Endophthalmitis Management

Jagdish Dukre

Diagnosis of endophthalmitis

Early recognition is critical.High index of suspicion to be maintained.A complete ocular and medical history is essentialSearch for septic foci.Thorough ophthalmic examination performed.

Microbiological investigations Aqeous tap Vitreous tap

(culture positivity >than with aqeous-EVS)

Aqueous tap

An anterior chamber paracentesis is performed using a 25 or 27 gauge needle and 0.1 ml of aqeous material is aspirated.

Vitreous tap

A trans pars plana aspiration with a 23 gauge needle

-3mm posterior to limbus in pseudophakic

and aphakic eyes. -4mm posterior to limbus in phakic eyes -0.2 ml of vitreous aspirated. Small gauge battery powered vitreous cutting

instruments(Visitec,Sarasota,USA) (culture +ity of tap=culture +ity of mech.cutter

biopsy)Three port vitrectomy

(culture +ity of tap=culture +ity of vitrectomy-EVS)

OCULAR INVESTIGATIONS contd…

Gram staining

Giemsa staining

KOH preparation

Cultures on Blood agar Chocolate agar Sabourad dextrose

agar

Thyoglycollate agar Robertson’s cooked

meat broth

OCULAR INVESTIGATIONS contd…

Repeat cultures may be neededWhen clinical response is not good inspite of using correct antibiotic

Due to presence of contaminants in media.

Presence of fungus which is especially likely to be missed initially.

Negative cultures may arise due toPresence of fastidious organisms

Insufficient sampling

Sterile endophthalmitis

Polymerase chain reaction-

May provide a more rapid method of specific diagnosis by allowing detection of DNA from infecting organisms.

It has a higher sensitivity and shorter detection time.

Especially useful for culture negative samples.

Nested PCR with universal eubacterial primers complimentary to regions of 16S rDNA conserved sequences detected 50 fg of bacterial DNA spike in normal vitreous. Nested PCR with P. acnes primers detected 10 fg of DNA.

universal primers to detect the presence of pathogen

DNA probe hybridization to determine the species of the bacteria.

ULTRASOUND

Helpful in cases with significant anterior segment media opacity.

Commonest feature is presence of variable echoes in vitreous cavity.

Thickening of choroid

Choroidal and retinal detachment

To search for retained lens remnants in the posterior segment.

Intraocular foreign body in post traumatic cases.

Comments: OS- low echo reflective inferior vit opacities, retina on.

high reflective spot seen superior(mid) vit cavity with severe reverberating echos.

?Air bubble. ???IOFB.

INVESTIGATIONS….contd

SYSTEMIC Routine investigations complete haemogram( raised TLC) blood sugar( predisposition in diabetics) Conjunctival smear ( existing organisms in adenexae) Blood and urine cultures ( endogenous endophthalmitis) Cultures from other sites(catheter tips,cerebrospinal fluid,skin

wounds,abscesses and joints) Chest x-ray, ECG and echocardiography. Abdominal ultrasound

DIFFERENTIAL DIAGNOSIS

History of intraocular surgery or trauma Severe sterile postoperative inflammation Lens induced inflammation

-phacoanaphylactic endophthalmitis

-retained lens material History of or predisposition to uveitis Inadvertant toxic substance introduced into eye.

Drug induced -metipranolol(usually mild) -latanoprost(usually mild) -rifabutin (frequently with hypopyon) Rebound inflammation after rapid antiinflammatory taper

No history of intraocular surgery or trauma Neoplastic infiltration Viral retinitis

Management

Once the clinical diagnosis is made ,to avoid further spread and for better control –all systemic source of infection should be eliminated-

All the indwelling catheters are removed Hyperglycemia,if present, is controlled If patient is on corticosteroids or other

immunosuppresives,the dose is monitored.

MEDICAL Rx- endophthalmitis

Acute infectious endophthalmitis is an ophthalmic emergency.

It requires prompt therapy.Rapid administration of antibiotics without

waiting for culture reports or even gram stain reports.

Emperical broad spectrum coverage of both gm. +ve & gm. –ve organisms. Antifungals- if strong suspicion of fungus.

ROUTE OF ADMINISTRATION

TOPICAL- frequent instillation of topical antibiotics and

steroids penetrate cornea and reach anterior segment

Fortified drug Percent. Conc. Mg/mlCephazolin 5% 50 Tobramycin 1.3% 13.6Vancomycin 0.3% 3

INTRAVITREAL-

-this is the most accepted mode of delivery of drugs to the posterior segment.

- drugs are administered via pars plana.

SYSTEMIC ADMINISTRATION- - intravenous antibiotics are administered in endogenous endophthalmitis

- systemic antibiotics are recommended for posttraumatic endophthalmitis. - role of systemic antibiotics has been severely questioned by Endophthalmitis Vitrectomy Study.

SUBCONJUNCTIVAL-

have no advantage over topical and is more painful.

INTRACAMERAL- is not indicated as frequent topical instillations reach significant levels of drugs in anterior

chamber.(except in suspected P.acne infections with little or no posterior segment involvement.)

Intra vitreal injections are the most preferred way to administer antibiotics locally.

Broad spectrum antibiotics are chosen.

For gram positive organisms(according to EVS)

Agent of choice-Vancomycin.

broad-spectrum activity against most gram positive species

1 mg in (0.1 ml) is given intravitreally

Non toxic in recommended clinical dosage.

Arch Ophth 1999; 117: 1023-1027

Single intravitreal vancomycin dose –provides adequate antibiotic concentrations for over one week

Time after intravitreal administration of vancomycin(hrs)

vitreal level (mg/ml)

4872

137.85182.36

Arch.ophth.1999; 117: 1023-27B J O 2001; 85: 1289-93

For gram negative organisms(according to EVS)

Gentamycin(0.4mg)-associated with retinal toxicityAmikacin was used(4 times less retinal toxicity)Amikacin covers large number of gram negative organisms and those resistant to other aminoglycosidesA survey of retinal specialists suggested that amikacin can also cause retinal toxicityThus, Ceftazidime has emerged as an alternative to amikacinMore effective than aminoglycosidesRetinal toxicity studies in primates reveal concentration of 2.25 mg/0.1 ml to be safe.

Vancomycin combined with amikacin or ceftazidime appears to

be best .

Br. J Ophth 1997; 81: 1006-15

For fungal infections-

Fungal endophthalmitis is treated with intravitreal amphotericin B(5microgm in 0.1 ml)

- after a positive culture is obtained or - if there is a strong suspicion of fungal infection. Intavitreal voriconazole is used for resistant fungal

endophthalmitis.Systemic therapy should be given but renal toxicity must be monitored closely.Oral high dose fluconazole(400-600mg/day)is beneficial in infections with candida.Adjunctive corticosteroid therapy is not given.

Role of steroids

To control the inflammation mediated damage while antibiotics take care of the infection.

Intravitreal steroids -along with antibiotics if fungus is not suspected.

Alternately one can wait for 24hrs for antibiotics to act and then administer intravitreal steroids or start oral steroids.

contd…

Usually 360 to 400 micrograms of dexamethasone is injected

.Subconjunctival injection dexamethasone(12mg) and topical steroids are used commonly.

Systemic glucocorticoids can be administered orally(30 mg twice a day for 5 to 10 days)if there is no contraindication.

OTHER MEDICATIONS

A topical cycloplegic is usually administered.

Raised pressure can be seen in fungal endophthalmitis.

Oral acetazolamide or topical beta blockers may be given.

EMPIRICAL MEDICAL THERAPY OF ENDOPHTHALMITIS

ACUTE ONSET POST CATARACT EXTRACTION

INTRAVITREAL Vancomycin hydrochloride 1.0 mg in 0.1 ml (normal saline) and Ceftazidime 2.25mg in 0.1ml(normal saline) or amikacin 200-

400micrograms in 0.1(normal saline) Dexamethasone 400micrograms in 0.1ml(optional)

SUBCONJUNCTIVAL Vancomycin hydrochloride 25mg in 0.5ml(normal salineand Ceftazidime 100mg in 0.5 ml(normal saline)or amikacin 25mg in

0.5ml(normal saline)if B-lactam allergy exists and Dexamethasone 6mg in 0.25ml(normal saline)

TOPICAL Vancomycin hydrochloride 50mg/ml and Amikacin 20mg/ml and Atropine sulphate 1% or scopolamine hydrobromide 0.25%and Prednisolone acetate 1%

ORAL Prednisone 30mg twice daily for 5 to 10 days (optional)

POST TRAUMATIC

Parallel to those listed for post cataract extraction,and in addition:

May also consider use of intravitreal clindamycin phosphate(450 micrograms)

Systemic antibiotics still considered standard of care. Options include selections from the following:

Clindamycin 600-900mg intravenously every 8 hrsCeftazidime 2gm intravenously every 8 hrsAmikacin 7.5mg/kg intravenously once,then 6mg/kg every 12hrsCiprofloxacin 750 mg po twice daily

BLEB ASSOCIATED ENDOPHTHALMITIS

Similar to post cataract extraction,but consider addition of systemic antibiotics as well.

SURGICAL TREATMENT

Surgical management of endophthalmitis begins BEFORE the infection occurs.

Careful operative technique to- Minimize wound abnormalities Avoidance of vitreous loss during cataract

surgery Careful microsurgical wound management

and closure in open globe injuries

VITRECTOMY

ADVANTAGES OF EARLY THERAPEUTIC VITRECTOMY

Clearing of ocular media Removal of potentially harmful bacterial products Reduction of bacterial load Removal of vitreous scaffolding by which tractional retinal

detachments may occur.

LIMITATIONS

Delay in treatment until operating room is available

Iatrogenic retinal holes and detachments

Choroidal haemorrhage

Problem of visualizing the posterior segment in an eye that has had recent surgery

Retinal detachment is difficult to treat in eyes that have undergone vitrectomy for endophthalmitis due to the need for air-fluid exchange and injection of aqeous antibiotic.

Concentration of antibiotic in the aqeous layer may lead to an increased risk of toxicity.

INDICATIONS FOR VITRECTOMY

In acute-onset post cataract extraction endophthalmitis ,the Endophthalmitis vitrectomy study showed that

In patients with visual acuity hand motions or better no difference in visual outcome with or without vitrectomy. In patients with initial light perception, vitrectomy produced -a threefold increase in the frequency of acheiving 20/40(6/12)vision or better -a twofold increased chance of achieving 20/100(6/30)vision or better, - a 50% decrease in the frequency of severe visual loss

Contd...

Immediate vitrectomy - in suspected fungal endoph. ( Debulking allows relatively weak antifungals to act better.) -In retained intraocular foreign body presenting with infection.

Immediate vitrectomy is done in infectious endophthalmitis because of risk of rapid toxic damage from IOFB.However it is performed 4-14 days after injury, to allow media to clear and a PVD to occur.Non magnetic FBs can be removed by vitrectomy and aid of a forceps and electromagnet can be used for metallic FBs.

Vitrectomy is done in nonmagnetic,large,or subretinal IOFBs,in eyes with opaque media(due to cataract or vitreous haemorrhage.)

Chronic infection due to sequestered organisms in the capsular bag after cataract surgery with IOL implantation can only be managed by surgery, which often involves removal of the intraocular lens.

TIPS TO PERFORM VITRECTOMY

Six mm long cannula is used to clear the edematous ciliary body so that accidental suprachoroidal infusion may be avoided.

High cutting rate and low suction are used.

The peripheral vitreous is avoided for fear of inducing peripheral retinal dialysis.

Surface retinal exudates are left alone.attempts to remove them with flute needle suction can lead to retinal breaks.

Corneal edema can affect visualisation

- visualisation improves on removing the exudates

from AC.

-corneal epithelium can be removed.

Use of viscoelastics in the anterior chamber can reduce the descemet’s folds significantly.

Wound dehiscence – if the surgical wound gives way,resuturing needs to be done with long bites of interrupted sutures.

Areas of scleral necrosis are occasionally seen in cases of bleb-induced endophthalmitis.which may need patch scleral grafting to correct the tissue loss.

MANAGEMENT OF THE INTRAOCULAR LENS

In post cataract surgery endophthalmitis,in cases of exudates on the IOL,visibility of the fundus can be severely impaired.

Very often the fibrin can be removed using a needle or a forceps under viscoelastic.

Sometimes exudates can be trapped between the posterior capsule and the IOL.A posterior capsulotomy can be done with a vitreous cutter and the trapped exudates can be removed.

Removal of the IOL should not be restrained from in severe cases.

Most cases of fungal endophthalmitis and eyes with sequestered organisms in the capsular bag such as propionibacterium endophthalmitis would need IOL removal along with the capsular bag.

EVISCERATION

Evisceration as an end stage procedure may be required in –

Uncontrolled infection and loss of light perception

In cases of panopthalmitis

COURSE AND OUTCOME

“if it isn’t worse, it’s better”Media clarity and visual acuity may not improve initially.

An early response may be determined on the basis of level of pain and lid injection.

Repeat intravitreal injections of antibiotics may be required if the condition worsens and infection persists as confirmed by a repeat culture.

Serial ultrasonography may be used to moniter clinical response and detect retinal detachment.

BASELINE RISK FACTORS FOR DECREASED VISUAL ACUITY OUTCOME

(AS DETERMINED BY EVS)

Older age Diabetes Corneal infiltrate or ring ulcerPosterior capsule not intactIntraocular pressure less than 5mm and more than 25mm HgAfferant pupillary defectRubeosis iridesAbsent red reflexVisual acuity of light perception,the most important risk factor,with a twofold greater risk of poor visual outcome compared with those with hand motion or better acuity during initial evaluation.

ROUTINE ANTISEPTIC MEASURES THAT CAN REDUCE THE OCCURANCE OF

POSTOPERATIVE INFECTIONSImproving the hygiene of the patients before and after the surgery.Use of povidine iodine(5%) in the conjunctival cul de sac preoperativelyStrict adhesion to sterilisation precautions.Specifically the phacoemulsification probe needs to be dismantled and autoclaved between two cases.Precaution in inspecting the irrigating fluid and viscoelastics just before their use.Careful draping of the patient to avoid the patient’s lid margins and lashes from the wound.

GRADING A-BEST B-GOOD C-FAIR

Prophylactic intervention Clinical recommendation

Preop lash trimming C

Preop saline irrigation C

Preop topical antibiotics C

Irrigating solutions with antibiotics

C

Preop povidine iodine antisepsis

B

Intraop heparin C

Post op subconj antibiotic C

Endophthalmitis vitrectomy study

Purpose-

To determine the role of initial pars plana vitrectomy in the management of postoperative bacterial endophthalmitis.

To determine the role of intravenous antibiotics in the management of bacterial endophthalmitis.

To determine which factors, other than treatment, predict outcome in postoperative bacterial endophthalmitis

Description – Two strategies for the Mx of endophthalmitis. Eyes received either

(1) initial pars plana vitrectomy with intravitreal antibiotics, followed by retap and reinjection at 36-60 hours or

(2) initial anterior chamber and vitreous tap/biopsy with injection of intravitreal antibiotics, followed by vitrectomy and reinjection at 36-60 hours .

In addition, all eyes were randomized to either treatment or no treatment with intravenous antibiotics

Results: There was no difference in final visual acuity or media clarity with or without systemic antibiotics. If patients presented with hand motions or better acuity, there was no difference in visual outcome with or without an immediate 3 port pars plana vitrectomy. , vitrectomy

-tripled the frequency of achieving 20/40 or better acuity; - approximately doubled the chance of achieving 20/100 or better acuity - decreased by more than half the frequency of severe visual loss in the subgroup of patients who presented with visual acuity of light perception only.

BIBLIOGRAPHY

Retina,Vitreous and Macula

Ophthalmology

Clinical practice in ophthalmologyParson’s diseases of the eyeBritish Journal of OphthalmologyRadiology

David R.Guyer,L.A.Yanouzzi,S.Chang,W.R.GreenMyronYanoff,

J.S.Duker Dr.Sandeep Saxena

Ramanjit Sihota Radhika Tandon

Sutton