DR MAZHAR ALI PANHWERCIVIL HOSPITAL KARACHI

Endophthalmitis Etiology, classification and clinical approach

DEFINITION

Intraocular inflammation involving ocular cavities(vitreous cavity and /or anterior chamber) & their adjacent structures which is either infectious or non – infectious .

CLASSIFICATION

Endophthalmitis can be classified according to the

• Infectivity – Infective / non infective ( sterile)

• Mode of entry – exogenous / endogenous

• Type of etiological agent

Classification

Infectious Sterile (Infectivity)

Exogenous Endogenous ( Mode of entry)

Post –trauma Post-operative Blebitis(PEI-IOFB)

Fulminant Acute Chronic

Cont.

Etiological agent

5

Bacterial Fungal viral Parasitic

Endophthalmitis

Gram positive bacteria 75%-85%

Gram negative bacteria 10%-15%

Fungi3%

Staphylococcus epidemidis (43%)

Pseudomonas (8%) Aspergillus

Streptococcus spp (20%)

Proteus (5%) Fusarium

Staphylococcus aureus (15%)

Haemophilus influenzae (1%)

Cephalosporium spp.

Propionibacterium acnes

Klebsiella( 0-1%)

Bacillus cereus (1%) Coliform spp (0-1%)

Exogenous Endophthalmitis

Vitreous and aqueous – primary site of involvement

Retina and uvea –secondary involvement

Basically 3 types 1) post operative 2) post traumatic 3) Blebitis

Source of infection is from exteriorMaily bacterial

1)Post-op Endophthalmitis

Surgery Bascom Palmer Eye Institute (1984-1994)

Katten et al(1984-1989)

ECCE with and without PCIOL

0.08% 0.072%

Secondary PCIOL 0.37% 0.3%

PPV 0.05% 0.05%

PK 0.18% 0.11%

Glaucoma filtration surgery

0.12% 0.06%

Incidence: 0.05%MC among all types: 49-76%

Source of infection

Airborne respiratory origin, air condition in O.T Solution and medications irrigating solutions, drops and ointment skin antiseptic, viscoelastic and silicon oilTissue periocular skin ,lid margin and lashes conjuctival sac, Lacrimal sac nasal mucosa, corneal graftObjects and materials surgical instruments, gloves, masks, IOL

Clinical Importance- all causes are preventable

Risk Factors

Preoperative risk factors blepharitis , active conjunctivitis Lacrimal drainage system infection or

obstruction , contaminated eye drops.

Operative risk factors wound abnormalities, PC rent ,vitreous

loss ,prolonged surgery & contaminated irrigation solutions

Types Of Presentations

Fulminant Acute Chronic

(<4 days) (4-7days) (>4 weeks) -gram –ve -staph.epidermidis -staph.aureus -coag.-ve cocci -streptococci delayed delayed entry onset bleb P.acne related fungi

S.epidermids

2)Post traumatic

Incidence-2-7%(unsterile conditions & contaminated objects)Contributes to 17-40% of all casesPenetrating ocular trauma is main culpritCausative organisms fulminant: acute: chronic: B. cereus S.epidermidis(MC) fungi: Streptococcus Gram.-ve fusarium

Bacillus cerus isolated in 50% of culture positive cases causes fulminante Endophthalmitis

Difficult to diagnose early.

Rapid worsening of symptoms and inflammation should be suspected as Endophthalmitis until proved otherwise.

Ring corneal infiltrate & ring abscess is typical of Bacillus. also assoc.with proptosis,chemosis & severe orbital pain in 24hrs

Commoner in rural setting due to retained IOFB.

Removal of IOFB with in 24 hr.reduces risk.

3)Bleb related endophthalmitis

4-18% of all casesAfter glaucoma filtration surgeryMay occur at any time (months- years )after surgeryMost of the time through intact bleb via conjuctival floraPoor prognosis as org. are more virulentCausative organism streptococci(MC)-faecalis,viridans,pneumoniae H.influenzae staph. are rareClinical signs infected white bleb Vitritis Hypopyon

Risk factors: use of antimitotic agents,inferior blebs,conjunctivitis,contact lens,periocular infections

Should be differentiated from BLEBITISBlebitis - low virulence organism - mild intraocular inflammation - no Vitritis

Endogenous(Metastatic) Endophthalmitis

2-15% of all casesHematogenous spread of organism from distant source Retina and choroid primarily involved due to high

vascularity.Fungi> bacteria Candida(MC)>AspergillusPredisposing factors - Diabetes - immunosuppresion(AIDS,malignancies medications) - recent major abdominal surgery - prolong indwelling catheter ( intravenous , TPN) - intravenous drug abuser - distant infection ( endocarditis, meningitis, septicemia

etc)no structural defect in globe

Clinical Approach

Symptoms: Decreased or blurred vision ( sudden / severe – acute) ( slowly / mild—chronic)Pain Photophobia Redness of eyes Swollen eyelids Discharge White lesion in black part of the eyeFloatersFever

Signs

Initial visual acuity ( prognostic significance)Ocular motility ( sign of orbital inflammation)Eyelid swollen , blepharospasm Conjunctiva hyperemia, chemosis, bleb examination if presentCornea edematous, opacification , DM folds keratic precipitate, infiltrates, occult penetrationAnterior chamber cells, flare , fibrinous exudates and HypopyonIris – muddy,boggy,resistant to dilatation,post.synechiae

Pupil-absent or sluggish reaction to lightLens - Membrane , exudates around IOLVitreous - Vitritis , exudates , yellowish appearance Fundus examination Absent red reflex and no fundal view Papilitis White lesion in retina and chorioid Retinal hemorrhage and periphlebitisIOP- usually low,may be high in early casesSigns of penetrating injury and Intraocular foreign

bodyWound dehiscence

Fungal Endophthalmitis

Caused by – Candida albicans, Aspergillus, Fusarium etc.

Causes - delayed post-operative endophthalmitis - endogenous endophthalmitis in

immunocompromised patients

Minimal pain, mild external ocular involvement

Progressive iridocyclitis, Vitritis ( string of pearl )

Yellow white choroidal lesion single or multiple

Diagnosis

A) Clinically B) Laboratory AC Tap (0.1ml) Vitreous tap (0.2 ml) Standard Media

Gram’s stain Blood agar ( most aerobic bacteria)

Giemsa stain Chocolate (aerobic , Neisssseria ,

Haemophilus ) Culture Thioglycolate broth ( aerobic ,anaerobic

bacteria) SDA ( fungi) Specialized Media Lowenstein –Jensen ( mycobacterium ,

nocardia) Non- nutrient agar E.coli enriched PCR

1) Ultrasound-vitreous membrane and opacities anatomical status of the retina extent of inflammation choroidal detachment IOFB presence and localization retained lens material

2) CT Scan – not much useful to detect IOFB3) ERG grossly abnormal - poor prognosis slightly subnormal - slight better

For endogenous endoph.:Complete blood count ( signs of infection)ESR ( malignancy ,chronic infections, rheumatic

diseases)Cultures ( for detection of source of infection) blood culture urine culture throat swab CSF stool indwelling catheter’s tipChest X-rayOther like HIV

Treatment

GOALS

1) Retention of useful vision.

2) Minimize the infection with antimicrobial agents.

3) Limit the inflammation.

4) Symptomatic relief.

For bacterial endoph.

Prompt therapy is critical Modalities

MEDICAL 1) Antibiotics Intravitreal, periocular, topical , systemic 2) Anti-inflammatory (steroids) topical ,periocular , systemic ( not for chronic Endophthalmitis) 3) Supportive – Cycloplegic,AGM

SURGICAL vitrectomy

Medical treatment

Intravitreal injection - preferred route in all types of endophthalmitis. - direct administration in vitreous - by passes Blood Ocular Barrier. Intravitreal injection

Vancomycin ( 1.0 mg in 0.1 ml ) Amikacin ( 400ug in 0.1 ml) Or Ceftazidime (2.25mg/0.1ml)

Subconjunctival injections Vancomycin (25mg in 0.5ml) Amikacin (25mg in 0.5ml)

Systemic : 1) penetrating ocular injury from contaminated objects.

2) Endogenous bacterial endophthalmitis. For Post-Op Endophthalmitis: - no role due to MIC in vitreous -Quinolones ( ciprofloxacin) can be tried

Rapid bacterial proliferation make even the Quinolones concentration inadequate to prevent the growth of organisms.

Ideal duration - at least 2-4 week

Drugs DosesVancomycin 1 gm iv.12 hrly

(10-30 mg/kg)Ceftazidime 2 gm iv. Bd

Amikacin 250 mg iv. Tid(15mg/kg)

Gentamycin 80 mg iv tid (3-5mg/kg)

Ciprofloxacin 750 mg po.bd

Ofloxacin 200 mg 12 hrly

Role Of Steroids

Indications recent onset after rule out of fungus.Contraindication Late onset endophthalmitis fungal endophthalmitisMechanism- reduce inflammation clinically and

histopathologicaly

limit ocular damage

Routes - Intravitreal(dexa400mgm in 0.1ml),systemic, sub-conjuctival(1 mg in 0.25ml), topical

Treatment in Fungal Endoph.

Indication of Intravitreal antifungal 1) pre-existing fungal keratitis endophthalmitis 2) fungal endogenous endophthalmitis ( culture +)

Commonly used medications intra-vitreal Amphotericin B- 5microgm/0.1ml oral fluconazole / ketoconazole ( better vitreal penetration)

Voriconazole Intravitreal -50 microgm/0.1ml oral- 200 mg bd intravenous- 6 mg/kg bd 2 doses

Steroids in any form C/I

Systemic antifungals

Vitrectomy

Advantages ( DIAGNOSTIC / THERAPEUTIC) 1) more material for culture esp. fungus.

2) removal of inflammatory mediators /organisms /toxins.

3) removal of source of infection.

4) better dispersion of antibiotics in the vitreous.5) clears the media and better posterior segment visualization

6) removes vitreous membrane which may be a source of late traction and subsequent detachment.

guided by Endophthalmitis vitrectomy study (EVS)

Complications

Retinal necrosis Retinal detachment

Retinal necrosis Vitreous tap Vitrectomy

Increased intraocular pressure Retinal vascular occlusion Optic neuropathy Panophthalmitis Hypotony

Ciliary body shut down Leaking wound Retinal detachment Cyclodialysis cleft Medication

Prevention

1 ) PRE-OPERATIVE a) preexisting conditions e.g.blepharitis, conjunctivitis ,

dacryocyctitis,, infected contra- lateral socket

b) povidone iodine ( BETADINE) drops

c) meticulous draping

d) topical antibiotic 2) INTRA-OPERATIVE irrigation of A/C with vancomycin3) POST –OPERTAIVE anterior sub-tenon antibiotic / sub conj. antibiotic

Bleb related 1) early diagnosis and treatment of conjunctivitis. 2) wearing of contact lens should be discouraged. 3) treatment of associated periocular infections.Traumatic 1) safety goggles. 2) timely and appropriate management of ocular

trauma.Endogenous 1) adequate and timely management of systemic

illness. 2) intravenous drug abuse reduction. 3) control of all predisposing factors.

THANK YOU

Endophthalmitis Vitrectomy Study(EVS)

Multicenter randomized trial carried out at 24 centres in U.S. (1990-1994)

Purpose : To determine The role of IV antibiotics in the management of

POERole of initial vitrectomy in management.Patients : N = 420 patients having clinical evidence

of POE within 6 weeks of cataract surgeryInterventionRandom assignment to immediate vitrectomy (VIT)

or vitreous biopsy (TAP). They were also randomly assigned to treatment with IV or no IV.

Study medications : After initial VIT or TAP, all patients received I/V injection of amikacin (0.4 mg) + vanco(1 mg)

Vanco(25 mg in 0.5 ml), Ceftazidime (100 mg in 0.5 ml),

Dexamethasone (6 mg in 0.25 ml) administered subconjunctivally.

IV treatment: ceftazidime (2 g every 8 hrs) + amikacin (6mg/kg every 12 hrs) for 5-10 days

Main outcome measuresEvaluation of visual acuity and clarity of ocular

media at 3, 9, 12 monthsNo difference in outcome between PPV followed by

I/V group compared to vitreous tap and I/V if vision better than light perception

No difference in final visual acuity or media clarity whether or not EVS systemic antibiotic( Amikacin , Ceftazidime) were employed

Vision with light perception or worse ,much better results in immediate PPV

Limitations of EVS 1) only for acute post -operative

endophthalmitis after cataract surgery

2) doesn’t mention the outcome of vitrectomy in other forms of endophthalmitis like;

- post –traumatic -chronic post operative etc -endogenous endophthalmitis