets can spray viridans streptococci toward the eye. “No-talking” or masking policies may help reduce this risk. JAMA NetworkScienceDirect

4. Patient speaking during the injection.
   The same droplet pathway applies to patients as well as staff; talking puts oral bacteria into the air near the needle. Rambam Maimonides Medical Journal

5. Contaminated drug or syringe.
   Very rarely, a contaminated batch (e.g., from repackaging or compounding) can seed many eyes. Proper sourcing and handling reduce this risk. PMC

6. Skipping a lid speculum or poor draping.
   A speculum holds the lids away from the injection site. Without it, lids or lashes may touch the needle. EyeWiki

7. Blepharitis or active ocular surface infection at the time of injection.
   Inflammation of the lid margins increases bacterial load, increasing the chance of contamination. EyeWiki

8. Severe dry eye or corneal epithelial defects.
   A damaged surface can harbor more bacteria and makes contamination easier. (General ophthalmic principle referenced in clinical statements.) American Academy of Ophthalmology

9. Poor hand hygiene or glove issues.
   Breaks in sterile technique, including improper gloving, can contaminate instruments or the injection site. Nature

10. Re-using or inappropriately handling instruments.
    Reuse can allow biofilms or residual microbes; modern practice favors single-use sterile devices. EyeWiki

11. Contaminated anesthetic, dilating drops, or cotton/applicators.
    Bottles that touch lashes/lids or are outdated can become contaminated and then spread bacteria to the eye surface. EyeWiki

12. Multiple injections during one visit without careful asepsis between them.
    Each pass is an opportunity for contamination unless the surface is re-prepped properly. EyeWiki

13. Improper needle path or wound construction.
    A leaky wound may allow surface fluid (with bacteria) to wick inward after the injection. PentaVision

14. Patients rubbing the eye soon after injection.
    Rubbing can draw bacteria from the lid margin across the wound track. PentaVision

15. High bacterial load from oral flora in the room.
    Clinics with poor airflow, no masks, and talking near the sterile field can increase airborne oral flora. AAO Journal

16. Immunosuppression or diabetes in the patient.
    Lower host defenses can make a small inoculum more likely to “take hold.” (Risk factor often noted in outcomes papers and clinical reviews.) PMC

17. Improper preparation of the injection site location.
    If the chosen quadrant is not cleaned well, bacteria near the site can be pushed inward. EyeWiki

18. Drug or vehicle factors that irritate tissue.
    Irritation is not infection, but inflamed tissue may be more vulnerable if microbes are introduced at the same time. (Distinguishing infection from sterile inflammation is still essential.) PMC

19. Using non-sterile gels or contact devices on the ocular surface before injection.
    Anything that touches the surface must be sterile or single-use to avoid introducing bacteria. EyeWiki

20. Rare contaminated prefilled items vs. benefit of true prefilled syringes.
    True manufacturer prefilled syringes tend to lower touch points and may reduce risk; improper repackaging in other settings can increase risk. asrs.org

Symptoms

1. Worsening blurred vision.
   Vision may drop quickly because the vitreous turns cloudy and the retina cannot be seen clearly. PMC

2. Eye pain that can be deep and aching.
   Pain is common and tends to worsen over hours. Sudden severe pain after an injection is a red flag. AMBOSS

3. Red eye.
   The white of the eye looks red because blood vessels are inflamed. Medscape

4. Light sensitivity (photophobia).
   Inflammation makes bright light uncomfortable. Review of Optometry

5. Floaters or hazy “fog” in front of the vision.
   Pus and inflammatory debris in the vitreous cause shadows and haze. PMC

6. Eyelid swelling.
   The lids can puff up from inflammation. EyeWiki

7. Discharge (watery or pus-like).
   Some patients notice tearing or a small amount of discharge. EyeWiki

8. Headache around the eye.
   Deep eye pain can radiate and feel like a headache.

9. Decreased contrast or dim vision.
   Colors and contrast can look “washed out.”

10. Poor red reflex.
    When a light is shined into the eye, the normal red glow is dull or absent because of cloudy media. EyeWiki

11. Hypopyon (a visible fluid level of white cells).
    A white “layer” may be seen in the front chamber in severe cases. Medscape

12. Corneal haze or edema.
    The clear front window can swell and turn hazy. EyeWiki

13. Tender eye to the touch.
    Even gentle pressure around the lids or globe can hurt. EyeWiki

14. Rapid symptom progression.
    Symptoms can worsen over hours to days; this speed helps distinguish infection from some sterile reactions. PMC

15. Occasionally fever or feeling unwell (rare in PIE).
    Systemic symptoms are uncommon in post-injection cases (more typical of endogenous infections), but clinicians still ask about them. NCBI

Diagnostic tests

Doctors combine history (recent injection), symptoms, and careful tests to make a fast, accurate diagnosis and to separate infectious PIE from non-infectious post-injection inflammation. Here are the key tests, explained in simple terms.

A) Physical exam (at the slit lamp and bedside)

1. External inspection of lids and conjunctiva.
   The doctor looks for lid swelling, redness, discharge, and signs of blepharitis. These “outside” clues point toward infection and show the surface bacterial load. Ento Key

2. Slit-lamp examination of the anterior segment.
   The narrow bright beam lets the doctor count inflammatory cells (“cells/flare”), look for hypopyon, corneal edema, and any wound track at the injection site. This is the cornerstone of the exam. Medscape

3. Assessment of the injection site.
   The doctor checks the scleral entry point for leakage, ooze, or tenderness. A leaky site raises suspicion of inward wicking.

4. Distant direct ophthalmoscopy (red-reflex check).
   A quick look for a dull or absent red reflex suggests cloudy vitreous from pus. EyeWiki

5. Dilated fundus examination (if media allow).
   With the pupil dilated, the retina is examined for vitritis “snow,” retinal hemorrhages, or retinitis. If the view is blocked, imaging is used. EyeWiki

B) Manual clinical tests (simple in-office checks)

6. Best-corrected visual acuity.
   Measuring vision (e.g., ETDRS or Snellen) quantifies severity and tracks response to treatment.

7. Pinhole visual acuity.
   A pinhole can rule out some optical blur; poor pinhole improvement supports a media or retinal problem.

8. Pupillary light reflex and swinging flashlight test (RAPD).
   A relative afferent pupillary defect suggests significant retinal or optic nerve compromise.

9. Intraocular pressure (IOP) measurement.
   IOP may be low (from ciliary body shutdown) or high (from severe inflammation), and either extreme helps gauge severity. Medscape

10. Confrontation visual fields.
    A rough screen for large field defects when formal perimetry is not possible.

11. Ocular motility and pain with movement.
    Pain with movements can accompany severe intraocular inflammation; marked pain and restricted movements would also prompt evaluation for orbital disease.

12. Photophobia check.
    Light sensitivity supports active anterior segment inflammation.

13. Van Herick or simple limbal assessment of chamber depth.
    Acute corneal edema and marked anterior inflammation are documented; depth assessment helps when planning taps.

C) Laboratory & pathological tests (microbe-focused)

14. Aqueous humor tap for Gram stain and culture.
    A small sample from the front chamber is sent for immediate staining and culture to look for bacteria or fungus. Retina Today

15. Vitreous tap/biopsy for Gram stain and culture.
    A deeper sample from the vitreous increases the chance of finding the causative organism. Many teams perform a “tap and inject” in the same sitting. PMC

16. Broad-range bacterial PCR (16S rRNA) and fungal PCR (18S/ITS).
    These molecular tests can detect bacterial or fungal DNA even when cultures are negative, and they often deliver answers faster. PubMedRetina Today

17. Metagenomic next-generation sequencing (mNGS).
    When routine tests are negative, mNGS can identify unusual or multiple organisms from a tiny sample and may hint at resistance genes; careful interpretation is needed. PubMedNature

18. Antibiotic susceptibility testing (when an organism grows).
    Sensitivity results guide antibiotic adjustment and are requested whenever feasible. BioMed Central

19. Blood cultures and systemic workup (selected cases).
    Although PIE is exogenous, if the history or exam raises concern for a systemic source (fever, sepsis, IV drug use), blood cultures and systemic labs are added. NCBI

D) Electrodiagnostic tests (used only in special situations)

20. Electroretinography (ERG) and visual evoked potential (VEP).
    These tests measure retinal and optic nerve function. They are not routine in acute PIE but can help in atypical or chronic cases to estimate retinal reserve when media are too cloudy for a view. (General electrodiagnostic principles; used selectively alongside the core tests above.)

E) Imaging tests (to “see through” cloudy media and guide care)

21. B-scan ocular ultrasonography.
    Ultrasound can “see” through an opaque cornea or vitreous. It shows mobile echoes and membranes in the vitreous (vitritis), and it helps detect retinal detachment or choroidal detachment when the fundus is not visible. It is quick, bedside-friendly, and very useful in the emergency setting. NCBIPMC

22. Optical coherence tomography (OCT) of the posterior segment (when the view allows).
    OCT can document vitreous haze, retinal edema, subretinal fluid, or macular damage. It helps monitor recovery after treatment even though it is not the primary diagnostic test for infection. NCBI

23. Anterior segment OCT (selected cases).
    This can visualize a hypopyon, anterior chamber debris, or tunnel tracks and is useful when the cornea is hazy. NCBI

24. Color fundus photography (when possible).
    Photos document vitritis, hemorrhages, or retinitis and provide a baseline for follow-up once the media clear.

25. CT or MRI of the orbit (rare, targeted use).
    If there are worrisome signs of spread outside the eyeball or features suggesting orbital cellulitis, imaging helps exclude extra-ocular disease. (General infectious-orbital practice standard.)

After an eye injection, most patients feel mild irritation for a few hours. That is normal. Concerning symptoms for PIE usually start within 2–7 days, often around day 3–4. Symptoms typically worsen over hours, not improve, and include pain, a red eye, and quickly dropping vision. Streptococcal infections can appear very fast and be very severe. If a patient has these warning signs, they should be seen urgently the same day. PMC+1Lippincott Journals

Non-pharmacological treatments (therapies and other measures)

Below are supportive and procedural non-drug steps used alongside medical and surgical care. Each item includes the description, purpose, and a simple mechanism of benefit.

1. Emergency triage and same-day retina evaluation
   Purpose: shorten time to antibiotics/surgery.
   Mechanism: every hour of delay lets germs multiply; faster care reduces bacterial load and inflammation.

2. Protective rigid eye shield (not a pressure patch)
   Purpose: prevent rubbing, squeezing, or accidental bumps.
   Mechanism: reduces mechanical spread of infection and pain triggers.

3. Limited activity + head elevation when resting
   Purpose: comfort; may help inflammatory debris settle inferiorly.
   Mechanism: gentle positioning reduces throbbing sensation and light sensitivity.

4. Strict hand and eyelid hygiene
   Purpose: lower surface bacteria around the eye.
   Mechanism: fewer organisms at the lid margin means less re-seeding of the ocular surface during care.

5. “No talking” and cough-etiquette when anyone is near the eye
   Purpose: reduce droplet spread of oral bacteria (notably streptococci).
   Mechanism: fewer airborne droplets landing on the injection/entry area. (Hospitals often add clinician masking.) JAMA NetworkPubMed

6. Clean procedure environment and sterile technique
   Purpose: minimize contamination during tap, injection, or vitrectomy.
   Mechanism: lowers environmental bioburden around the operative field. (Core element of all intravitreal procedures.) American Academy of Ophthalmology

7. Diagnostic sampling (“tap”) of aqueous or vitreous
   Purpose: identify the microbe and its drug sensitivities.
   Mechanism: cultures and newer PCR tests detect bacterial/fungal DNA when cultures are negative, guiding targeted therapy. PentaVisionPMC

8. B-scan ocular ultrasound if the view is hazy
   Purpose: “see through” cloudy media to check retina, membranes, or detachment.
   Mechanism: sound waves map the vitreous and retina when the fundus cannot be visualized. EyeWiki

9. Anterior chamber paracentesis (tiny fluid release in front of eye)
   Purpose: diagnostic sample; sometimes reduces very high pressure briefly.
   Mechanism: removes a small volume to analyze and can lower pressure spikes.

10. Cycloplegic rest (via clinic—non-drug explanation)
    Purpose: let the iris and ciliary body “rest” to decrease pain from spasm.
    Mechanism: relaxing the focusing muscle reduces ache and light sensitivity (the actual drops are medications; the therapy goal is muscle rest).

11. Pain-relief strategies without eye pressure
    Purpose: comfort while definitive treatment works.
    Mechanism: cold packs to brow/temple, dark room, avoiding squeezing.

12. Education on red-flag symptoms and follow-up plan
    Purpose: ensure rapid return if worsening.
    Mechanism: earlier re-evaluation catches treatment failure sooner.

13. Blood-sugar optimization (for people with diabetes)
    Purpose: help immune function and wound repair.
    Mechanism: better glycemic control improves leukocyte activity.

14. Nutrition, hydration, and sleep support
    Purpose: general recovery support.
    Mechanism: adequate protein, fluids, and rest aid immune responses.

15. Fellow-eye protection and safety counseling
    Purpose: reduce risk to the only seeing eye if vision is impaired.
    Mechanism: protective eyewear and home safety adjustments.

16. Low-vision rehabilitation (if residual damage)
    Purpose: maximize function after infection clears.
    Mechanism: magnifiers, contrast lighting, and training improve daily tasks.

17. Transport and caregiver support planning
    Purpose: safe travel to urgent visits and procedures.
    Mechanism: reduces missed appointments and delays.

18. Mental health support
    Purpose: manage stress and anxiety from sudden vision loss.
    Mechanism: counseling reduces stress hormones that may worsen perceived pain and sleep.

19. Avoid contact lenses and eye makeup until cleared
    Purpose: lower surface contamination while healing.
    Mechanism: reduces bacterial load at lids/lashes and cornea.

20. Documented injection-suite protocols
    Purpose: prevent future episodes.
    Mechanism: checklists for antisepsis, speculum use, and no-talking policies keep care consistent and safe. Karger

Non-pharmacologic steps do not cure PIE by themselves. They are supportive while definitive treatment (intravitreal antibiotics and, sometimes, vitrectomy) works. NCBI

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Drug treatments

(Information only; not a prescription. Doses below describe common in-clinic regimens used by ophthalmologists.)

1. Intravitreal Vancomycin
   Class: Glycopeptide (Gram-positive coverage, including MRSA and streptococci).
   Dose/route/frequency: 1.0 mg/0.1 mL, injected into the vitreous; repeat in 48–72 h if needed based on response and organism.
   Purpose: kill Gram-positive bacteria, the most common causes.
   Mechanism: blocks cell wall synthesis; concentration-dependent bactericidal effect in vitreous.
   Key side effects: rare retinal toxicity at standard dose; inflammation from injection itself. EyeWikiBioMed Central

2. Intravitreal Ceftazidime
   Class: 3rd-gen cephalosporin (Gram-negative coverage incl. Pseudomonas).
   Dose: 2.25 mg/0.1 mL intravitreal; may repeat at 48–72 h if needed.
   Purpose: cover Gram-negatives with vancomycin for broad empiric therapy.
   Mechanism: cell wall synthesis inhibitor.
   Side effects: rare macular toxicity; allergy in cephalosporin-allergic patients. EyeWikiBioMed Central

3. Intravitreal Amikacin (alternative to ceftazidime)
   Class: Aminoglycoside (Gram-negative coverage).
   Dose: 0.4 mg/0.1 mL intravitreal (used when ceftazidime cannot be used).
   Purpose: Gram-negative kill if beta-lactam allergy or resistant organism.
   Mechanism: blocks bacterial protein synthesis (30S ribosome).
   Caution: macular infarction risk at higher doses or in susceptible eyes; used cautiously. U.S. Pharmacist

4. Intravitreal Dexamethasone (adjunct in bacterial cases, optional)
   Class: Corticosteroid (anti-inflammatory).
   Dose: commonly 0.4 mg/0.1 mL intravitreal at time of antibiotics in selected bacterial cases.
   Purpose: reduce damaging inflammation after antibiotics are given.
   Mechanism: down-regulates cytokines; may speed clearing of inflammatory debris.
   Evidence note: studies are mixed; commonly used but not definitively proven; avoid if fungal infection is suspected. SpringerLinkPMCEnto Key

5. Topical Fortified Vancomycin
   Class: Glycopeptide.
   Dose: 25–50 mg/mL eye drops, often hourly while awake initially, then taper.
   Purpose: heavy surface coverage for Gram-positives.
   Mechanism: high local concentration at cornea/anterior chamber; adjunct to intravitreal therapy.
   Side effects: surface irritation, epithelial toxicity if prolonged. Welcome to RetinaLinkNCBI

6. Topical Fortified Ceftazidime (or Cefazolin) / Tobramycin
   Class: Beta-lactam or aminoglycoside.
   Dose: ceftazidime 50 mg/mL (or cefazolin 50 mg/mL) alternating hourly with tobramycin 14 mg/mL; taper with improvement.
   Purpose: very broad anterior-segment coverage.
   Mechanism: high local levels bathe wound and anterior chamber.
   Side effects: surface toxicity, allergy. ScienceDirect

7. Cycloplegic drops (e.g., Atropine 1%)
   Class: Antimuscarinic.
   Dose: 1 drop 1–2×/day as directed by the specialist.
   Purpose: pain relief by ciliary muscle rest; prevents posterior synechiae.
   Mechanism: paralyzes accommodation and dilates the pupil to reduce spasm pain. (Adjunct; not antimicrobial.) Welcome to RetinaLink

8. Systemic Fluoroquinolone (selected cases)
   Drug/dose: Moxifloxacin 400 mg once daily or Levofloxacin 500–750 mg once daily for several days as directed.
   Purpose: add systemic coverage—commonly used adjunct in practice for severe cases or streptococcal concern after injection.
   Mechanism: penetrates ocular tissues; adds Gram-positive and Gram-negative activity.
   Evidence: practices vary; used in many series but not universally required for postsurgical disease (EVS); chosen case-by-case.
   Side effects: GI upset, tendon issues, QT prolongation (rare). BioMed CentralCRSToday

9. Antifungal Intravitreal Therapy (if fungal is suspected/confirmed)
   Options/doses: Amphotericin B 5 µg/0.1 mL or Voriconazole 0.1 mg/0.1 mL intravitreal; often with systemic antifungals if endogenous.
   Purpose: kill yeast/molds; do not give steroids here.
   Mechanism: amphotericin binds ergosterol; voriconazole inhibits ergosterol synthesis.
   Side effects: dose-related retinal toxicity possible—dosing is specialist-controlled. Welcome to RetinaLink

10. Repeat intravitreal antibiotic injection (“re-inject”)
    Class: same agents as #1–3.
    Timing: if the eye fails to improve or worsens at 24–48 hours, clinicians may repeat intravitreal antibiotics.
    Purpose: restore high intraocular drug levels against persistent organisms.
    Evidence/practice: widely practiced in refractory cases. Medscape

Important: Post-injection endophthalmitis is typically treated with intravitreal vancomycin + ceftazidime as first-line empiric therapy for broad coverage. That combo is the core of modern care. EyeWiki

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Dietary “molecular” supplements

There’s no supplement that treats or cures endophthalmitis. Antibiotics and (when needed) surgery do that. The items below are optional whole-body support ideas to discuss with your clinician. Avoid any product that delays getting urgent care.

1. Vitamin C (ascorbic acid) — 250–500 mg/day with food
   Function/mechanism: antioxidant; cofactor for collagen repair supporting wound healing.

2. Vitamin D3 — typically 800–2000 IU/day if deficient
   Function: supports immune signaling; many adults are deficient.

3. Zinc — 8–11 mg/day (do not exceed long-term)
   Function: cofactor for many immune enzymes; supports epithelial repair.

4. Omega-3 fatty acids (EPA/DHA) — ~1 g/day combined
   Function: anti-inflammatory lipid mediators; helpful for overall ocular surface comfort.

5. Lutein + Zeaxanthin — 10–20 mg lutein with 2–4 mg zeaxanthin/day
   Function: macular antioxidants; general retinal health support (not an infection treatment).

6. N-acetylcysteine (NAC) — 600 mg 1–2×/day
   Function: glutathione precursor; antioxidant support.

7. Selenium — ~55 µg/day
   Function: component of antioxidant enzymes (glutathione peroxidases).

8. Probiotic (evidence varies) — follow label
   Function: gut microbiome support; theoretical immune modulation.

9. B-complex (esp. B2, B6, B12) — per label
   Function: supports cellular metabolism and nerve health during recovery.

10. Curcumin (with piperine for absorption) — 500 mg/day equivalent
    Function: anti-inflammatory properties; avoid if on anticoagulants; quality varies.

Reminder: These are adjuncts and not a substitute for urgent ophthalmic treatment.

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Regenerative drugs,” or “stem cell drugs

I can’t list “immunity-booster” or “stem cell” drugs with dosages for PIE because no such products are approved, proven, or recommended for treating this eye infection, and unregulated stem-cell injections have caused blindness. It would be unsafe and misleading to suggest them. Instead, here are safer, practical alternatives to discuss with your doctors:

• Vaccination and respiratory hygiene to reduce upper-airway colonization and droplet spread (indirect prevention for future injections).

• Optimize systemic conditions (e.g., diabetes control, nutrition, smoking cessation) to support healing.

• Evidence-based ocular treatments only: intravitreal antibiotics +/- vitrectomy as needed, plus appropriate adjuncts.

• Vision rehabilitation and counseling if the infection damages the retina.

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Procedures/surgeries

1. Vitreous Tap (Needle Biopsy) with Immediate Intravitreal Antibiotics
   What: tiny sample of vitreous is drawn for culture/PCR, followed immediately by vancomycin + ceftazidime injection.
   Why: gives both diagnosis and instant therapy without delay. Standard first step in many cases. EyeWiki

2. Pars Plana Vitrectomy (PPV)
   What: micro-incision retinal surgery that removes infected vitreous, breaks up membranes, and infuses antibiotics.
   Why: Improves outcomes in the sickest eyes (classic EVS criteria: initial vision “light perception” only). Many centers also consider earlier vitrectomy in severe presentations or streptococcal infections after injections. Lippincott JournalsSpringerOpen

3. Anterior Chamber Washout/Paracentesis
   What: drain turbid anterior fluid and debris; can also instill medication.
   Why: lowers anterior inflammation, helps comfort, and yields a sample for testing.

4. Repeat Intravitreal Injection Session (Re-tap/Re-inject)
   What: a second intravitreal antibiotic dose after 24–48 h if the eye worsens or cultures demand.
   Why: restores effective drug levels against persistent microbes. Medscape

5. Evisceration/Enucleation (rare, last resort)
   What: removal of eye contents (evisceration) or entire eye (enucleation).
   Why: for uncontrolled panophthalmitis with a blind, painful eye to remove infection and relieve pain.

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Prevention steps

1. Povidone-iodine or chlorhexidine antisepsis before every shot (both effective choices). PubMedophthalmologyretina.org

2. “No talking” policy during injection; many clinics also mask the injector. JAMA Network

3. Eyelid speculum + avoid touching lashes or lid margin with the needle. American Academy of Ophthalmology

4. Do not use routine prophylactic antibiotic drops—they do not reduce PIE and may worsen resistance. AAO JournalPMCNature

5. Screen and treat active eyelid or eye infections (blepharitis, conjunctivitis) before injection.

6. Delay injection if you are acutely ill with cough, sore throat, or fever.

7. Hand hygiene for staff and patient; clean, standardized injection room workflow. Karger

8. Avoid speaking/coughing over the field; cough into elbow facing away if unavoidable. JAMA Network

9. Lash/skin prep plus adequate contact time for antiseptic (per clinic protocol). American Academy of Ophthalmology

10. Clear post-injection instructions: what to expect vs. warning signs that require immediate call-back.

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When to see a doctor

After an intravitreal injection, call immediately (same day) or go to emergency eye care if you notice any of the following—especially within the first week:

• Rapidly worsening vision or new “fog”

• Severe eye pain or deep ache

• Marked redness, swelling of lids

• Light sensitivity and new floaters

• White or yellow reflex/level inside the eye (hypopyon)

These are classic red flags of endophthalmitis and need urgent retina assessment. PentaVision

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What to eat and what to avoid

These tips support whole-body recovery; they do not treat endophthalmitis.

Eat more of:

1. Lean proteins (fish, eggs, legumes) for healing.

2. Colorful vegetables and fruits (vitamin C, carotenoids).

3. Whole grains for steady energy.

4. Healthy fats (olive oil, nuts, omega-3-rich fish).

5. Fluids—water and broths to stay hydrated.

Avoid or limit:

1. Excess sugar (spikes inflammation; problematic if you have diabetes).
2. Ultra-processed foods high in salt and trans fats.
3. Alcohol (interferes with sleep and wound repair).
4. Smoking/vaping (impairs ocular and systemic healing).
5. Unverified “eye cure” supplements that promise to treat infections—seek medical care instead.

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Frequently asked questions

1) How soon after an injection can endophthalmitis show up?
Most cases appear within a few days; call immediately if warning signs occur at any time in the first week.

2) Is it common?
Thankfully rare (large centers report very low rates), but consequences are serious—hence the careful prevention and strict after-care. jdc.jefferson.edu

3) What germs cause PIE most often?
Both Gram-positives (e.g., Staphylococcus, Streptococcus) and Gram-negatives; oral streptococci are more prominent in PIE because of droplet spread. PMC+1

4) Why is “no talking” during the shot a big deal?
Speaking spreads oral droplets that can carry streptococci; no-talking reduces that risk, and many clinicians mask as an added layer. JAMA Network

5) Do antibiotic eye drops before or after the shot prevent PIE?
Evidence says no—they don’t lower infection rates and may promote resistance. Antiseptic povidone-iodine or chlorhexidine is the proven preventive step. AAO JournalPubMed

6) What is the standard immediate treatment if PIE is suspected?
A vitreous tap plus intravitreal vancomycin + ceftazidime to cover Gram-positive and Gram-negative bacteria. EyeWiki

7) Will I need surgery?
Sometimes. If the eye is very severe at presentation, a pars plana vitrectomy to remove infected vitreous may improve the chance of visual recovery. Lippincott Journals

8) What if it’s fungal?
Intravitreal amphotericin B or voriconazole (often with systemic antifungal if the infection started in the bloodstream); steroids are avoided. Welcome to RetinaLink

9) Are intravitreal steroids helpful?
They’re optional in some bacterial cases; studies are mixed. They’re avoided if fungal infection is suspected. Your surgeon will individualize. SpringerLinkPMC

10) What does the ultrasound (B-scan) show?
It can reveal vitreous opacities, membranes, or retinal detachment when the view is too cloudy for direct exam. EyeWiki

11) Could I lose vision even with treatment?
Yes, especially with streptococcal infections, delayed care, or if a detachment occurs—but fast, appropriate therapy gives the best odds.

12) Will I need oral antibiotics too?
Practices vary. Some doctors add a short course of a fluoroquinolone in severe cases; others rely on intravitreal therapy alone, per classic EVS guidance for postsurgical disease. BioMed Central

13) Can PIE happen again?
It’s rare, but risk exists with each injection. Following prevention steps (antisepsis, no talking, standardized protocols) helps keep rates very low. Karger

14) Is chlorhexidine as good as povidone-iodine?
Recent studies suggest similar efficacy as an antiseptic for intravitreal injections. Your clinic will use one consistently. PubMed

15) What can I personally do to help?
Follow day-of-injection instructions, don’t talk during the procedure, tell your team if you’re sick, and call promptly if any warning signs appear.

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The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: August 22, 2025.