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In Clinical Practice

Taking a practical approach to clinical medicine, this series of smaller

reference books is designed for the trainee physician, primary care
physician, nurse practitioner and other general medical professionals
to understand each topic covered. The coverage is comprehensive but
concise and is designed to act as a primary reference tool for subjects
across the field of medicine.
Harry W. Flynn Jr., Nidhi Relhan Batra, Stephen G. Schwartz,
Prashanth G. Iyer, Lyubomyr Lytvynchuk and Andrzej Grzybowski

Endophthalmitis in Clinical Practice

2nd ed. 2023
Harry W. Flynn Jr.
Department of Ophthalmology, Bascom Palmer Eye Institute, University
of Miami Miller School of Medicine, Miami, FL, USA

Nidhi Relhan Batra

Department of Ophthalmology, Bascom Palmer Eye Institute, University
of Miami Miller School of Medicine, Miami, FL, USA

Stephen G. Schwartz
Department of Ophthalmology, Bascom Palmer Eye Institute, University
of Miami Miller School of Medicine, Naples, FL, USA

Prashanth G. Iyer
Department of Ophthalmology, Bascom Palmer Eye Institute, University
of Miami Miller School of Medicine, Miami, FL, USA

Lyubomyr Lytvynchuk
Department of Ophthalmology, Justus-Liebig-University Giessen, Eye
Clinic, University Hospital Giessen and Marburg GmbH, Giessen,
Germany

Andrzej Grzybowski
Foundation for Ophthalmology Development, Institute for Research in
Ophthalmology, Mickiewicza, Poznań , Poland

ISSN 2199-6652 e-ISSN 2199-6660

In Clinical Practice
ISBN 978-3-031-35183-9 e-ISBN 978-3-031-35184-6
https://doi.org/10.1007/978-3-031-35184-6

© The Editor(s) (if applicable) and The Author(s), under exclusive

license to Springer Nature Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively
licensed by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in
any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.

The use of general descriptive names, registered names, trademarks,

service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.

The publisher, the authors, and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
material contained herein or for any errors or omissions that may have
been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer

Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham,
Switzerland
Foreword
Over the past few decades, we have a better understanding of the
pathophysiology of intraocular infections through clinical and
microbiological studies, and we can initiate more prompt diagnosis and
treatment to improve outcomes in the management of endophthalmitis.
It is amazing to witness the changes in the differential diagnoses and
management of endophthalmitis in recent years. With the increases in
invasive ophthalmic procedures, there is a need for a concise, up-to-
date reference on clinical endophthalmitis which includes options for
antimicrobial therapy and the role of pars plana vitrectomy. This book,
entitled Endophthalmitis in Clinical Practice, meets the need very well.
Multiple chapters in the book are dedicated to specific subtopics in
endophthalmitis management. The background section includes
historical information as well as details on the Endophthalmitis
Vitrectomy Study (EVS), as well as controversies in the use of
intracameral antibiotics during cataract surgery.
This follows a discussion on the various etiologies of
endophthalmitis and includes initial treatment strategies in each
subgroup. As part of diagnostic evaluation, sections include imaging for
documentation of clinical features, echographic characteristics, and
complications affecting visual outcomes. Management of more difficult
cases may require retreatment after initial antimicrobials and
uncommonly may require removal of the capsular bag and the
intraocular lens (IOL) in specific cases. Illustrations of pre- and
posttreatment cases are shown from the authors’ clinical practice.
Pars plana vitrectomy is often considered in more rapidly advancing
cases, especially in endophthalmitis after cataract surgery in patients
presenting with light perception visual acuity. The use of vitrectomy
may be limited by corneal or media opacities, but small-gauge
vitrectomy approaches may allow a simpler approach to core
vitrectomy without the need for conjunctival dissection or suture
placement.
Antimicrobial therapy is then discussed. This includes initial broad
coverage of both Gram-positive and Gram-negative bacteria. Likewise,
antifungal agents including amphotericin B and voriconazole can be
utilized in suspected or confirmed endophthalmitis caused by fungi.
Alternative agents for resistant organisms are reviewed and the
tailoring of treatment for subsequent management.
The use of intravitreal injections for retinal diseases has become the
leading ophthalmic procedure in the United States. In these patients,
endophthalmitis can occur from solution contamination as well as from
the injection procedure itself. These cases generally present early after
injection and frequently involve oropharyngeal flora from
contamination of the needle or the ocular surface during drug delivery.
Streptococcus as well as other Gram-positive organisms in these cases
may have a more advanced clinical presentation with poor visual and
anatomic outcomes.
This text will undoubtedly prove to be a valuable asset for clinical
ophthalmologists as well as retinal specialists. The abundant clinical
illustrations, concise tables, and reference material enhance its
readability. With the exception of the EVS, there are no major
randomized clinical trials on which to base definitive
recommendations. Rather, the authors utilize published case series and
their own experience to provide guidelines regarding the prompt and
efficient management of endophthalmitis.
Richard K. Forster
Conflict of Interest
Funding/Grant Support—This work was supported in part by
National Institutes of Health center core grant P30EY014801 and by
unrestricted grant from the Institute for Research in Ophthalmology,
Foundation for Ophthalmology Development, Poznan, Poland.

Financial Disclosures
Dr. Harry W. Flynn Jr.—None
Dr. Nidhi Relhan Batra—None
Dr. Prashanth Iyer—None
Dr. Lyubomyr Lytvynchuk—None
Dr. Stephen G. Schwartz discloses personal fees from Alimera,
Bausch + Lomb, and Welch Allyn within the past 3 years.
Dr. Andrzej Grzybowski reports grants from Alcon, Bausch&Lomb,
Zeiss, Teleon, J&J, CooperVision, Hoya; lectures honoraria from Thea,
Polpharma, Viatris; member of Advisory Boards: Nevakar, GoCheckKids,
and Thea; all outside the submitted work.
Endophthalmitis
Endophthalmitis is characterized by marked inflammation of
intraocular fluids and tissues. Infectious endophthalmitis may be
categorized by the apparent cause of the infection, including the onset
of symptoms, the degree of inflammation, and other factors. The
classification helps to plan further management and helps in predicting
the treatment outcomes.
Endophthalmitis may be exogenous (caused by inoculation of
microorganisms from the external environment) or endogenous
(caused by hematogenous spread from other parts of the body). All
categories of endophthalmitis are associated with variable degrees of
marked intraocular inflammation, typically with hypopyon, in addition
to visual loss, redness, and pain.
The diagnosis, treatment, and prophylaxis of endophthalmitis have
been discussed in this book.
1. Classification of Endophthalmitis

2. Differential Diagnosis of Endophthalmitis

3. Making the Diagnosis of Endophthalmitis

4. Endophthalmitis Categories

5. Antimicrobial Treatment

6. Endophthalmitis Prophylaxis

7. Endophthalmitis and Retinal Detachment

8. Antibiotic Stewardship

9. Outcomes (Anatomical and Functional) and Complications of

Treatment
10. Endophthalmitis: Miscellaneous Categories
How to Use This Book
Endophthalmitis remains an uncommon but serious cause of visual
loss. Early diagnosis and treatment may restore useful vision for many
patients. However, visual outcomes may be poor despite prompt and
appropriate therapy in other patients. This book is intended to be a
practical guide to the clinical management of patients with
endophthalmitis.
The guidelines included in this book are based on the current peer-
reviewed literature, as well as the authors’ experience and opinions.
Summary statements from published studies are adapted for inclusion
in the current text. These adaptations are used to ensure that the exact
message is conveyed since rephrasing of sentences may change the
original message. The Endophthalmitis Vitrectomy Study (EVS) was a
randomized clinical trial that has provided high-level evidence for
endophthalmitis associated with cataract surgery or secondary
intraocular lens (IOL) surgery between 1991 and 1994. However, many
patients with endophthalmitis from other causes have a different
spectrum of microbial etiologies, a different set of clinical features, and
a different visual prognosis. The best available evidence for these
patients consists of clinical case series and individual case reports.
This book provides guidance for an overall approach to the
diagnosis and management of endophthalmitis, but the broad
guidelines do not always apply to an individual patient, and treatment
has to be individualized. The ultimate judgment regarding the care of
an individual patient must be made by the treating physician,
incorporating the specific clinical features, systemic risk factors, the
microorganisms involved, and the wishes of the patient.
This book is not intended to be an all-inclusive document nor a
medical-legal resource. It is intended to provide practical guidelines in
the care of patients with endophthalmitis.
Contents
1 Endophthalmitis:​Classification and Most Frequently Reported
Organisms
2 Differential Diagnosis of Endophthalmitis
Toxic Anterior Segment Syndrome
Retained Lens Fragments
Flare-Up of Pre-existing Uveitis
Vitreous Hemorrhage
Retinoblastoma
Uveal Melanoma
Intravitreal Triamcinolone Acetonide
Viral Retinitis
Noninfectious Inflammation from Intravitreal Injections
Brolucizumab-Related Intraocular Inflammation
Drug-Associated Uveitis (a Rare Cause of Pseudoendophthal​
mitis)
3 Diagnosis of Endophthalmitis:​Clinical Presentation, Pathology,
Microbiology, and Echography
Clinical Presentations
Microbiology
How to Perform TAP and Inject
Intravitreal Antimicrobial Injection
Results of Anterior Chamber TAP Versus Vitreous TAP
Culture Media
Other Testing
Echography
4 Acute-Onset Endophthalmitis:​Clinical Categories, Incidence
Rates, Signs/​Symptoms, Risk Factors, Microbiology, Treatment,
and Follow-Up
Acute-Onset Post-Operative Endophthalmitis Following
Cataract Surgery
Incidence
Signs/​Symptoms
Risk Factors
Microbial Isolates
Initial Management of Acute-Onset Post-Operative
Endophthalmitis
Intravitreal antimicrobials
Follow-Up Management of Acute-Onset Post-Operative
Endophthalmitis
Acute-Onset Endophthalmitis Following Pars Plana Vitrectomy
Incidence
Signs/​Symptoms
Risk Factors
Microbial Isolates
Endophthalmitis after Pars Plana Vitrectomy for Vitreous
Floaters
Initial Management of Acute-Onset Endophthalmitis
Following Vitrectomy
Follow-Up Management in Patients with Acute-Onset
Endophthalmitis Following Vitrectomy
Post-Traumatic Endophthalmitis
Incidence
Signs/​Symptoms
 Risk Factors
Microbial Isolates
Initial Management of Post-Traumatic Endophthalmitis
Follow-Up Management in Patients with Post-Traumatic
Endophthalmitis
Endophthalmitis Associated with Intravitreal Injection
Incidence
Signs/​Symptoms of Endophthalmitis after Intravitreal
Injections
Risk Factors
Microbial Isolates
Initial Management of Endophthalmitis Associated with
Intravitreal Injection
Follow-Up Management in Patients with Endophthalmitis
Associated with Intravitreal Injection
Additional Discussion Points
Vitreous TAP Versus AC TAP/​Paracentesis
Controversies in Care
Systemic Immunosuppressiv​es and the Risk of Post-Cataract
Surgery Endophthalmitis
5 Delayed-Onset (Chronic) Endophthalmitis and Miscellaneous
Categories:​Incidence Rates, Signs/​Symptoms, Risk Factors,
Microbiology, Treatment, and Follow-Up
Delayed-Onset (Chronic) Post-Operative Endophthalmitis
Following Cataract Surgery
Incidence
Signs/​Symptoms
Risk Factors
 Microbial Isolates
Initial Management of Delayed-Onset Endophthalmitis
Follow-Up Management in Patients with Delayed-Onset
Post-Operative Endophthalmitis
Two to Three Days after Initial Treatment
Conjunctival Filtering Bleb:​Associated Infection and
Endophthalmitis
Incidence of Bleb-Associated Endophthalmitis
Signs/​Symptoms
Risk Factors
Microbial Isolates
Initial Management of Conjunctival Filtering Bleb-
Associated Endophthalmitis
Follow-Up Management in Patients with Conjunctival
Filtering Bleb-Associated Infection or Endophthalmitis
Endophthalmitis Associated with Glaucoma Drainage
Devices
Incidence
Signs/​Symptoms
Risk Factors
Microbiology
Initial Management of Glaucoma Drainage Device-
Associated Endophthalmitis
Follow-Up Management in Patients with Endophthalmitis
Associated with Glaucoma Drainage Devices
Delayed-Onset Endophthalmitis Associated with Keratitis
Incidence
Signs/​Symptoms
 Risk Factors for Keratitis that May Lead to Endophthalmitis
Microbial Isolates
Initial Management of Endophthalmitis Associated with
Keratitis
Follow-Up Management in Patients with Endophthalmitis
Associated with Keratitis
The Role of Corneal Collagenous Cross-Linking (CXL) in the
Treatment of Keratitis and Corneal Ulcers
The Role of Photodynamic Therapy in Advanced Keratitis with
Threat of Endophthalmitis
Endophthalmitis after Pterygium Removal
Endophthalmitis After Strabismus Surgery
Endophthalmitis Post-Suture Removal
Endophthalmitis after Blepharoplasty
6 Endogenous Endophthalmitis:​Incidence Rates, Signs/​Symptoms,
Risk Factors, Microbiology, Treatment, and Follow-Up
Endogenous Fungal Endophthalmitis
Incidence
Signs/​Symptoms
Risk Factors
Malignancy
Microbial Isolates
Initial Management of Endogenous Fungal Endophthalmitis
Follow-Up Management in Patients with Endogenous Fungal
Endophthalmitis
Screening of Endogenous Candida Endophthalmitis in the
Hospital Setting
Endogenous Bacterial Endophthalmitis
 Incidence
Signs/​Symptoms
Risk Factors
Malignancy
Microbial Isolates
Initial Management of Endogenous Bacterial
Endophthalmitis
Follow-Up Management in Patients with Endogenous
Bacterial Endophthalmitis
7 Pars Plana Vitrectomy for the Management of Endophthalmitis:​
Endophthalmitis Vitrectomy Study and Beyond
Endophthalmitis Vitrectomy Study
Early Vitrectomy for Endophthalmitis (beyond the EVS)
Endophthalmitis in Phakic Eyes
Endoscopic Vitrectomy for Endophthalmitis
8 Antimicrobial Treatment, Resistance, and Alternatives
Antimicrobial Routes
Summary of Antimicrobial Dosages
Preparation of Antimicrobials
Preparation of Intravitreal Antimicrobials
Preparation of Subconjunctival Antibiotics
Preparation of Fortified Topical Antimicrobials
Adverse Effects of Antimicrobials
Antimicrobial Resistance and Alternatives
Data on Antimicrobial Resistance
Pharmacokinetics​and Pharmacodynamics​of Antimicrobials
9 Endophthalmitis Prophylaxis
 Antisepsis
Topical Antibiotics
Topical Antibiotics:​Literature
Systemic Antibiotics
Endophthalmitis Prophylaxis for Specific Case Scenarios
Endophthalmitis Prophylaxis for Cataract Surgery
Corneal Wound Closure
Endophthalmitis Prophylaxis for Intravitreal Injections
Endophthalmitis Prophylaxis for Open Globe Injuries
10 Retinal Detachment (RD) and Endophthalmitis
Frequency:​Retinal Detachment in Endophthalmitis
Visual Outcomes:​Retinal Detachment in Endophthalmitis
Presentation:​Retinal Detachment in Endophthalmitis
Risk Factors Associated with Poor Visual Outcomes in Eyes with
RD and Endophthalmitis
Role of Silicone Oil in Endophthalmitis Patients
Hyperoleon
Antimicrobial Properties of Silicone Oil
Literature:​Silicone Oil in Endophthalmitis and
Rhegmatogenous Retinal Detachment
11 Antibiotic Stewardship
12 Outcomes (Anatomic and Functional) and Treatment-Related
Complications
Treatment Outcomes of Acute-Onset Post-Operative
Endophthalmitis Following Cataract Surgery
Outcomes as Reported by the EVS
Lalwani et al.​2008
 Yannuzzi et al.​2016
Treatment Outcomes of Delayed-Onset Post-Operative
Endophthalmitis Following Cataract Surgery
Clark et al
Shirodkar et al.​(2012)
Treatment Outcomes of Endophthalmitis after Pars Plana
Vitrectomy
Treatment Outcomes of Endophthalmitis Following Glaucoma
Surgery
Conjunctival Filtering Bleb-Associated Infection and
Endophthalmitis
Endophthalmitis Associated with Glaucoma Drainage
Devices
Treatment Outcomes of Post-Traumatic Endophthalmitis
Colyer et al.​(Ophthalmology 2007)
Mieler et al.​(Ophthalmology 1990)
Banker et al.​(OSLI Retina, 2017)
Treatment Outcomes of Endogenous Endophthalmitis
Schiedler et al.​(2004)
Lingappan et al.​(2012)
Sridhar et al.​(2013)
Treatment Outcomes of Endophthalmitis Associated with
Intravitreal Injection
Goldberg et al.​(Ophthalmology 2013)
Gregori et al.​(Retina 2015)
Yannuzzi et al.​(OSLI-Retina 2018)
Complications Associated with Endophthalmitis Prophylaxis/​
Treatment
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. W. Flynn Jr. et al., Endophthalmitis in Clinical Practice, In Clinical Practice
https://doi.org/10.1007/978-3-031-35184-6_1

1. Endophthalmitis: Classification and

Most Frequently Reported Organisms
Harry W. Flynn Jr.1 , Nidhi Relhan Batra1, Stephen G. Schwartz2 ,
Prashanth G. Iyer1, Lyubomyr Lytvynchuk3 and Andrzej Grzybowski4
(1) Department of Ophthalmology, Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine, Miami, FL, USA
(2) Department of Ophthalmology, Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine, Naples, FL, USA
(3) Department of Ophthalmology, Justus-Liebig-University Giessen,
Eye Clinic, University Hospital Giessen and Marburg GmbH,
Giessen, Germany
(4) Foundation for Ophthalmology Development, Institute for
Research in Ophthalmology, Mickiewicza, Poznań , Poland

Harry W. Flynn Jr. (Corresponding author)

Email: [email protected]

Stephen G. Schwartz
Email: [email protected]

Keywords Endophthalmitis – Categories – Post-operative –

Endogenous – Post-traumatic

1. Post-operative endophthalmitis
Following cataract surgery: Acute-onset post-operative
endophthalmitis
 Coagulase (−) Staphylococci, Staphylococcus aureus,
Streptococcus, Gram-negative bacteria
Following cataract surgery: Delayed-onset post-operative
endophthalmitis
Cutibacterium acnes, coagulase (−) Staphylococci, fungi
Following glaucoma surgery: Conjunctival filtering bleb-
associated infection and endophthalmitis
Streptococcus species, Haemophilus influenzae, Staphylococcus
species
Following glaucoma surgery: Endophthalmitis associated with
glaucoma drainage devices
Following elective corneal transplant
2. Post-traumatic endophthalmitis
Bacillus species (30–40%), Staphylococcus species,
Cutibacterium acnes, Pseudomonas, and Streptococcus species.

3. Endogenous Endophthalmitis
Candida species, Staphylococcus aureus, Gram-negative bacteria
(Klebsiella), Aspergillus.

4. Endophthalmitis Associated with Keratitis

Pseudomonas, Staphylococcus/Streptococcus species, Fusarium,

Paecilomyces, Candida.
5. Endophthalmitis Associated with Intravitreal Injection

Staphylococcus/Streptococcus species, Abiotrophia defectiva(Figs.

1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 1.10, 1.11, 1.12,1.13, 1.14, 1.15,
1.16, 1.17, 1.18, 1.19, 1.20, 1.21, 1.22, 1.23, 1.24, and 1.25).
Figure 1.1 Acute-onset endophthalmitis. A 78-year-old male patient with acute-
onset post-operative endophthalmitis following cataract surgery. (a) The patient
presented with conjunctival congestion, mild corneal edema, hypopyon, hazy view to
the posterior segment, and hand motions (HM) visual acuity. Patient underwent
vitreous tap and intraocular antibiotics (vancomycin and ceftazidime). The vitreous
culture was positive for Staphylococcus epidermidis resistant to all fluoroquinolones
and sensitive to vancomycin. (b) At 8-month follow-up, the patient regained best
corrected visual acuity of 20/30

Figure 1.2 Acute-onset endophthalmitis. A 68-year-old male patient with acute-

onset post-operative endophthalmitis following cataract surgery. (a) The patient
presented with conjunctival congestion, mild corneal edema, hypopyon, and hand
motions (HM) visual acuity. The patient underwent vitreous tap and intraocular
antibiotics and was culture positive for methicillin-resistant Staphylococcus aureus
(MRSA) resistant to all fluoroquinolones. (b) At 6-month follow-up, the patient
regained best corrected visual acuity of 2/200 with persistent corneal haze

Figure 1.3 Acute-onset endophthalmitis. A 66-year-old male patient with acute-

onset post-operative endophthalmitis following cataract surgery. (a) The patient
presented with conjunctival congestion, fibrinous reaction in the anterior chamber,
hypopyon, polypropylene suture at 12 o’clock to close a sector iridectomy, restricted
view to the posterior segment, and hand motions (HM) visual acuity. The patient
underwent vitreous tap and intraocular antibiotics and was culture positive for
coagulase-negative Staphylococcus. (b) At 1-year follow-up, the patient regained best
corrected visual acuity of 20/30. The polypropylene suture was not removed at the
time of treatment

Figure 1.4 Acute-onset endophthalmitis. A 70-year-old male patient with acute-

onset post-operative endophthalmitis following cataract surgery. (a) The patient
presented with conjunctival congestion, mild corneal edema, hypopyon, and hand
motions (HM) visual acuity. Patient underwent vitreous tap and intraocular
antibiotics and was culture positive for coagulase-negative Staphylococcus. (b) At 1-
year follow-up, the patient regained best corrected visual acuity of 20/25

Figure 1.5 Acute-onset endophthalmitis. A 76-year-old female patient with acute-

onset endophthalmitis following cataract surgery with intracameral moxifloxacin.
(a) The patient presented with conjunctival congestion, fibrinous reaction in the
anterior chamber, hazy view to the posterior segment, and hand motions (HM) visual
acuity. Patient underwent vitreous tap and intraocular antibiotics (vancomycin and
ceftazidime) and was culture negative. (b) At 3-week follow-up, the patient regained
best corrected visual acuity of 20/25 with resolution of inflammation

Figure 1.6 Acute-onset endophthalmitis. A 78-year-old male patient with acute-

onset post-operative endophthalmitis following cataract surgery. (a) The patient
presented with conjunctival congestion, mild corneal edema, hypopyon, fibrinous
membrane in the anterior chamber, and hand motions (HM) visual acuity. Patient
underwent vitreous tap and intraocular antibiotics and was culture positive for
methicillin-sensitive Staphylococcus aureus (MSSA) susceptible to fourth-generation
fluoroquinolones. (b) At 6-month follow-up, the patient regained best corrected
visual acuity of 20/50. The visual acuity reduction was associated with cystoid
macular edema

Figure 1.7 Acute-onset endophthalmitis. A 74-year-old male patient with acute-

onset post-operative endophthalmitis following cataract surgery. (a) The patient
presented with conjunctival congestion, fibrinous membrane in the anterior chamber
over the intraocular lens, hazy view of the posterior segment, and hand motions
(HM) visual acuity. The patient underwent vitreous TAP (culture negative) and
intraocular antibiotics. (b) At 2-week follow-up, the patient regained best corrected
visual acuity of 20/25 with resolving inflammation and infection

Figure 1.8 Acute-onset endophthalmitis. A 78-year-old male patient with acute-

onset post-operative endophthalmitis 1 day following cataract surgery. (a) The
patient presented with conjunctival congestion, mild corneal edema, hypopyon,
fibrinous membrane in the anterior chamber, hazy view of the posterior segment,
and light perception (LP) visual acuity. The patient underwent pars plana vitrectomy
and intraocular antibiotics. The vitreous culture was positive for Serratia marcescens.
(b) At 1-year follow-up, the patient regained best corrected visual acuity of 20/50
Figure 1.9 Acute-onset endophthalmitis. A 65-year-old male patient with acute-
onset post-operative endophthalmitis following cataract surgery. (a) The patient
presented with conjunctival congestion, mild corneal edema, hypopyon,
polypropylene suture in the iris superiorly, fibrinous membrane in the anterior
chamber, hazy view of the posterior segment, and light perception (LP) visual acuity.
The patient underwent vitreous tap and intraocular antibiotics. The vitreous culture
was positive for Streptococcus viridans. (b) At 1-year follow-up, the patient regained
best corrected visual acuity of 20/25
Figure 1.10 Acute-onset endophthalmitis. A 76-year-old female patient with acute-
onset endophthalmitis following cataract surgery with intracameral moxifloxacin.
Presenting features 4 days after cataract surgery include fibrin in anterior chamber,
hazy view of the vitreous cavity, and cystic retinal thickness on OCT
Figure 1.11 Bleb-associated endophthalmitis. A 66-year-old male patient with
bleb-associated endophthalmitis following trabeculectomy. (a) The patient presented
with conjunctival congestion, purulent blebitis, mild corneal edema, hypopyon,
fibrinous membrane in the anterior chamber and pupillary area, hazy view to the
posterior segment, and hand motions (HM) visual acuity. The patient underwent pars
plana vitrectomy and intraocular antibiotics. The vitreous culture was positive for
coagulase-negative Staphylococcus. (b) At 6-month follow-up, the patient regained
best corrected visual acuity of 20/30 with resolution of endophthalmitis

Figure 1.12 Bleb-associated endophthalmitis. A 66-year-old male patient with

bleb-associated endophthalmitis following trabeculectomy. (a) The patient presented
with conjunctival congestion, bleb infection, mild corneal edema, hazy view to the
posterior segment, and light perception (LP) visual acuity. The patient underwent
pars plana vitrectomy and intraocular antibiotics. The vitreous culture was positive
for Moraxella species. (b) At 6-month follow-up, the patient regained best corrected
visual acuity of 20/100 with resolution of endophthalmitis
Figure 1.13 Bleb-associated endophthalmitis. A 72-year-old female patient with
bleb-associated endophthalmitis following trabeculectomy. (a) At presentation, the
patient had conjunctival congestion, bleb infection, corneal edema, hazy view to the
posterior segment, and hand motions (HM) visual acuity. The patient underwent pars
plana vitrectomy and intraocular antibiotics. The vitreous culture was positive for
Streptococcus species. (b) At 1-year follow-up, the patient had resolution of
endophthalmitis, but the visual acuity deteriorated to no light perception (NLP)

Figure 1.14 Bleb-associated endophthalmitis. A 72-year-old female patient with

bleb-associated endophthalmitis following trabeculectomy. (a) At presentation
patient had conjunctival congestion, bleb infection, corneal edema, hypopyon,
fibrinous membrane in the anterior chamber and pupillary area, hazy view to the
posterior segment, and light perception (LP) visual acuity. The patient underwent
vitreous tap and intraocular antibiotics. The vitreous culture was positive for
Enterococcus faecalis. (b) At 2-month follow-up, the inflammation and infection
started resolving, but the visual acuity deteriorated to no light perception (NLP)
Figure 1.15 Bleb-associated endophthalmitis. A 66-year-old female patient with
bleb-associated endophthalmitis following trabeculectomy. (a) At presentation, the
patient had conjunctival congestion, bleb infection, corneal edema, hypopyon, hazy
view to the posterior segment, and 2/200 visual acuity. The patient underwent
vitreous tap and intraocular antibiotics. The vitreous culture was negative for any
organism. (b) At 6-month follow-up, the patient had complete resolution of
endophthalmitis and best corrected visual acuity improved to 20/400

Figure 1.16 Chronic/delayed-onset post-operative endophthalmitis. A 69-year-old

male patient with delayed-onset post-operative endophthalmitis following cataract
surgery. (a) The patient presented with gradual painless decrease in vision,
conjunctival congestion, hypopyon, inflammatory cells in the anterior chamber, and
20/200 visual acuity. Patient underwent pars plana vitrectomy and intraocular
antibiotics injection. The vitreous culture was positive for Cutibacterium acnes. A
repeat pars plana vitrectomy, removal of the intraocular lens, and intraocular
antibiotics injection were performed. (b) At 6-month follow-up, the patient regained
best corrected visual acuity of 20/25 with resolution of inflammation
Figure 1.17 Chronic/delayed-onset post-operative endophthalmitis. A 77-year-old
female patient with delayed-onset post-operative endophthalmitis following cataract
surgery. (a) The patient presented with gradual painless decrease in vision,
conjunctival congestion, hypopyon, fibrinous membrane in the anterior chamber, and
hand motions (HM) visual acuity. The patient underwent pars plana vitrectomy and
intraocular antibiotics injection. The vitreous culture was positive for Xanthomonas
species. (b) At 1-year follow-up, the patient regained best corrected visual acuity of
20/50 with resolution of inflammation

Figure 1.18 Endogenous endophthalmitis. (a) A 60-year-old female patient with

uncontrolled diabetes mellitus presented with sudden blurring of vision, vitreous
floaters, and hand motions (HM) visual acuity. The fundus examination showed
hyperemic disc and presence of subretinal exudates at the posterior pole. The patient
underwent vitreous tap and intraocular antibiotics. The vitreous culture was
positive for Staphylococcus aureus. (b) At 1-month follow-up, the inflammation and
infection started resolving with best corrected visual acuity improving to 20/40
Figure 1.19 Endophthalmitis after intravitreal injection. A 56-year-old male
patient presented 1 day after intravitreal anti-VEGF injection for age-related macular
degeneration (AMD) with sudden painful decrease in vision. (a) The patient
presented with conjunctival congestion, conjunctival chemosis, hypopyon, fibrinous
membrane in the anterior chamber, hazy view of the posterior segment, and hand
motions (HM) visual acuity. The patient underwent vitreous tap and intraocular
injection (vancomycin, ceftazidime, and dexamethasone). The vitreous culture was
positive for coagulase-negative Staphylococcus. (b) At 1-year follow-up, the
inflammation and infection resolved with best corrected visual acuity improved to
20/50

Figure 1.20 Endophthalmitis after intravitreal injection. A 60-year-old male

patient with neovascular age-related macular degeneration (AMD) presented 1 day
after intravitreal aflibercept injection with sudden painful decrease in vision. The
patient presented with conjunctival congestion, corneal edema, hypopyon, fibrinous
reaction in the anterior chamber, hazy view of the posterior segment, and light
perception (LP) visual acuity. The patient underwent pars plana vitrectomy and
intraocular injection (vancomycin and ceftazidime). The vitreous culture was culture
negative
Figure 1.21 A 60-year-old male patient with age-related macular degeneration
(AMD) received compounded intravitreal bevacizumab. Two days after injection, the
patient presented with pain, redness, and counting fingers (CF) visual acuity. (a) Slit-
lamp examination showed the presence of fibrin in anterior chamber. (b) Posterior
segment was hazy with no clarity of fundus details. The patient underwent a vitreous
tap and intraocular injection of antibiotics. (c) At 6 months follow-up, the
inflammation and infection resolved and best corrected visual acuity improved to
20/25. The patient was one of the 12 patients among an outbreak of Streptococcus
endophthalmitis after compounded intravitreal bevacizumab
Figure 1.22 Endophthalmitis after intravitreal injection. A 60-year-old male
patient with central retinal vein occlusion/neovascular glaucoma (CRVO/NVG)
presented 2 days after intravitreal aflibercept injection with sudden painful decrease
in visual acuity. (a) The patient presented with conjunctival congestion, corneal
edema, exudates filling the anterior chamber, no view of the posterior segment, and
light perception (LP) visual acuity. The patient underwent vitreous tap and
intraocular injection. (b) At 3-week follow-up, the inflammation and infection
persisted, and visual acuity deteriorated to no light perception (NLP). The patient
underwent evisceration, and the specimen culture was positive for Streptococcus
species

Figure 1.23 A 72-year-old male patient with bleb-associated endophthalmitis

following trabeculectomy. (a) The patient presented with conjunctival congestion,
bleb infection, mild corneal edema, hypopyon, cataract, hazy view to the posterior
segment and counting fingers (CF) visual acuity. Patient underwent vitreous tap and
intraocular antibiotics. The vitreous culture was positive for Moraxella species. (b)
At 6-month follow-up, the patient regained best corrected visual acuity of 20/25
after subsequent cataract surgery

Figure 1.24 Endophthalmitis after intravitreal injection. A 60-year-old male

patient with neovascular age-related macular degeneration (AMD) presented 2 days
after intravitreal ranibizumab injection with sudden painful decrease in vision. (a)
Slit-lamp examination showed conjunctival congestion, corneal edema, hypopyon,
infectious exudates in the anterior chamber, no view of the posterior segment, and
light perception (LP) visual acuity. The patient underwent vitreous tap and
intraocular antibiotic injection. The vitreous culture was positive for Streptococcus
mitis/oralis. (b, c) Inflammation and infection remained uncontrolled. (d) Two weeks
after pars plana vitrectomy, lensectomy, and silicone oil injection, inflammation and
infection reduced. However, 6 months later, the patient underwent enucleation for
the painful blind eye
Figure 1.25 Endophthalmitis after intravitreal injection. A 60-year-old male
patient with neovascular age-related macular degeneration (AMD) presented 1 day
after intravitreal ranibizumab injection with sudden painful decrease in vision. (a)
Slit-lamp examination showed conjunctival congestion, corneal edema, hypopyon,
fibrinous membrane in the anterior chamber, no view of the posterior segment, and
hand motions (HM) visual acuity. The patient underwent vitreous tap and
intraocular antibiotic injection. The vitreous culture was positive for Streptococcus
sanguis. (b–d) Inflammation and infection persisted and visual acuity became no
light perception (NLP)

References: Endophthalmitis (General Reviews)

American Academy of Ophthalmology Cataract/Anterior Segment
Summary Benchmark–2021 for Preferred practice pattern
guidelines. https://​www.​aao.​org/​summary-benchmark-detail/​
cataract-anterior-segment-summary-benchmark-2020. Accessed 3
April 2022
Cataract in the Adult Eye PPP - 2021. American Academy of
Ophthalmology (AAO) Preferred PRactice Pattern (PPP)
Cataract/Anterior Segment Panel, Hoskin Center for Quality Eye Care.
Accessed April 4 2022
Packer M, Chang DF, Dewey SH, Little BC, Mamalis N, Oetting TA, et al.
Prevention, diagnosis, and management of acute postoperative
bacterial endophthalmitis. J Cataract Refract Surg 2011;37(9):1699–
714
Schwartz SG, Flynn Jr. HW, Scott IU. Endophthalmitis: classification
and current management. Expert Rev Ophthalmol 2007;2(3):385–96
Vaziri K, Schwartz SG, Kishor K, Flynn HW, Jr. Endophthalmitis: state
of the art. Clin Ophthalmol 2015;9:95–108
Wykoff CC, Parrott MB, Flynn HW, Shi W, Miller D, Alfonso EC.
Nosocomial acute-onset postoperative endophthalmitis at a
university teaching hospital (2002–2009). Am J Ophthalmol
2010;150(3):392–8.e2
Kernt M, Kampik A. Endophthalmitis: pathogenesis, clinical
presentation, management, and perspectives. Clin Ophthalmol 2010
Mar 24;4:121–35
Scott IU, Flynn HW Jr, Feuer W, Pflugfelder SC, Alfonso EC, Forster RK,
Miller D. Endophthalmitis associated with microbial keratitis.
Ophthalmology 1996 Nov;103(11):1864–70
Reyes-Capo DP, Yannuzzi NA, Smiddy WE, Flynn HW Jr;
Endophthalmitis/Anti-VEGF Study Group*. Trends in
Endophthalmitis associated with intravitreal injection of anti-VEGF
Agentsat a tertiary referral center. Ophthalmic Surg lasers imaging
Retina 2021 Jun;52(6):319–326
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. W. Flynn Jr. et al., Endophthalmitis in Clinical Practice, In Clinical Practice
https://doi.org/10.1007/978-3-031-35184-6_2

2. Differential Diagnosis of
Endophthalmitis
Harry W. Flynn Jr.1 , Nidhi Relhan Batra1, Stephen G. Schwartz2 ,
Prashanth G. Iyer1, Lyubomyr Lytvynchuk3 and Andrzej Grzybowski4
(1) Department of Ophthalmology, Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine, Miami, FL, USA
(2) Department of Ophthalmology, Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine, Naples, FL, USA
(3) Department of Ophthalmology, Justus-Liebig-University Giessen,
Eye Clinic, University Hospital Giessen and Marburg GmbH,
Giessen, Germany
(4) Foundation for Ophthalmology Development, Institute for
Research in Ophthalmology, Mickiewicza, Poznań , Poland

Harry W. Flynn Jr. (Corresponding author)

Email: [email protected]

Stephen G. Schwartz
Email: [email protected]

Keywords Toxic anterior segment syndrome (TASS) – Retained lens

material – Uveitis – Hemorrhage – Pseudoendophthalmitis

Endophthalmitis is a clinical diagnosis, confirmed with subsequent

laboratory testing. Endophthalmitis must be distinguished from
noninfectious inflammation as well as noninflammatory cellular
infiltration, including hemorrhage and tumor cells. Endophthalmitis
with negative intraocular cultures is relatively common, reported in the
range of about 20% following intraocular surgery and up to 50%
following intravitreal injection.
It is important to consider the various conditions which may mimic
as infectious endophthalmitis. The following are some conditions that
should be differentiated from infectious endophthalmitis:
(a) Toxic anterior segment syndrome (TASS)

(b) Retained lens material

(c) Flare-up of pre-existing uveitis

(d) Chronic vitreous hemorrhage

(e) Retinoblastoma (in children)

(f) Retained triamcinolone acetonide

(g) Viral retinitis

(h) Pseudoendophthalmitis from intravitreal injections

Toxic Anterior Segment Syndrome (Fig. 2.1)

Toxic anterior segment syndrome (TASS) is an acute post-operative
sterile inflammation of the anterior segment which occurs due to toxic
effects on corneal endothelium (Fig. 2.1). The following are
characteristic features of TASS:
Usually identified on the first day following cataract surgery—
Symptoms of TASS characteristically appear 12–48 h after the
surgery.
Prominent corneal edema is observed from limbus to limbus—Corneal
edema with limbus to limbus involvement is noted in most cases.
Prominent anterior chamber cells (usually without hypopyon)—The
inflammation usually does not involve the vitreous. Inflammation in
the anterior segment is may be severe with fibrinous reaction.
Figure 2.1 Toxic anterior segment syndrome (TASS) with limbus to limbus corneal
edema
The most common symptom of TASS is blurred vision. Patients may
present with blurred vision and mild pain on the same day of the
surgery or within 24 h after the surgery. In addition, the iris may be
irregular with unreactive pupils. Damage to the trabecular meshwork
may result in secondary glaucoma. Differentiating features between
TASS and endophthalmitis are shown in Table 2.1.

Table 2.1 Differences between toxic anterior segment syndrome (TASS) and
endophthalmitis

Differences between TASS and endophthalmitis

TASS Endophthalmitis
Cause Noninfectious reaction to Bacterial, fungal, or viral
toxic agent present in: infection
• Irrigating solutions
• Antibiotic injection
• Endotoxin
• Residue
Onset 12–24 h 4–7 days
Another random document with
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 "Sticking together," was Master Henly's concise and descriptive answer.

"Glad to hear it," said Willard, repressing a strong inclination to laugh.

"Is Mrs. Tom within?"

"She was when I left the house," said Carl, who seemed determined not
to commit himself.

"Any one with her?" again inquired the young gentleman, looking as
indifferent as possible.

"No, nobody," was the unexpected answer.

"What!" exclaimed Willard, surprised. "I thought I saw a young lady

enter a moment ago!"

"Oh, Christie—she's nobody," said the gallant Mr. Henly.

"Christie—Mrs. Tom's niece—I thought she was away!" exclaimed

Willard.

"So she was, but I went for her this morning; couldn't be bothered doing
her work and my own both any longer," said Carl.

"I suppose I may go in?" said Willard, feeling a sudden thrill of pleasure
at the knowledge that this radiant girl was an inhabitant of the island.

"Yes, I suppose you may, if you like," said Carl, in a tone of the utmost
unconcern.

Thus kindly permitted, Willard advanced and rapped at the door. It was
opened by Mrs. Tom, whose surprise was only equaled by her delight at
being honored by this unexpected visit.

Near the window that overlooked the lodge, stood the golden-haired
vision of the beach. She turned round with a quick, shy glance, and blushed
most enchantingly beneath the deep, dark eyes of the stranger.
 "My niece, Christie, Mr. Drummond," said Mrs. Tom, directing his
attention to her with a wave of her hand. "She got back this mornin'. I allers
find it powerful lonesome here without Christie."

"I have no doubt of it," said Mr. Drummond, seating himself. "But I
have had the pleasure of seeing Miss Christie before."

"Where?" asked Christie, opening her blue eyes in wonder.

"Down on the beach, a few moments ago."

"Oh, yes."

And again Christie blushed vividly, as she recollected how she had been
caught singing.

"Where's Miss Sibyl and Master Guy?" inquired Mrs. Tom.

"Miss Sibyl has gone to N—— with the clergyman's family, and will
not return for a week; and Captain Campbell has gone to Westbrook, where
his vessel is undergoing repairs. So I am left all alone, and came to pay my
respects to you."

"Then you'll stay and spend the evenin'?" said Mrs. Tom, smiling
complacently.

Mr. Drummond professed his willingness; and the little widow,

delighted at the condescension, set about preparing tea instantly, assisted by
Christie, whose wild, shy glances were bent on his face whenever she
fancied herself unobserved. Half pleased, half afraid of him at first, she was
reserved and timid; but as this wore off, he drew her into conversation, and,
to his surprise, found her intelligent and well-educated. This Mrs. Tom
accounted for, by saying she had gone to school for the last five years at
Westbrook, residing there with the friend she had now been visiting.

The evening passed away with the rapidity of magic. Christie, after
much solicitation, consented to sing for him; and if anything was needed to
fairly enchant him, that sweet, clear voice would have done it. Then, too,
Carl added to the general hilarity, by drawing out a rusty Jew's-harp, and
playing a favorite tune of his own composition. Not once during the
evening did he think of Sibyl; her dark, resplendant face, and wild fierce,
black eyes, were forgotten for the golden locks and sweet, fair face of blue-
eyed Christie—this dainty island Peri.

The hour for leaving came all too soon. As he reluctantly rose to go, he
pressed the hand Christie extended, to his lips, with such passionate ardor
that the blood flushed to her very temples, but not with pleasure. Ere he left,
Mrs. Tom cordially invited him to visit her house while he remained on the
island—an invitation he was not loth in accepting.

Christie stood at the window, watching his tall, elegant form as he

walked toward the castle in the bright, clear moonlight.

"I like him, Cousin Christie; don't you?" said Carl, when he had gone.

But Cousin Christie turned away without reply, longing to lay her
burning cheek on the pillow, and muse over the new and delicious joy that
was thrilling her whole heart, and in her slumber to lie dreaming "Love's
young dream."

And Willard Drummond, forgetting his vows, forgetting Sibyl,

forgetting honor, forgetting all but this lovely island-maiden, sought his
couch with but one name on his heart and lips—

"Christie, Christie!"

CHAPTER VII.

THE HEART'S STRUGGLE.

 "She loves, but knows not whom she loves,
Nor what his race, nor whence he came;
Like one who meets in Indian groves
Some beauteous bird without a name,
Brought by the last ambrosial breeze
To show his plumage for a day
To wondering eyes, then wing away."—LALLA ROOKH.

Pale, feverish, and unrefreshed, after a night of restless dreams, Willard

Drummond arose from a vision of Christie to hail a new day.

Passion and principle were at war already. Bound by every pledge of

love, by every vow, to Sibyl, his whole soul was steeped in this new, all-
absorbing passion that had taken possession of him. He had fancied he
loved her, until he beheld radiant, dazzling, bewildering Christie and from
that moment he could have yielded heaven for her. Every feeling of his
inmost heart and soul was up, in arms. Every feeling of honor bade him fly
from this intoxicating siren, whose power he felt growing stronger each
moment over him; but the voice of passion cried: "Remain! love her, if you
will! What right has Sibyl to stand between you and the heaven of your
dreams?" And, like all who allow the struggle between right and wrong to
wage its warfare in their bosom, Willard Drummond was lost. For, with his
hot, fervid, Southern nature, worldly considerations, former vows, reason,
principle, justice, even honor, were swept away, like a wall of smoke,
before the fierce impetuosity of passion.

With a head throbbing, and pulse quick and feverish with the inward
conflict, Willard descended to breakfast.

Captain Campbell stood in the sitting-room, awaiting his coming. With

a courteous "good morning," he advanced to meet him; but started back in
surprise at beholding his extreme pallor.

"My dear fellow," he exclaimed, in a tone of solicitude, "you are ill—

very ill, I am afraid. What in the world is the matter?"
 "Nothing. I had bad dreams, and did not sleep well," said Drummond,
with a forced smile. "A cup of Aunt Moll's excellent coffee will set me all
right again."

"I don't know about that," said Captain Campbell, with his eyes fixed
anxiously on his face, "You are looking terribly feverish, and you were
complaining of a headache yesterday. I hope you are not going to be ill."

"I assure you it is nothing," said Willard, in a tone of slight impatience.

"You are needlessly alarming yourself. A bad night's rest is the cause of
all."

"Well, if it is not, I will have to call up Mrs. Tom to nurse you till Sibyl
comes. And, by the way, I regret exceedingly that I shall be obliged to leave
you solitary and alone for some days. Important business, that cannot be
postponed, demands my immediate attention."

Willard's heart suddenly bounded—he would scarcely have

acknowledged to himself the reason—at the words.

"It seems hardly courteous or hospitable to leave you thus," continued

the young captain; "but I know you will excuse me, my dear fellow, when I
tell you it cannot possibly be helped."

"Oh, certainly, certainly!" interrupted Drummond, cordially. "Go, by all

means. I will get along well enough in your absence. When do you leave?"

"Immediately after breakfast. It is an affair that cannot be postponed. In

fact, I will not have time even to go and see Sibyl; but, as you will probably
be there during the day, you can tell her. Perhaps you will come over to the
mainland with me?"

"No, I think not," said Willard, with affected carelessness. "I may go
during the course of the day."

"But how? I will take the boat."

"Oh, with Carl Henly. He has one, I believe."

 "Well, suit yourself. And now I'm off. Take care of yourself, my boy;
and au revoir!"

"Good-by!" said Willard, accompanying him to the door. "Aunt Moll

and I will keep bachelor's hall till you come back."

Captain Guy laughed, and hurried down to the beach. And when he was
gone, Willard arranged his slightly disordered dress and disheveled locks,
and sauntering out, almost mechanically took the road to the cottage.

It came in sight at last—this little, quaint, old house, that held all of
heaven to him now.

"Shall I enter—shall I thrust myself into temptation?" was his thought.

"If I look again on this fairy sylph I am lost!"

He thought of Sibyl, and her dark, bright, menacing eyes arose before
him, as if to warn him back.

"For your honor's sake—for your life's sake—for your soul's sake—go
not there!" said the threatening voice of conscience.

"And have I not a right to love whom I please? Why should I offer
violence to myself in leaving this bright enchantress, for that dark, wild
Amazon? Go, go, and be happy," said passion.

And, as if to overthrow his last good resolution, the image of Christie,

radiant, dazzling, and beautiful, as he had beheld her first, in the bright
flush of the fading sun light, arose before him, and once again passion
conquered.

He approached and entered the cottage.

Mrs. Tom sat near the window, spinning and singing to herself.
Willard's eyes wandered around in search of another; but bright Christie
was not to be seen.

The widow arose, smiling, to welcome her guest, and placed a chair for
him near herself. And still Willard's eyes went wandering round the room.
 "She will appear presently," he thought, not yet liking to inquire for her.

"What a venerable-looking affair your wheel is, Mrs. Tom," he said,

surveying it, with its hard polished wood and bright brass rings.

"Yes, it's as old as the hills," said Mrs. Tom, resuming her work; "and
has been in our family since the flood. I think I spun on that there wheel all
the yarn that makes the socks, mittens, and comforters for half the county
round; besides making sheets, blankets, and lots of other things for
ourselves," said Mrs. Tom, with conscious pride.

"You deserve a premium for industry, Mrs. Tom," said Willard.

"Well, you may be jokin' now, and I dare say you are; but it is true, for
all that. Many a true word is spoke in jest, you know," said Mrs. Tom, as her
wheel went merrily round. "There ain't many women in this place o' my age
and means, can do, or does do more work than me, though I say it as hadn't
oughter. I knit, and spin, and sew, wash, brew, bake, sow, and reap, and fifty
other things, too numerous to mention, besides. Carl, if I go out there I'll put
an end to your lazin', you idle, good-for-nothin' vagabone, you!" she added,
breaking off in sudden wrath, as she espied Carl, leaning on the spade with
which he should have been digging in the garden.

"You should make Carl do these things, Mrs. Tom," said Willard, still
impatiently watching the door and wondering why Christie did not come.

"Carl?" said Mrs. Tom, with a short laugh. "Lor'-a-massy! he ain't worth
his salt; that there's the laziest, most worthlessest young scape-goat ever any
living 'oman was plagued with. I hain't a minute's peace with him night nor
day; and if scolding was a mite of good, the Lord knows he might have
been a saint by this time, for he gets enough of it."

Willard laughed. And in such conversation the morning slipped away—

very rapidly to Mrs. Tom, but each moment an age to our impatient lover.
For Christie was absent still; and a strange reluctance, for which he could
not account, still prevented Willard from asking for her. It was an inward
sense of guilt that troubled him; for, feeling toward her as he did, he felt he
had no right even to mention her name.
 At last, in despair, he arose to go. Mrs. Tom relieved his mind by
saying:

"Christie will be disappointed at not seeing you," said the old lady,
following him out. "She went out berrying to the woods this morning, and
hain't got home yet."

Willard started at the information; and, inwardly cursing the folly that
had detained him so many hours talking to a foolish old woman, he darted
off, with a rapidity that quite amazed Mrs. Tom, in the direction of the pine
woods.

"What a confounded fool I have been," he exclaimed, savagely, "to stay

there listening to the way to make butter, and flannel, and 'yarb tea,' as if the
old beldame thought I was going to be somebody's housekeeper, or a female
doctress; and all the time this enchanting little blue-eyed witch was
wandering alone by herself. What an opportunity I have lost! and now I
suppose I may search for an hour and not find her."

He turned an abrupt angle in the winding path, and stifled a sudden

exclamation of surprise and delight; for there before him, reclining on the
grass, with half-veiled eyes, and soft, musing smile, sat the object of all his
thoughts, wishes, and desires.

He paused for a moment to contemplate the picture before him, for, if

Christie had seemed beautiful when he first beheld her, oh, doubly lovely
did she appear now in her attitude of unstudied grace.

Her dress was a loose, light muslin robe, fitting to perfection her
rounded waist and swelling bust. Her straw hat lay on the ground beside
her, and her golden, sunshiny hair floated, with all its wealth of rippling
ringlets, round her ivory throat. How dazzlingly fair looked that smooth,
snowy brow, contrasted with the full crimson lips and delicately flushed
cheeks—how enchanting the long curved lashes, falling over the deep-blue
eyes—how beautiful that faultless form, that soft, gentle, happy smile of
guileless girlhood.
 Willard Drummond's breath came and went, quick and short, as he
gazed, and his dark eyes filled with a subdued fire.

He advanced toward her. His shadow, falling on the grass at her feet,
was the first token she had of his coming. With a quick, startled cry, she
sprang to her feet in terror; but when she saw who it was that stood before
her, she stopped short, while the color flushed gloriously to her rounded
cheeks. Her first impression was: He has read my thoughts in my face, and
knows I was thinking of him.

"Have I disturbed you, bright Christie?" he asked, coming nearer.

"Oh, no!" she answered, blushingly. "I was only waiting to rest a little
while before going home."

"And dreaming, I perceive," said Willard. "May I ask, of what—of

whom?"

"I wasn't dreaming," said Christie, innocently. "I was wide awake all the
time."

"Day-dreaming, I mean," said Drummond, with a smile. "Do you know,

fairest Christie, I have been at your cottage all the morning, waiting to see
you?"

"To see me?" said Christie, with another quick, glad blush.

"And not finding you there, I have come in search of you," he

continued.

"And found me," she said, laughing. "If I had known you were coming I
should have staid at home."

"Perhaps it is better as it is, bright one; for I have found you alone. It is
very pleasant to have found so fair companion on this lonely isle."

"Yes, it is a lonely place," said Christie, musingly; "and yet I like it

better than Westbrook, or any other place I have ever been in. Only I would
like always to have a friend with me to talk to; and that, you know, I cannot
have here. Aunt Tom is always too busy to go out; and Carl don't care about
the trouble of talking, much less walking, so I always have to go alone."

"And if he would go, I fancy Master Carl is hardly the kind of

companion Miss Christie would select," said Willard.

"Not if I could find any better," said Christie, with a laugh; "but I have
grown so accustomed to being alone now that I do not mind it at all, as I
used to."

"And so you are perfectly happy here, fairest Christie, reigning queen of
this fairy isle?"

"Ah, no! beautiful Miss Sibyl is queen of the isle. I am only her most
loyal subject," said Christie, gayly; "you ought to know that, having paid
her your allegiance."

"What if I should say that the subject is more lovely than the queen?"
said Willard, in a low voice, and in a tone that brought the hot blood
flushing to Christie's face.

"I should say you were laughing at me, as of course you would be.
Certainly no one would ever think of me while Miss Sibyl was near. Oh!
how I wish she would always stay here, and then I would have a
companion."

"Ah, bright one! if I were in her place, what would I not surrender for
such a privilege!"

"Would you?" said Christie, looking at him in unfeigned surprise; "then

why not stay? I am sure I should be glad to have you here always."

Her innocent words, her enticing beauty, her child-like candor, were a
strong temptation. For one moment he was about to fall before her, to clasp
her in his arms, to hold her there forever, while he breathed forth his mad,
passionate love, and told her nothing on earth should ever part them now.
But again rose before him the dark, warning face of Sibyl to allay the fever
in his blood. It seemed to him he could see her black, fierce eyes gleaming
on them through the trees—he could almost hear her voice shouting
"Traitor!"

All unconscious of the struggle raging in his breast, Christie stood

leaning against a tree, her curved crimson lips half parted—her blue eyes
fixed on a cloud drifting slowly over the sky, little dreaming of the far
darker clouds gathering rapidly, now, over the horizon of her life.

And still in Willard's heart went on the struggle. He dared not look at
her as she stood before him—-bright, radiant, bewildering—lest the last
lingering remains of fidelity and honor should be swept away by the fierce
impetuosity of passion in his unstable heart.

But his good angel was in the ascendant still, for at that moment the
voice of Carl was heard calling loudly;

"Christie! Christie!"

"Here, Carl! Here I am," she answered; and in another instant honest
Carl stood before them.

"Aunt Tom sent me looking for you," said the young gentleman, rather
sulkily; "and I've been tramping through the woods this half-hour, while
you were taking it easy here," said Carl, wiping the perspiration from his
brow.

"It was all my fault, my good Carl," said Willard, as Christie hastily
snatched up her hat and basket and fled, having a just terror of Mrs. Tom's
sharp tongue. "Make my excuses to your good aunt, and here is something
for yourself."

Carl's dull face brightened wonderfully as Willard drew a gold piece

from his pocket and pressed it into his hand, and then turned his steps
slowly in the direction of Campbell Castle, thinking all earthly happiness
lay centered in the opposite direction.

Mrs. Tom's reproaches fell unheeded, for the first time, on Christie's ear
that day. She heard not a word of the long lecture delivered with more than
the good widow's usual eloquence, for she was thinking of another voice,
whose lowest tone had power already to thrill to the innermost recesses of
her heart. She loved without knowing it, without wishing to define the new,
delicious feeling filling her breast, only conscious she had never been so
happy before in her life, and longing for the time when she should see him
again. Ah, well had it been for her had they never met more.

CHAPTER VIII.

THE TRIUMPH OF PASSION.

"All other passions have their hour of thinking,
And hear the voice of reason. This alone
Sweeps the soul in tempests."

"Well," said Aunt Moll, to her son and heir, Lem, as he entered the long,
high kitchen of Campbell's Lodge, "I would like ter know what dat ar
Master Drummin's up ter? I doesn't understan' dese yer new-fangled young
men 'tall. Fust he comes a courtin' of our Miss Sibyl, and jes' as soon as her
back's turned he goes rite off an' takes up wid dat ar Miss Chrissy."

"'Tain't no business your'n, ole woman," said Lem, gruffly. "I 'spec's as
how Marse Drummin' knows what he's about."

"Yes, honey; but 'pears to me I ought to tell Miss Sibyl 'bout it. Ef he is
her beau, he oughtn't to be takin' up wid dat ar Miss Chrissy.'

"Better let Miss Sibyl look arter her own beau," replied her dutiful son.
"How does ye know he's a courtin' Miss Chrissy?"
 "'Cause I seed dem, chile—yes I did—las' night, down on de shore. De
moon was shinin' jes' as bright as a new pin, an' I took dat ar litter o' kittens
down to de shore to drown 'em, when I seed Marse Drummin' a walkin'
along wid Miss Chrissy, and he had his head stooped down jes' so,"—and
Aunt Moll ducked her woolly head to illustrate it—"an' was whisperin' soft
stuff, jes' as folks do when dey're in love."

"Well, what den?" asked Lem, growing interested.

"Well dey come up ah' seed me, in course, an', Lor', Lor'! I jes' wish you
seed de look Marse Drummin' give me. 'Peared as ef he'd a liked to knocked
my ole head off. But I warn't afeared, 'deed I warn't, chile; so I jes' stood
still an' drapped a courtesy, an' Miss Chrissy, she got red rite up to de roots
ob her hair. 'Good-evenin', marse and young miss,' sez I; 'don't be skeered; I
only wants to drown dese little kittens,' sez I, for I thought as I might be
perlite jest as well as not.

"'Oh, how does yer do, Aunt Moll?' sez Miss Chrissy, a laughin' an'
blushin'; 'how is Lem and yer rheumatiz, dese times?'

"'T'ank you, honey,' sez I, 'dey's pretty well, bof ob dem.'

"An' den Marse Drummin' he pulled her arm right troo his'n, and
marched her off wid him; an' den I pitched de kittens right in de water an'
come home."

"Well, dat ar warn't much," said the skeptical Lem. "Dey might be
walkin' on de beach, but that ain't by no means courtin'. Marse Drummin'
walk wid her, 'cause Miss Sibyl's gone, an' he ain't got nobody else to talk
to."

"'Cisely so, chile; but dat ain't all," says Aunt Moll. "Dis berry mornin',
as I was passin' troo de hall, de sittin'-room door was open, and I heered
voices a talkin' dere; so I listened and peeked in, an' dar was Marse
Drummin', rampin' up and down, a talking to hisself."

"Well, dat ain't nothin', eider," said the still contradictory Lem. "I've
hearn dat ar Carl talk to hisself when Miss Tom sent him out to work; an' he
ain't in love wid no one."

"But listen, honey, and don't you be puttin' me out so, 'cause 'tain't
'spectful—'deed it ain't," said Aunt Moll, getting slightly indignant. "As I
was sayin', I clapt my ear to de door, an' I heered him sayin' jes' as plain as
nothin' 'tall;

"'Oh, dischanting, onwildering Chrissy! ef I had nebber met you, I

might yet be happy!' Dar, what he say dat for ef he warn't in lub?"

This last was a settler. Lem felt that his mother had the best of the
argument, and unwilling to seem defeated, he went out, leaving the old lady
to enjoy her triumph.

Three days had passed since the departure of Sibyl, and certainly
Willard's conduct seemed to justify Aunt Moll's suspicions. Unable to break
the thrall which bound him, wishing, yet unable to fly from the spell of the
enchantress, he lingered still by her side. There were shame, dishonor, sin,
in remaining, but oh! there were death, misery, and desolation in going. All
worldly considerations, her unknown birth, her obscure connections, her
lowly rank, were swept away like walls of cobweb before the fierce torrent
of passion that overwhelmed, conquered every other feeling in its
impetuous tide.

And she loved him, this angel of beauty, this fairy princess of the isle;
he could see it in the quick flush of joy at his approach, the quick, burning
glances shot from her beautiful eyes, more quickly averted when they met
his—her low, impassioned tones, her bright, beautiful blushes. There was
joy, there was rapture in the thought; and yet, unless he forgot honor, vows,
all that should have been sacred, what did this love avail?

And so, like a tempest-tossed bark on a tempest-tossed sea, he strove

with passion and honor, love and remorse, right and wrong.

Once only, fearing lest her suspicions might be aroused by his absence,
he had visited Sibyl, whose rapturous greeting and confiding love made him
feel far more of a villain than ever. He looked forward with dread to the
period of her return, fearing for the discovery of his falsity; but, more than
all, fearing for the effects of her fierce wrath on Christie, knowing well
what must be the strength of Sibyl's passion when unchained.

And so, when Mrs. Brantwell proposed that Sibyl should remain with
her another week, instead of returning to the dreary isle, instead of feeling
irritated now, he backed the proposal, saying that perhaps it would be better
for her to do so, more especially during her brother's absence.

And Sibyl, in her deep love and woman's trust, suspecting nothing,
fearing nothing, consented, to the inward joy and sincere relief of her false
lover.

Resolving to visit her frequently, and so allay any suspicions that his
absence might give rise to, Willard Drummond returned to the island and to
—Christie, yielding himself without further effort to the witching spell of
her love.

Mrs. Tom suspected nothing of the contraband courting carried on under

her very eyes. It was the most natural thing in the world, she thought, that,
in the absence of Sibyl and her brother, the young man should spend whole
days with them, for it was not pleasant having no one to talk to but a couple
of negroes, as she very well knew. Then, it was not to be wondered at, that
he preferred talking and walking with Christie to any of the rest, for she was
"book-l'arned" like himself, which neither she nor Carl was. She did wonder
a little sometimes, and said as much to Christie, why he should stay on the
island at all, in the absence of the other.

"But, I suppose," was always her conclusion, "It's because it's Miss
Sibyl's home, and, for her sake, he stays there until she comes."

But Christie, though she only blushed and was silent, was of a different
opinion—one that she would scarcely own to her own heart. As to his being
in love with Christie, Mrs. Tom would have scouted the idea with scorn and
unbelief, had she heard it. Every circumstance was against such a
conclusion. He was rich, highly connected, and proud as a prince of the
blood; she was poor, unknown, and, compared with him, uneducated.
Besides, in the good widow's opinion, she was a child in feeling, as she
certainly was in years, scarcely knowing the meaning of the word love.
 Ah! she had been till he came; and his fervid, impassioned words, his
burning glances, his thrilling touch, had swept away the glamour of
childhood and simplicity, and revealed to her the passionate woman's heart
within her. His words, his looks, his tones, were all new revelations to the
artless, island maiden, changing her, as if by magic, from a child to a
woman. She revered him as the embodiment of all that was brave, generous,
and noble; worshipped him as a god, and loved him with all the affection of
her fresh, young heart, with all the ardor of a first, deep love.

As yet, she knew not whether that love was returned; for, unfaithful as
he was in thought to Sibyl, passion had not yet so totally conquered his
reason as to make him sin in words. He had never said, "Christie, I love
you;" but, ah, how often had his eyes said this, and much more; and how
long would this slight barrier stand before the fiery impetuosity of unstable
youth?

And so that day passed, and the next, and the next, and the next, and
with every passing hour the temptation grew stronger and harder to be
resisted. Matters must come to a crisis now, or never. Sibyl, in a day or two,
would be home, and this wild frenzy of his could be hidden no longer. If she
should come, as matters stood now, all would be lost.

And thus, torn between conflicting emotions, Willard sought Christie,

on the day before Sibyl was expected home, with the determination of
bringing this struggle to an end, then and there.

It was a glorious August afternoon. The island wore its bright dress of
green, and nestled in the blue shining river like an emerald set in sapphire.
The birds in the deep pine forest were filling the air with their melody, and
the odor of the wild roses came floating softly on the summer breeze.

But Willard Drummond was in no mood to admire the beauties of

Nature. The morning had been spent in pacing up and down his room,
hesitating, resolving, doubting, wishing, yet undecided still. For, when duty
and principle would appear for a moment victorious, the waving golden
hair, the beautiful blue eyes, the gentle, loving face of Christie would arise
before him, scattering all his good resolutions to the winds. And, mingled
with this, there was a sort of superstitious foreboding of evil to come. He
thought of his dream, and of the yellow-haired siren luring him on to
destruction; and of Sibyl, fiery daughter of a fiery race, fierce, vindictive,
and implacable in her wrongs.

"Oh, that I had never met this dark, passionate girl!" he murmured,
distractedly, "who now stands between me and the heaven of my dreams; or
would that I had seen this beautiful, enchanting Christie first! Oh, for that
angel as my wife! And but for those fatal vows once made to Sibyl, she
might be mine. I was mad, crazed, to mistake my fancy for that dark, wild-
eyed girl for love! And now, for that one mistake, am I to be wretched for
life? Shall I give up this beautiful, radiant creature, who loves me, for one I
care for no longer? No; the struggle is past. Christie shall be my bride, and I
will brave the worst that may follow!"

He set his teeth hard; and, as if fearing second reflection might make
him change his mind, he left the house and hurried out to meet Christie.

Down on the shore, under the shade of an overhanging willow, he knew

Christie had a favorite seat, where, on pleasant days, she used to take her
work. Here he was sure of finding her, and in this direction he bent his
steps.

She sat, sewing, under the shade of the drooping willow, singing softly
to herself, and looking like some sylvan goddess of a sylvan scene; or some
beautiful sea-nymph, just risen from her grotto of coral and chrystal.

Radiant and bewildering was the smile and blush with which she
welcomed him—a smile and blush that might have been found too strong
even for more potent principles than his.

He seated himself beside her, with a look of moody abstraction, all

unusual with him, watching her covertly from under his eyelashes, as she
bent smiling and happy over her work.

For a time, Christie chatted gayly on various commonplace matters; but,

at last, catching her tone from his, she, too, grew silent and thoughtful. She
bent lower over her work, wondering if she had offended him, and
involuntarily sighed.
 He heard it, and said:

"And wherefore that sigh, Christie! Are you unhappy?"

"No not unhappy; but troubled."

"And why should you be troubled, bright one? What can there be to
grieve one so fair?"

"I—I—feared I had offended you," she answered, timidly. "You appear

out of spirits."

"You offend me, gentle one—you who never offended any one in your
life? No, no; it is not that."

"Then you are unhappy," she said, shyly.

"Yes, I am miserable—wretched!" he cried, vehemently. "I wish to

Heaven I had never been born!"

"Oh, Mr. Drummond! what has happened!" she cried, laying her hand
on his, and looking up wistfully in his face.

Her touch, her tone, her look swept away every remaining trace of
fidelity. He forgot everything he should have remembered—his vows, his
honor, his truth—and saw nothing but the bright, radiant, bewildering
vision before him. In an instant he was on his knees at her feet, exclaiming,
with impassioned vehemence:

"Christie! Christie! my life, my dream, my hope, I love you. See, I am

at your feet, where my heart, my name, my fortune, long have been. With
my whole heart, and soul, and life, I love you with a love stronger than
death or the grave. All the devotion and hopes of my life I offer you, if you
can only say you love me."

He was pale and panting; his eyes were fierce and burning; his tones
low, thrilling, and passionate.
 Trembling, shrinking, blushing, yet, with a deep, intense, fervent joy
thrilling through her heart and being, Christie listened. The blood swept in
torrents to her face, neck, and bosom, which rose and fell with her rapid
breathing. She dare not look up to meet his ardent, burning, gaze.

"Christie, Christie! my love, my life! look up; speak—answer me—tell

me that you love me!"

Still no reply, only those downcast eyes, deepest blushes, and quick,
hurried breathing.

"Speak! speak! my beautiful love! only one word from those sweet lips;
but one touch of your dear hand to tell me I may live," he cried, growing
more wild and impassioned.

With a low, glad cry of intense joy, she buried her blushing face on his
shoulder.

"Thanks! my heart's thanks for this sweetest, loveliest Christie!" he

cried, with exultant joy, pressing her yielding form to his bounding heart.
"My life, with all its hopes, energies, and ambitions, shall be devoted to but
one purpose now—that of rewarding you for your priceless love."

"Oh, Mr. Drummond, your love is all the reward I ask!" she said, in the
deep, earnest voice of perfect trust.

"Not Mr. Drummond now, sweetest Christie. I am Willard to you, now

and forever. Let me always hear that name in music from your lips, and
earth has no higher boon in store for me."

"But oh! can you love me thus—me, a poor, little, nameless, uncultured
girl, while you are rich, distinguished, and highly connected. Oh, Willard,
will you not, some day, repent this choice—you, who might win the highest
and fairest in the land?"

"Repent! never—never! Perish my heart, if it ever admit of any love but

thine; palsied be my arm, if it ever encircle any form but this; accursed be
my lips, if they ever perjure the words I have spoken now; lost forever be
my soul, when it is false to thee!" he cried, with passionate vehemence.

"Oh, Willard! dearest, hush! I do not doubt you—Heaven forbid. I

should die, if I thought you could be false to me."

"Speak not of death; it is not for such as you, bright, beautiful Christie.
And now, only one thing is wanting, to make me the happiest of men."

She lifted her radiant face with a look of earnest inquiry.

"Christie, one little word from you, and ere the sun rises on a new day,
my joy will be complete—my cup of earthly happiness will be filled to the
brim."

Still the same earnest, anxious gaze.

"Dearest love, you will not refuse? It will be but a small matter to you,
and will make me supremely blessed."

"And that?" she inquired, wonderingly.

"Brightest Christie, be my bride—my wife!" he cried, folding her closer

in his arms, and speaking in a thrilling whisper.

Again the eloquent blood swept over her stainless neck and bosom, but
she did not reply.

"You will not refuse me, my own Christie, this last, greatest favor?
Comply now—to-day; for if the present opportunity passes, it may never
occur again."

"But how—how can we be wedded here?" she said, shyly, lifting her
eyes to his impassioned ones, and dropping them in brightest blushes.

"Christie, yonder lies a boat; it is three hours to sunset; long before that
time we can reach Westport; there we can find a clergyman, and there you
can become my own for life!"