PREVENTION AND TREATMENT OF ENDOPHTHALMITIS

A. Antoniadis MD

Author has no financial interest in any of the products mentioned

Epidemiology

• Acute postoperative endophthalmitis is the most common form of endophthalmitis

• Following cataract surgery 0.08% - 0.68%

• Rates increasing since clear corneal incisions

• Highest risk after 2ndary IOL (0.2-0.37%), and lowest after pars plana vitrectomy (0.03-0.046%).

PREVENTION

Pre- and intra-operative care must be taken in order to prevent the disastrous complication of the most delicate and promising ophthalmic operation.

PREOPERATIVE

• Treatment of all eye infections including the eye surface and adnexa

PREOPERATIVE

• Managment and treatment of Blepharitis and Meibowmanitis

PREOPERATIVE

• Surgical correction of Entropion, Ectropion and Trichiasis.

PREOPERATIVE

• Lacrimal Duct Catheterization in suspiciously tearing eyes.

DURING OPERATION

• Thorough topical antisepsis (Povidone Iodine-Betadine surgical scrub)

• Careful placement of the drape and spectrum

• Povidone iodine 5% (Betadine) drops 3min. before surgery

• Strict maintenance of all antiseptive directions

• Intracameral injection of 0,1 ml Ceforuxime (Zinadol)

TREATMENT

• Early Diagnosis

• Differential Diagnosis

• Early Treatment

Differential Diagnosis of Acute Endophthalmitis

1. Occult the retention of lens cortex or nucleus particles.

2. Hypopyon uveitis (Behcet’s S.)

3. Blebitis(trabeculectomy)

4. Keratitis (bullosa)

5. Toxic anterior segment syndrome (TASS)

Acute Postoperative Endophthalmitis

• Refers to infectious endophthalmitis shortly after ocular surgery

• Mostly present within 1-2 weeks, usually 3-5 days after the surgery.

Acute Postoperative Endophthalmitis

• Initial symptoms: rapidly progressive, including:

pain 74%, red eye 82%, ocular discharge, and blurring.

25% of patients have no pain!

Microbiological Characteristics

• Bacteria are the most common infecting agents.

• Most commonly bacteria from patient’s own periocular flora, introduced during surgery.

• In the EVS, 94.2% of culture-confirmed cases involved Gram Positive bacteria.

• 70% were GP, coagulase negative staphylococcus: (Staph. epidermis)

Acute Postoperative Endophthalmitis

• Common signs: decreased visual acuity 94%, lid swelling 34%, conjunctival and corneal edema, anterior chamber cells + fibrin, hypopyon 85%, vitreous inflammation, retinitis, and blunting or absence of red reflex.

• Retinal Periphlebitis: earliest sign (cannot easily be seen because of blurred media)

Treatment of Acute Postoperative Endophthalmitis

• Systemic antibiotics administration: with no significant benefit. Usually too slow to enter the eye in adequate concentrations.

• Surgical management:

1, Pars Plana Vitrectomy (PPV) with simultaneous drugs injection.

2, Transcleral antibiotics administration (TAP) without vitrectomy, using a 25G trocar canula.

Immediate PPV vs. TAP & Inject

• According to EVS, patients who presented with LP only initial V.A. had a significant, threefold better chance of obtaining 5/10 vision after immediate PPV (33%) compared to TAP and inject (11%).

• 56% of patients obtained 2/10 or better V.A. after immediate PPV compared to 30% after TAP & inject.

• When initial V.A. was HM or better: No significant difference between the two treatment groups in final visual acuity was fount.

INTRAVITREAL DRUGS

• Vancomycine (Voncon) 1.0 mg/0.1 ml

• Ceftazidime (Solvetan) 2.25mg/0.1ml

• Amikacine (Briklin) 200-400mg/0.1ml

• Dexamethasone (Dexaton) 400mg/0.1ml

• Fungal: Amphotericin B 5-10 ug/0.1 ml

• In the EVS, Vancomycin and amikacincovered 99.4% of all infecting organisms.

Thank you for your attention!