Eye emergency · UK patient guide
Endophthalmitis is an eye emergency. Same day to hospital.
Red flag — do not wait
Pain, redness and a sudden drop in vision within days to weeks of cataract surgery, an eye injection or an eye injury — go to an ophthalmology A&E today, or call 111. Do not wait for a clinic appointment.
Endophthalmitis is a sight-threatening infection inside the eye. This page is a plain-English UK guide to what it is, how it is treated (the EVS protocol, intravitreal antibiotics and pars plana vitrectomy), and what to expect. It does not replace same-day emergency care.
First — the honest advice
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This is an eye emergency — same day
Endophthalmitis is a sight-threatening infection inside the eye. If you suspect it after cataract surgery, an injection or an eye injury, go to an eye A&E now — do not wait for a clinic appointment.
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Vitreoretinal surgeons, not general clinics
Treatment needs a vitreoretinal team with intravitreal antibiotics and pars plana vitrectomy on the same site, following the RCOphth and EVS protocols.
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Independent, and free
We are paid by no clinic, so the recommendation is impartial and costs you nothing — but for endophthalmitis the first step is always the nearest eye casualty.
Red flags and prognosis
Speed of treatment is the single biggest factor in whether you keep your sight.
Endophthalmitis can destroy vision within hours. Recognise the pattern — pain, redness, sudden visual loss after intraocular surgery, injection or trauma — and act the same day.
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This is a genuine emergency
Untreated endophthalmitis can destroy vision within hours to days. Same-day intravitreal antibiotics are the single most important intervention.
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Prognosis depends on the organism
Coagulase-negative staphylococci carry the best outlook. Streptococcal, gram-negative and fungal infections do far worse — fungal disease is often diagnosed late.
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Half of severe cases lose useful vision
Even with prompt EVS-protocol treatment, roughly 50% of severe cases end with final vision worse than 6/60. Speed and organism drive outcome more than technique.
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The EVS protocol still guides UK practice
The 1995 Endophthalmitis Vitrectomy Study established: immediate PPV for light-perception vision, vitreous tap and inject for better vision, and no benefit from systemic antibiotics in post-cataract cases.
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Sample first, then treat
A vitreous sample must be taken before antibiotics where at all possible — it drives targeted therapy and helps distinguish sterile from infective inflammation.
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Steroids are delayed, not withheld
Intravitreal or oral steroids reduce collateral damage from inflammation, but are typically delayed around 48 hours until fungal infection is excluded.
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Repeat injections are common
A second intravitreal injection at 48–72 hours is standard when the clinical response is slow or the culture supports it.
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Prevention is powerful
Povidone-iodine 5–10% pre-op, intracameral cefuroxime at cataract surgery (ESCRS trial), and strict aseptic technique for injections have driven post-op rates below 0.1%.
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Red flags after any intraocular procedure
Increasing pain, worsening vision, worsening redness, floaters or a hypopyon in the days after cataract surgery or an injection — go to eye A&E the same day.
If in doubt
Ring the surgeon who did your cataract surgery or injection — most have a same-day emergency number on your discharge letter. Otherwise: nearest eye A&E, or call 111 and say “possible endophthalmitis after eye surgery”.
What happens
From the first symptom to specialist treatment — in order.
The RCOphth and EVS protocol in plain English — what a vitreoretinal team will do the moment you arrive.
- 01
Recognise
Recognise the red flags
Pain, a red eye and a sudden drop in vision within days to weeks of intraocular surgery, an injection or an eye injury. A hypopyon (pus level in the eye) is a late sign — do not wait for it.
- 02
Recognise
Get to an eye A&E immediately
Call 111, go to the nearest ophthalmology emergency department, or ring your surgeon’s on-call number. Same day, not tomorrow. Do not drive if your vision is affected.
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In hospital
Vitreous tap and intravitreal antibiotics
For vision better than light perception: a vitreous tap and inject (VTI) — a sample sent for microscopy, culture and 16S PCR, then intravitreal vancomycin plus ceftazidime (or amikacin).
- 04
In hospital
Immediate pars plana vitrectomy
If vision is light perception only, the EVS protocol calls for immediate PPV — the infected vitreous is removed and intravitreal antibiotics are delivered inside the eye.
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In hospital
Adjuncts and monitoring
Topical fortified antibiotics, oral or IV cover in selected cases, intensive review over 24–48 hours, and intravitreal steroids delayed by around 48 hours once the organism is known.
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After
Endogenous work-up if no eye trigger
If there is no recent surgery, injection or trauma, the eye infection is seeded from elsewhere — blood cultures, echocardiogram and imaging look for the systemic source (candida, staph, strep).
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After
Rehabilitation and prognosis
Repeat injections may be needed. Even with best care, roughly half of severe cases end with vision worse than 6/60 — organism and speed of treatment matter more than anything else.
Who gets endophthalmitis
Four routes in — and the classic signs to spot.
Post-cataract, post-injection, post-trauma and endogenous (seeded from the bloodstream) — the presentation is broadly the same, the source and organism differ.
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Red flag: post-cataract endophthalmitis
New pain, redness and vision drop within 1–14 days of cataract surgery. Incidence 0.05–0.1%. Go to eye A&E today, not tomorrow.
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Red flag: post-injection endophthalmitis
Pain, vision drop or floaters within days of an intravitreal injection (anti-VEGF, steroid). Rare but sight-threatening — same-day review.
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Red flag: post-trauma endophthalmitis
A penetrating eye injury — especially with soil, plant matter or metal fragments — needs same-day vitreoretinal assessment and prophylactic intravitreal cover.
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Endogenous endophthalmitis
Bloodstream seeding of the eye — often candida in the immunosuppressed, IV drug users or patients with indwelling lines; staph or strep from endocarditis or sepsis.
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Hypopyon (pus in the anterior chamber)
A visible white/yellow layer of pus at the bottom of the front of the eye is a late but classic sign. It is an emergency — do not wait for it to appear.
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Sudden loss of red reflex
On examination, loss of the red reflex and vitritis on B-scan support the diagnosis when the view of the retina is blocked.
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Chronic post-op endophthalmitis
A more indolent picture weeks to months after cataract surgery — often Propionibacterium acnes; may need capsulectomy and intravitreal antibiotics.
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Prevention matters
Povidone-iodine 5–10% pre-op, intracameral cefuroxime at cataract surgery, strict aseptic technique for intravitreal injections — the evidence base for all three is strong.
How it is treated
Intravitreal antibiotics, and — where indicated — immediate vitrectomy.
The EVS protocol still guides UK practice. Empiric intravitreal vancomycin and ceftazidime cover the usual organisms until culture and PCR return.
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Vitreous tap and inject (VTI)
The first-line procedure for eyes with vision better than light perception. Vitreous sample for MC&S, Gram stain and 16S PCR, then intravitreal vancomycin plus ceftazidime (or amikacin if allergic).
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Immediate pars plana vitrectomy (PPV)
Indicated for light-perception-only vision per the Endophthalmitis Vitrectomy Study. Removes infected vitreous, clears bacterial load and delivers intravitreal antibiotics.
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Intravitreal antibiotics — empiric
Vancomycin 1 mg/0.1 mL for gram-positive plus ceftazidime 2.25 mg/0.1 mL for gram-negative. Amikacin 0.4 mg/0.1 mL if beta-lactam allergy. Repeat at 48–72 hrs if no improvement.
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Adjunct topical and systemic cover
Fortified topical vancomycin and ceftazidime hourly, cycloplegic, systemic antibiotics in trauma and endogenous cases (moxifloxacin, meropenem depending on source).
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Intravitreal or systemic steroids
Dexamethasone is often given, but delayed roughly 48 hours until fungal disease is excluded and the organism is known — steroids worsen fungal endophthalmitis.
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Antifungals for candida endophthalmitis
Systemic voriconazole or fluconazole for candida chorioretinitis; intravitreal voriconazole or amphotericin B when vitritis is present. Prolonged 4–6 week courses.
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Sample handling and molecular diagnostics
Vitreous and aqueous samples go for microscopy, culture and sensitivity, Gram stain, and 16S rRNA PCR — PCR raises yield when culture is negative or antibiotics were started first.
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Endogenous work-up
Blood cultures, transthoracic and transoesophageal echocardiogram, urine culture, chest imaging and — where relevant — line tip culture. Treat the source, not just the eye.
NHS vs private
The NHS eye A&E is free, immediate, and the right first step.
Endophthalmitis is one of the very few situations where paying privately can cost you time. Get to the nearest ophthalmology emergency department first — private VR review is for follow-up, second opinion or shared care.
In short
Do not shop for a private appointment. Go to eye A&E today.
| Item | Indicative range | Typical duration | Turnaround |
|---|---|---|---|
| Emergency eye casualty (NHS) | Free | Same day | Immediate |
| Private VR consultant emergency review | £350–£650 | Same day | Same visit |
| Vitreous tap and intravitreal antibiotics (VTI) | £2,500–£4,500 | 30–45 min | Same day |
| Pars plana vitrectomy for endophthalmitis | £6,500–£12,000 | 60–120 min | Admission |
| Microbiology — MC&S, Gram, 16S PCR | £250–£600 | Same day | 24–72 hrs |
| Follow-up VR review | £250–£450 | 30 min | Next day |
Private ranges reflect our vetted vitreoretinal panel for follow-up, second opinion, or shared care with an NHS consultant. Insurance cover for emergency intraocular surgery is usually straightforward — we help confirm cover after the acute event.
Our vetted UK network
A small panel of vitreoretinal consultants, we picked them.
For follow-up and shared care after the acute event, and for private second opinions. Introductions are made privately, once we understand the case.
Selection criteria
How we choose every VR consultant in our panel.
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Vitreoretinal consultants on call for out-of-hours endophthalmitis
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Access to intravitreal antibiotic preparations and theatre for PPV within hours
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On-site microbiology with Gram stain, culture and 16S PCR pathway
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Formal shared care with the referring cataract or injection surgeon
Prevention
The three measures that drive the rate below 0.1%.
The evidence base is strong for all three. If you are booking cataract surgery or attending for regular intravitreal injections, these are reasonable questions to ask.
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Povidone-iodine 5–10% pre-op
The most important single step. Applied to the ocular surface before any intraocular procedure, it reduces the conjunctival bacterial load dramatically.
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Intracameral cefuroxime at cataract
The ESCRS randomised trial showed a roughly five-fold reduction in post-cataract endophthalmitis when cefuroxime is injected into the anterior chamber at the end of surgery.
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Aseptic technique for injections
Strict aseptic technique — including drape, lid speculum and povidone-iodine — for every intravitreal anti-VEGF or steroid injection keeps post-injection rates in the low single digits per 10,000.
Reading your operation note
Your VR admission letter in four parts. Read the last one first.
Whether the eye had a vitreous tap and inject or an immediate PPV, the letter the vitreoretinal team sends keeps to the same shape.
A quiet reminder
Ophthalmology language is dense — we translate it for you.
If you would like us to talk you through the note before your review, just ask.
- 01 Header
Trigger, timing and presenting vision
Whether the eye is post-cataract, post-injection, post-trauma or endogenous, days since the trigger, and the presenting visual acuity (a critical prognostic marker).
- 02 Technique
VTI or PPV, empiric antibiotic doses
Whether a vitreous tap and inject or immediate PPV was performed, plus the exact intravitreal antibiotic doses used (vancomycin, ceftazidime or amikacin).
- 03 Findings
Microbiology — Gram, culture, 16S PCR
Gram stain result on vitreous, MC&S with sensitivities, 16S rRNA PCR result, and — if endogenous — blood culture and echocardiogram findings.
- 04 Impression
Prognosis, re-injection plan, follow-up
Read this first: expected visual prognosis, whether a repeat intravitreal injection or PPV is planned, systemic antibiotic plan, and the next review appointment.
Recognised by major UK insurers
Emergency intraocular surgery is usually covered by comprehensive private policies. We confirm cover after the acute event, not during it.
Frequently asked
Everything patients ask about endophthalmitis.
Straight answers on what it is, why it is an emergency, what treatment looks like, and what to expect afterwards.
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Is endophthalmitis really an emergency?
Yes — a genuine emergency. Bacteria multiplying inside the eye can destroy the retina within hours. If you suspect it after cataract surgery, an intravitreal injection or an eye injury, go to an ophthalmology A&E the same day. Do not wait for a routine clinic appointment.
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What are the warning signs after cataract surgery or an eye injection?
Increasing pain (not the mild ache of the first day), worsening redness, a drop in vision, new floaters, and a whitish level of pus in the front of the eye (hypopyon). These usually appear 1–14 days after surgery or an injection. Any combination is a same-day trip to eye casualty.
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How common is endophthalmitis after cataract surgery in the UK?
Rare — roughly 0.05–0.1% of modern cataract cases, or 1 in 1,000 to 1 in 2,000. Intracameral cefuroxime at the end of surgery has reduced rates further. Rare does not mean impossible — the same rules apply if you develop symptoms.
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What treatment will I get in the eye A&E?
A vitreoretinal specialist will take a vitreous sample for microscopy, culture and 16S PCR, then inject antibiotics directly into the eye (usually vancomycin plus ceftazidime). If vision is down to light perception, they will take you to theatre the same day for a pars plana vitrectomy — this is the EVS protocol.
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Will I get my vision back?
Honest answer: it depends on the organism and how quickly treatment started. Coagulase-negative staph infections do best; streptococcal, gram-negative and fungal infections do far worse. Even with best modern care, roughly half of severe cases end with vision worse than 6/60. Same-day treatment gives the best chance.
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What is endogenous endophthalmitis?
The infection has seeded the eye from elsewhere in the body — most often candida in immunosuppressed patients, IV drug users or those with indwelling lines, or streptococci and staphylococci from endocarditis. It needs blood cultures, an echocardiogram and often systemic antifungals (voriconazole, fluconazole) alongside eye treatment.
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Can endophthalmitis be prevented?
The evidence-based measures are: 5–10% povidone-iodine on the eye before any intraocular procedure, intracameral cefuroxime at the end of cataract surgery, and strict aseptic technique for intravitreal injections. Together these have driven post-operative rates well below 0.1%.
Sources and guidelines
- Royal College of Ophthalmologists. Guidelines for the management of endophthalmitis.
- Endophthalmitis Vitrectomy Study Group. Results of the EVS. Arch Ophthalmol 1995;113:1479–96.
- European Society of Cataract & Refractive Surgeons. ESCRS study on intracameral cefuroxime.
- NICE. Cataracts in adults: management (NG77).
Published 2026-07-30 · Next review 2027-07-30 · Approx 6 min read. This page is patient information and does not replace individual medical advice.
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