Endophthalmitis für Praktiker¤sentationen...• DD lens-induced uveitis SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 6 Endogenous Endophthalmitis • Metastatic

Endophthalmitis für Praktiker

Prof. Dr. Matthias Becker

www.triemli.ch/augenklinik

[email protected]

Augenzentrum

http://www.triemli.ch/augenklinik

SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 2

Learning Objectives: Endophthalmitis

The audience knows…

• …how to make the diagnosis

• …how take the first steps of therapy

• …has knowledge about the most important aspects of the „current state of the art“


AirVote

a. I only refer to the best cataract surgeons – they never produce

endophthalmitis cases!

b. Topical antibiotics are a critical MUST in postoperative cataract

management

c. „Tap & Inject“ is a great option to safe time and start treatment early

d. Be careful with povidone-iodine: never use it inside the eye!

e. Pain is an unusual symptom for endophthalmitis


Endophthalmitis (EO) – Take home messages

• Endophthalmitis probably cannot be completely prevented, but its incidence may

be reduced

• Consensus on best postoperative management is still lacking

• Have your emergency network ready – just in case…

• Shoot first – ask questions later…? „Tap & Inject“ revisited

• Use of povidone-iodine in irrigating fluid or as an intravitreal injection is a viable

prophylactic and therapeutic future option

• Pain is an important clinical finding in EO


Exogenous Endophthalmitis

• Acute postoperative EO• < 30 days postop

• Post-Cataract: 0.07 – 0.32%

• Post-IVOM: 0.0075% per injection (0.03-0.06% office procedure)

• Post-Glaucoma, post-Vitrectomy, trauma, foreign body, corneal ulceration, periocular infection

• Gram-positive (coagulase-negative staphylococci: Staph. epidermidis, Staph. aureus)

• Gram-negative (Pseudomonas aeruginosa)

• Postoperative delayed-onset EO• > 6 weeks postop

• Anaerobic gram-positive (Propionibacterium acnes)

• DD lens-induced uveitis


Endogenous Endophthalmitis

• Metastatic

• Predesposing systemic risk factors

• Diabetes

• liver/cardiac disease

• in-dwelling catheters

• iv-drug abuse

• Streptococcus, Staphylococcus, Candida,

Klebsiella


Post Injection endophthalmitis (PIE)

• Risk higher after intravitreal corticosteroids than after intravitreal anti-

VEGF agents

• Prophylactic antibiotics are not a necessary part of intravitreal injection

preparation and management (meta-analysis)

Open J Ophthalmol. 2013;3:46

• Post Injection Cluster-endophthalmitis (PICE): outbreak of five or

more cases on a particular day in a single operating room in same

center


Ocular examination

• Ocular tenderness

• Swollen lids

• Conjunctival hyperemia

• Discharge from eyes (watery / purulent /

mucopurulent)

• Circumcorneal congestion

• Corneal edema, associated corneal ulcer

• Anterior chamber reaction

• Hypopyon

• Iris swollen with hazy details

• Vitreal infiltration

• Fungal balls or fluffy exudates or string of pearls

may be seen in fungal endophthalmitis

• Poor fundus red-reflex

• Media haze

• No lens or anterior vitreous details

• Intraocular pressure may be raised and affects

prognosis of the condition


Endophthalmitis Management – Where are we “Now”

• Preoperative 5% povidone-iodine

antisepsis

• Intravitreal antimicrobial injections

• Improved vitrectomy instrumentation

• Newer alternative antimicrobials

• Polymerase chain reaction (PCR)

• Peptide nucleic acid–fluorescence in

situ hybridization (PNA-FISH)

• Big data allows to better evaluate

outcomes and to compare rates of

endophthalmitis (IRIS Registry)


• So far only prospective randomized partially masked multicenter trial

• 16’603 patients

• Use of intracameral cefuroxime at the end of surgery reduced the occurrence of

postoperative endophthalmitis by factor 4.97x

• High rate of endophthalmitis (0.33%) in cohort not receiving intracameral

cefuroxime. More easily allowed intracameral cefuroxime to significantly improve

the endophthalmitis rate

• Study was stopped prematurely

• Use of multiple surgical techniques

Endophthalmitis Study Group

J Cataract Refract Surg 2007;33:978


Criticisms of Intracameral Antibiotics (IA)

• Potential risk of dilutional error

• Contamination

• Cost-benefit concerns

• Number needed to treat

• Emerging antimicrobial resistance

• Potential complications

• Infection

• TASS: Toxic anterior segment

syndrome

• HORV: Hemorrhagic occlusive

retinal vasculitis


Criticisms of Intracameral Cefuroxime

• Complete lack of activity against

Enterococci, Pseudomonas species,

and Enterobacteriaceae species

• Low activity against methicillin-

resistant Staphylococcus aureus

(MRSA) and S. epidermidis (MRSE)

• Increasing resistance of coagulase-

negative staphylococci

• Enterococci and coagulase-

negative Staphylococci are

responsible for majority of EO

• Add Ampicillin to Cefuroxime,

because of its activity against

Enterococci


Intracameralists vs. Topicalists

• Several studies reporting…

• No benefit of IA when topical

antibiotics (TA) were used

• No benefit of TA use when IA were

used

• Preoperative topical antibiotics

significantly reduce conjuctival flora –

effect on postoperative

endophthalmitis??


Current recommendation for postoperative therapy in

cataract surgery

Lwowski CM, et al. Klin Monbl Augenheilkd 2019;236:636

Nepafenac, Bromfenac, Ketorolac

• Using antibiotic eye drops in addition to antibiotic injections probably lowers

the incidence of endophthalmitis compared with using either injections or eye

drops alone («moderate-certainty evidence»)Gower EW, et al. Cochrane Database Syst Rev 2017;2:CD006364


Current Intravitreal Antimicrobials for Endophthalmitis

• Vancomycin

• Ceftazidime

• Amikacin

• Amphotericin-B

• Voriconazole

• Reduction of anterior chamber contamination rate

after cataract surgery by intraoperative irrigation

with 0.25% povidone-iodine

Am J Ophthalmol 2011;151:11


IRIS registry

• World’s largest specialty clinical data registry

• Aggregated, de-identified data

• 61 million unique patients (USA)

• 253 million patient visits

• 15’000 clinicians in ophthalmology practices

have registered to electronically contribute

their data through their electronic health

record systems


Pershing S, et al. Ophthalmology 2020;127:151

• United States cataract surgery patients, 2013-2017 (5’401’686 patients)

• Acute-onset endophthalmitis in 0.04%

• Risk factors may include younger age, cataract surgery combined with other

ophthalmic surgeries, and anterior vitrectomy

• Excellent vision after surgery (44% achieving driving-level vision)

• Big data from clinical registries like IRIS has great potential

• Evaluating rare conditions such as endophthalmitis

• Including developing benchmarks

• Longer-term time trend investigation

• Comprehensive analysis of risk factors and prophylaxis


Shoot first - ask questions later

• Give antibiotic injections earlier than

we currently do

• Referring ophthalmologist the moment

that endophthalmitis is suspected

• Then send patient in for biopsy

• Improved PCR techniques confirm the

diagnosis without relying on live

organisms

• Additional intravitreal dexamethasone

does not improve outcome


Conclusions

• Trend from earlier vitrectomy for debridement of bacteria, toxins and

inflammatory debris, better diffusion of antibiotics and potentially a more rapid

visual recovery towards

• »Big data» will continue to provide outcome measures and trends for

endophthalmitis prevention and treatment

• Big data is good at detecting associations, but it cannot tell us which associations

are meaningful


Endophthalmitis (EO) – Take home messages

• Endophthalmitis probably cannot be completely prevented, but its incidence may

be reduced

• Consensus on best postoperative management is still lacking

• Have your emergency network ready – just in case…

• Shoot first – ask questions later…? „Tap & Inject“ revisited

• Use of povidone-iodine in irrigating fluid or as an intravitreal injection is a viable

prophylactic and therapeutic future option

• Pain is an important clinical finding in EO


AirVote

a. I only refer to the best cataract surgeons – they never produce

endophthalmitis cases

b. Topical antibiotics are a critical MUST in postoperative cataract

management

c. „Tap & Inject“ is a great option to safe time and start treatment early

d. Be careful with povidone-iodine: never use it inside the eye

e. Pain is an unusual symptom for endophthalmitis


Documents

Endophthalmitis für Praktiker¤sentationen...• DD lens-induced uveitis SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 6 Endogenous Endophthalmitis • Metastatic