How to prevent infections after eye surgery

May 10, 2023

Noy Ashkenazy, M.D. Ophthalmology

Elderly man with an eye shield after ophthalmology surgery — The risk of infection after eye surgery can be reduced by practicing good hygiene and wearing an eye shield, especially at night, to avoid accidentally rubbing or bumping your eye.

As people live longer, they may experience more eye injuries and age-related eye conditions, such as cataracts, cornea diseases, glaucoma, macular degeneration, diabetic retinopathy, or vitreoretinal problems like retinal detachment or bleeding in the eye.

These conditions result from damage to the tissues of the eye and may require an ophthalmologist – an eye surgeon with specialized training to treat eye diseases – to perform a vision-saving eye procedure or inject medication inside the eye.

If you need eye surgery, your ophthalmologist will talk with you about the benefits and risks, such as post-surgical eye infection. You can have confidence knowing that having an eye infection after surgery is rare. However, if it happens, getting advanced care right away can help you avoid significant vision problems.

Below are some examples of eye infections we treat most often in our specialized clinic, and tips to prevent them.

Endophthalmitis

One of the most serious eye infections is endophthalmitis, which is an inflammation of the tissues and fluids inside the eye. More than 95% of endophthalmitis cases in the U.S. are caused by staphylococci or streptococci, common bacteria associated with other serious illnesses such as MRSA, bacterial pneumonia, and toxic shock syndrome.

There are two main types of endophthalmitis:

Exogenous (most common) occurs when bacteria or fungi get into the eye from a source outside the body. For example, after surgery or intravitreal injection. It can also be caused by an eye injury or incision that is contaminated with bacteria or other organisms.
Endogenous is an infection that spreads from another part of the body to the eye through the bloodstream. People who have compromised immune systems are more at risk for endogenous infections.

Endophthalmitis can cause rapid, progressive vision loss, and must be treated as a medical emergency. It can cause permanent damage to the retina, which receives images and transmits them to the brain through the optic nerve, as well as the vitreous, the clear gel that lies between the front of the eye and the retina.

The ophthalmologist and surgical team take extensive measures at the time of eye surgery to reduce your risk of endophthalmitis, such as making sure the eye is prepped and handled in a sterile fashion throughout the procedure.

Due to these precautions, endophthalmitis is very rare. Fewer than 0.1% of patients develop it after intravitreal injections or cataract surgery. Between 3% and 10% of people with a penetrating eye trauma develop endophthalmitis – and that could be reduced to less than 1% with timely symptom recognition and treatment of an eye injury.

It is important to know the signs of endophthalmitis so it can be treated immediately to reduce the risk of complications. Symptoms of endophthalmitis can begin days after surgery and may include:

Eye pain
Decreased or blurred vision
Floaters or spots in your vision
Pus or discharge from the eyes
Redness that gets worse after eye surgery or treatment for an eye injury

See a doctor right away if you notice these symptoms; don't wait for your next appointment. UT Southwestern is one of the few medical centers in the area with an ophthalmologist and retinal and vitreous specialist on call 24/7 to treat eye emergencies at William P. Clements Jr. University Hospital.

An ophthalmologist can determine whether an infection or another condition is causing your symptoms and get you the best care to preserve your vision. Endophthalmitis treatment usually requires a retina specialist to culture the eye fluids and identify the bacteria or organism that caused the infection. This may be followed by an injection of antibiotics into the eye.

Uveitis

Uveitis can present like an eye infection but is not necessarily associated with having eye surgery. Uveitis is a rare inflammatory disease of the middle layer of the eye (the uvea). In nearly every case, the patient has done nothing “wrong” to cause their symptoms. About 40% of cases are associated with inflammation in other areas of the body, including autoimmune conditions such as lupus, multiple sclerosis, or rheumatoid arthritis. It affects just 38 per 100,000 people and, like many autoimmune diseases, often presents in patients younger than 40.

Uveitis is uncommon and often misdiagnosed until severe complications develop. While untreated uveitis can cause vision loss, when properly diagnosed it is treatable and can be well controlled with medication.

Most ophthalmologists see a few cases of uveitis per year. UT Southwestern has two uveitis specialists. We diagnose and treat this condition regularly and help manage our patients’ immunosuppressive therapies.

Eye drop-related infections

Single-use squeeze bottle eye drops reduce contamination risk.

In February 2023, the U.S. Food and Drug Administration (FDA) recalled EzriCare Artificial Tears Lubricant Eye Drops and Artificial Eye Ointment due to an outbreak of Pseudomonas aeruginosa, a common bacteria that is one of the most frequent causes of ocular and nonocular infections. Several brands of drops have since been voluntarily recalled, but if your eye drops are not included in the official recall list, they are not at known risk of contamination.

Many patients use “artificial tears” for dry eyes, a very common condition. Artificial tears are also a great way to treat eye discomfort caused by irritants to the surface of the eye. Preservative-free artificial tears are preferred for long-term use due to the lack of preservatives, which can irritate the eyes. Preservative-free tears are often packaged in individual single-use vials.

How we diagnose and treat eye infections

Diagnosis begins with an eye and vision exam from an ophthalmologist using advanced equipment that allows us to see the intricate structures deep inside the eye. If you’ve had an eye injury, we may perform an ultrasound to make sure there are no foreign objects in your eye.

The ophthalmologist will look for white blood cells inside the eye, which can indicate infection or inflammation. Excessive white blood cells make it difficult to see the retina or its blood vessels under imaging – an indication the eye may be inflamed or infected.

If we suspect you have an infection, we may need to do an aqueous/vitreous tap, in which we use a tiny needle to take some fluid from your eye to test for the source of infection. Depending on what type of bacteria or fungi appear in the tap results, we may also take blood and urine samples or order additional imaging tests.

If the infection is contained in the eye, we can inject antibiotics or antifungal medication or give you a steroid to reduce swelling or inflammation caused by the infection. For severe infections, IV antibiotics or vitrectomy surgery may be necessary. In this procedure, we remove the infected vitreous gel from your eye and replace it with a permanent artificial saline substance to preserve your vision.

Retinal, cornea, or macular injuries should be diagnosed by a specialist and treated immediately to preserve or potentially restore vision. In some cases, patching and medication can treat the condition. However, surgery may be necessary to repair damaged eye tissue.

If you have an endogenous infection, we will refer you to a specialist who can treat the infection from the source.

Tips to prevent eye infections

It’s not always possible to prevent an eye infection, but there are steps you can take to reduce your risk, including practicing good daily eye hygiene:

Wash your hands before you touch your eyes, apply eye drops, or insert or remove contacts.
Wear protective eyewear when engaging in activities that can cause eye injuries, such as using power tools, doing yard work, or playing sports.

If you have had eye surgery, follow your doctor’s instructions about eye care and activity restrictions, which may include:

Use the antibiotic and anti-inflammatory drops as prescribed. Ask a loved one or caregiver for help if you can’t put them in yourself.
Maintain good hand hygiene and wash your hands before touching your face.
Do not allow tap water directly into your eye after surgery – water from the faucet has bacteria and other organisms inside.
Keep the tip of your eye drop bottles clean and dry. Do not let the eye drop bottle touch the eye or other surfaces because it can contaminate the dropper.
Wear an eye shield, especially at night, to avoid accidentally rubbing or bumping your eye.
Attend all post-surgical checkups.

If you have a condition that can compromise your immune system – such as HIV, cancer, or diabetes – make sure it’s managed well to help prevent infection from spreading through the body, including to the eyes.

Vitreoretinal eye infections are complex conditions that can have serious consequences for your vision. But by recognizing the symptoms and seeking medical treatment quickly, together we can take the necessary steps to get you the right treatment.

To talk with an ophthalmologist, call 214-645-8300, 214-645-2020, or request an appointment online.