ENDOPHTHALMITISENDOPHTHALMITIS

ByBy: :

SAAD AL-DAHMASHSAAD AL-DAHMASH

EndophthalmitisEndophthalmitis

The term refers to The term refers to intraocular inflammation intraocular inflammation predominantly involving predominantly involving the vitreous cavity and the vitreous cavity and A/C, as a result of A/C, as a result of intraocular colonization by intraocular colonization by microrganismsmicrorganisms..

PathophysiologyPathophysiologyIn 29 In 29 –– 43% of cataract surgery , 43% of cataract surgery , intraocular contamination occurs with intraocular contamination occurs with facultative bacteria from ocular facultative bacteria from ocular surface without development of surface without development of endophthalmitisendophthalmitis. .

Immune privilege mechanisms are Immune privilege mechanisms are particularly effective in the anterior particularly effective in the anterior part of the eyepart of the eye..

pathophysiologypathophysiologyOcular infection with infectious bacterial load Ocular infection with infectious bacterial load /with impairment of immune privilege of the /with impairment of immune privilege of the eye ,leads to intense destructive eye ,leads to intense destructive inflammatory reactioninflammatory reaction. .

( (Bact. Toxins ,proteases + intense host Bact. Toxins ,proteases + intense host inflammatory response ---------- injury to retina inflammatory response ---------- injury to retina ,CB, A/S structures,CB, A/S structures. .

Intense inflammatory response ----- negative Intense inflammatory response ----- negative microbiological studiesmicrobiological studies. .

ClassificationClassification

11 ) )Endogenous : bacterial / fungal / Endogenous : bacterial / fungal / parasiteparasite..

22 ) )ExogenousExogenous: : a) postoperativea) postoperative..

b) post traumaticb) post traumatic. . c) Bleb associatedc) Bleb associated. .

d) miscellaneous ; e.g. microbial d) miscellaneous ; e.g. microbial keratitis ,scleritis (infectious)keratitis ,scleritis (infectious)

IncidenceIncidence

**Post cataract 0.07 Post cataract 0.07 –– 0.5 0.5.% .%

**post PKP 0.11%post PKP 0.11%..

**post PPV 0.05post PPV 0.05.% .%

**Bleb related 0.2 Bleb related 0.2 –– 9.6 9.6.% .%

**traumatic 2.4 traumatic 2.4 –– 8.0 % , up to 40% in 8.0 % , up to 40% in rural areas with IOFBrural areas with IOFB..

Signs and symptomsSigns and symptoms

**Decrease VADecrease VA..

**painpain..

**A/C reaction +/- hypopyonA/C reaction +/- hypopyon..

**VitritisVitritis. .

**others: lid swelling , discharge , others: lid swelling , discharge , C.edema, chemosisC.edema, chemosis..

D.DxD.Dx

**TASSTASS..**Complicated , prolong surgeryComplicated , prolong surgery. .

**Preexisting uveitisPreexisting uveitis. . *Retained lens material.

**Associated ocular injuryAssociated ocular injury. .

NB : presence of significant vitritis = NB : presence of significant vitritis = infectious Endoph. Till proven infectious Endoph. Till proven otherwiseotherwise. .

Microbial spectrumMicrobial spectrum

Post cataract :CNS 33-77%Post cataract :CNS 33-77% Staph. Aurus 10-21%Staph. Aurus 10-21%

Streptococci 9-19%Streptococci 9-19% G G ––ve, fungi 6-22%ve, fungi 6-22%

Delayed onset (chronic) post cataractDelayed onset (chronic) post cataract:: Prop. Prop.

Acne ,corynebacteria,fungiAcne ,corynebacteria,fungi..Post glaucoma Sx: CNS 67% earlyPost glaucoma Sx: CNS 67% early

Strept, H influStrept, H influ..

ContCont..

Post traumatic : CNS 16 Post traumatic : CNS 16 –– 44 44 % %

Bacillus 17 Bacillus 17 –– 32% 32%

G -ve 10 -18%G -ve 10 -18%

Strept. 8 Strept. 8 –– 21% 21%

Fungi 4 Fungi 4 –– 14 14% %

Source Source of infectionof infection

**Mainly eye lids and conjunctivaMainly eye lids and conjunctiva..

**Other sources : e.gOther sources : e.g..

- - lacrimal drainage syst. lacrimal drainage syst. InfectionsInfections..

- - BlephritisBlephritis..

- - infected socket in contralateral infected socket in contralateral prosthetic eye prosthetic eye . .

Risk factors for Endoph. Post Risk factors for Endoph. Post cataract surgerycataract surgery

**Disruption of the integrity of the barrierDisruption of the integrity of the barrier between A/S and P/S ( post. Caps.tear,zonular between A/S and P/S ( post. Caps.tear,zonular dialysis,vitreous loss)dialysis,vitreous loss)..

**clear corneal incision > scleral tunnelclear corneal incision > scleral tunnel..

**wound leakage in the first day post opwound leakage in the first day post op..

**Silicon IOL > PMMASilicon IOL > PMMA..

**no difference of incidence between no difference of incidence between sutureless and suture technique if no leaksutureless and suture technique if no leak..

**No diff. between inpatients and No diff. between inpatients and outpatientsoutpatients..

**No diff. between No diff. between DMDM and non DM and non DM..

**No diff. between disposable and reusable No diff. between disposable and reusable instrumentsinstruments..

ProphylaxisProphylaxis

**Antiseptics: 5% povidone Antiseptics: 5% povidone –– iodine for iodine for at least 3 minutes is the most at least 3 minutes is the most important important prophylaxisprophylaxis in many in many studies; decreasing conj +periorbit.skin studies; decreasing conj +periorbit.skin

floraflora. .

**Single use instruments is always Single use instruments is always preferable esp. tubespreferable esp. tubes..

**there has been no randomised controlled there has been no randomised controlled studies of preoperative cutting of eye studies of preoperative cutting of eye lashes, available data in the literature lashes, available data in the literature showedshowed no association with the reduction no association with the reduction of the risk of Endophof the risk of Endoph..

**But taping back of the lashes with adhesive But taping back of the lashes with adhesive tape is recommendedtape is recommended..

* *Treat any underlying predisposing cause Treat any underlying predisposing cause e.g. blephritise.g. blephritis . .

AntibioticsAntibiotics

Topical antibioticsTopical antibiotics esp. 4 esp. 4thth generation fluoroquinolones appears generation fluoroquinolones appears to be very effective in reducing conj. to be very effective in reducing conj. Flora load , achieving high Flora load , achieving high concentrations in the in the A/Cconcentrations in the in the A/C..

But no controlled clinical trial prove But no controlled clinical trial prove their effect in reducing incidence of their effect in reducing incidence of EndophEndoph..

AbxAbx

Systemic antibioticsSystemic antibiotics preopertive or preopertive or post op has not proven to be of post op has not proven to be of benefit against post op Endophbenefit against post op Endoph..

In penetrating ocular trauma systemic In penetrating ocular trauma systemic +/- intravitreal Abx shown to have +/- intravitreal Abx shown to have some protective effects ; two recent some protective effects ; two recent studiesstudies..

AbxAbx

Adding Adding antibiotics to irrigation antibiotics to irrigation solutionsolution , there was a debate , there was a debate about there use but there is no about there use but there is no study based evidence showing study based evidence showing reduction of Endophreduction of Endoph..

Also , risk of endoth. Toxicity not Also , risk of endoth. Toxicity not studiedstudied. .

AbxAbx

Injection of intracameral 1mg/0.1ml Injection of intracameral 1mg/0.1ml of cefuroxime (3000ug/ml @ a/c ) of cefuroxime (3000ug/ml @ a/c ) at the end of surgeryat the end of surgery::

It has bee shown the risk of Endoph. It has bee shown the risk of Endoph. with this regimen reduced by almost 5 with this regimen reduced by almost 5 folds (ESCRS ) studyfolds (ESCRS ) study

NB: cefuroxime resist. NB: cefuroxime resist. MRSA,MRSE,Ent.faecalis,pseud.aurMRSA,MRSE,Ent.faecalis,pseud.aur..

AbxAbx

Subconjunctival antibioticsSubconjunctival antibiotics::

It is very common practice to inject Abx It is very common practice to inject Abx subconj. at conclusion of surgerysubconj. at conclusion of surgery..

**GentamycinGentamycin is not effective against Strept. is not effective against Strept.

Species ,prop.acneSpecies ,prop.acne..**Subconj.cefuroxime Subconj.cefuroxime --- 20ug/ml in A/C much --- 20ug/ml in A/C much

lower than intracamerallower than intracameral..**till now no proven evidence of ittill now no proven evidence of it’’s helps help . .

AbxAbx

**post op Abx usepost op Abx use: :

It is recommended to use post op Abx of It is recommended to use post op Abx of same type used preop esp. quinolones same type used preop esp. quinolones for 1 - 2 weeks until the wound is for 1 - 2 weeks until the wound is secured ; but this also not proven to be secured ; but this also not proven to be effective but it is not harmfuleffective but it is not harmful..

NBNB they recommendation to start them they recommendation to start them in the first day very frequent (Q2hrs) for in the first day very frequent (Q2hrs) for one day then QID to decrease A/C one day then QID to decrease A/C contamination loadcontamination load..

DiagnosisDiagnosis**It is mainly clinicalIt is mainly clinical..

**Delay in diagnosis is not uncommon (steroids Delay in diagnosis is not uncommon (steroids ,complications ,expected post op inflam.),complications ,expected post op inflam.)..

**B-scan is an aid , but some times it is B-scan is an aid , but some times it is misleadingmisleading. .

**if doubt, be safe and consider it as Endophif doubt, be safe and consider it as Endoph ,. ,.

no body is blaming of over protection but no body is blaming of over protection but missing serious irreversibly damaging missing serious irreversibly damaging pathology is this the situationpathology is this the situation . .

Management of acute post op Management of acute post op EndophthalmitisEndophthalmitis

**It is a real ophthalmic emergencyIt is a real ophthalmic emergency..

**controversies in managementcontroversies in management: :

Vitreous tap + A/C sampling + intravitreal Vitreous tap + A/C sampling + intravitreal Abx&steroids---- in cases VA >=HM Abx&steroids---- in cases VA >=HM (EVS)(EVS)

VSVSPrimary Vitrectomy +intravitreal Primary Vitrectomy +intravitreal Abx&steroids in all cases (ESCRS)Abx&steroids in all cases (ESCRS)..

MxMx

ESCRS recommend Primary Vitrectomy ESCRS recommend Primary Vitrectomy +intravitreal Abx&steroids as a gold +intravitreal Abx&steroids as a gold

standard of carestandard of care : :

To:To: dec. bact. Load , pus , remove dec. bact. Load , pus , remove most of the inflammatory destructing most of the inflammatory destructing cells and mediators , removing the cells and mediators , removing the scaffold (vitreous)scaffold (vitreous)

MxMxEVS recommendsEVS recommends: :

a) Vitreous tap + A/C sampling + intravitreal a) Vitreous tap + A/C sampling + intravitreal Abx&steroids---- in cases VA >=HMAbx&steroids---- in cases VA >=HM..

b) Vitrectomy +intravitreal antibiotics b) Vitrectomy +intravitreal antibiotics &steroids in cases VA < HM&steroids in cases VA < HM..

WhyWhy? ? --Comparative results founded ( organism Comparative results founded ( organism

virulence)virulence)..--Avoiding delay vitreous tap + AbxAvoiding delay vitreous tap + Abx. .

--Avoiding vitr. Complications In a fragile retinaAvoiding vitr. Complications In a fragile retina ..

* *Inravitreal antibiotics Inravitreal antibiotics can be repeated every can be repeated every 48 hours according to 48 hours according to the responsethe response

Adjunctive measuresAdjunctive measures

According to EVS According to EVS systemic Abxsystemic Abx do not do not appear to have any effect on the course appear to have any effect on the course and the outcome of endophthaalmitisand the outcome of endophthaalmitis..

But :But : they use ( amikacin + ceftazidime ) they use ( amikacin + ceftazidime ) systemically ; and ( vancomycin systemically ; and ( vancomycin +ceftazidime ) intravitrealy+ceftazidime ) intravitrealy..They donThey don’’t use same Abx , they dont use same Abx , they don’’t take in t take in consideration of G +ve to be the most consideration of G +ve to be the most common to be coveredcommon to be covered..

So, at least in theory; IV Abx of So, at least in theory; IV Abx of same type of intravitreal Abx can same type of intravitreal Abx can contributes towards maintaining contributes towards maintaining effective Abx level within the eyeeffective Abx level within the eye. .

Also , some practitioners will use Also , some practitioners will use topical fortified same Abx for topical fortified same Abx for

same principlesame principle . .

ContCont. Adjunctive measures. Adjunctive measures

**As mentioned earlier , the destructive As mentioned earlier , the destructive agent in Endoph. Is the intense agent in Endoph. Is the intense inflammatory response + the bacterial inflammatory response + the bacterial toxinstoxins. .

**Systemic (oral) steroids is recommended, Systemic (oral) steroids is recommended, studies does not shown any negative studies does not shown any negative effect on the infection course in cases of effect on the infection course in cases of bacterial endophthalmitisbacterial endophthalmitis. .

**also , topical steroids has same principlealso , topical steroids has same principle . .

Chronic (delayed onset) post Chronic (delayed onset) post operative endophhalmitisoperative endophhalmitis

It is very commonly misdiagnosed as uveitis It is very commonly misdiagnosed as uveitis or post op. inflammationor post op. inflammation. .

ProblemsProblems::a)High rate of recurrencea)High rate of recurrence..

b)Difficulty in culturing the b)Difficulty in culturing the organism(mostly prop. Acne) because organism(mostly prop. Acne) because it is enclosed in the synechised it is enclosed in the synechised capsular bagcapsular bag..

Dx &MxDx &Mx

**If clinical diagnosis suspectedIf clinical diagnosis suspected: :

11stst step step:: start systemic Clarithromycin 250mg po start systemic Clarithromycin 250mg po

BD for 2/52 ( it is concentrated 200 X BD for 2/52 ( it is concentrated 200 X more in macrophages,PMN containing more in macrophages,PMN containing intracellular bacteria as prop.acne )intracellular bacteria as prop.acne )

If improvement is successful keep close If improvement is successful keep close F/UF/U

22ndnd step step: :

If no improvement in step one, consider If no improvement in step one, consider PPV + intravitreal Abx ( vancomycin PPV + intravitreal Abx ( vancomycin +cefazoline ) + posterior capsulotomy+cefazoline ) + posterior capsulotomy. .

33rdrd step step:: If no mprovements in step 2 remove IOL If no mprovements in step 2 remove IOL

+surrounding bag+surrounding bag . .

Outcomes of treatmentOutcomes of treatment

**in general more virulent organisms as in general more virulent organisms as : staph aureus,strept, bacillus : staph aureus,strept, bacillus sp,pseud. Carry the worst visual sp,pseud. Carry the worst visual outcomesoutcomes..

**low virulent organisms as ( CNS, P low virulent organisms as ( CNS, P acne ) carry better visual outcomesacne ) carry better visual outcomes. .

Out comes from EVSOut comes from EVS

@ @3/123/12--- --- 41%41% had >=20/40had >=20/40..

69%69% had >=20/100had >=20/100..

@@99 –– 12/1212/12---- ---- 53%53% had >=20/40had >=20/40..

74%74% had >=20/100had >=20/100..

15%15% had < 5/200had < 5/200..

@ @final follow up visit final follow up visit 5% had NLP 5% had NLP . .

ContCont..

Chronic endoph. Carries a Chronic endoph. Carries a favorable visual prognosis , favorable visual prognosis , one study showed final VA one study showed final VA >=20/40 in 80% of cases>=20/40 in 80% of cases. .

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