Endophthalmitis prevention and management

Nitin Renge.

Endophthalmitis• Infectious endophthalmitis is a condition in which the internal structures of the

eye are invaded by replicating microorganisms,resulting in an inflammatory response that ultimately may involve all tissues of the eye

• An inflammation of the inner structures of the eyeball Uveal tissue , Retina associated with pouring of exudates in the vitreous cavity, anterior chamber and posterior chamber.

• Endophthalmitis can be classified according to the

Infectivity – Infective / non infective ( sterile)

Mode of entry – exogenous / endogenous

Type of etiological agent

Classification• Endophthalmitis Infectious Exogenous Post traumatic

Endogenous Post-operative

(Haematogenous Spread)

Sterile Acute Chronic Bleb

or Delayed Associated

• Type of etiological agent-

Bacterial

Endophthalmitis Fungal

viral

Parasitic

• Miscellaneous - microbial keratitis, intravitreal injections,or suture removal

Infective agents that commonly cause endophthalmitisI. BacteriaA. Gram-positive cocci

1. Staphylococcusa. S. aureusb. S. epidermidis and

related species2. Streptococcus

a. S. pneumoniaeb. Viridans groupc. S. faecalis

B. Gram-positive bacilli1. Bacillus

a. B. cereusb. B. subtilis

2. Corynebacterium3. Listeria monocytogenes4. Clostridium spp.5. Propionibacterium acnes

C. Gram-negative cocci1. Neisseria2. Moraxella

D. Gram-negative bacilli1. Acinetobacter spp.2. Haemophilus influenzae3. Pseudomonas

a. P. aeruginosab. Pseudomonas spp.

4. Enterobacteriaceaea. Escherichia colib. Klebsiellac. Proteusd. Serratiae. Enterobacter

II. Higher bacteriaA. Nocardia spp.B. Actinomyces israeliiC. Mycobacterium

III. FungiA. CandidaB. AspergillusC. Histoplasma capsulatumD. Blastomyces dermatitidis

IV. HelminthsA. Onchocerca volvulusB. Taenia solium (Cysticercus

cellulosae)C. Toxocara canis and T. cati

V. ProtozoaA. Toxoplasma gondii

VI. EctoparasitesB. Maggots (myiasis)

• Key features -

■ Decreased vision

■ Pain

■ Conjunctival hyperemia

■ Intraocular inflammation, usually with hypopyon

• Associated features -

■ Recent surgery

■ Trauma

■ Immunosuppression

■ Diabetes

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 exterior, Maily bacterial

• Gram-positive, coagulase-negative micrococci cause less severe infections compared with more virulent Gram-negative and “other” Gram-positive organisms

• Streptococcal endophthalmitis often results in earlier onset and notably worse outcomes than infections by staphylococcal species

PATHOGENESIS

Bacterial entry into eye

Cascade of inflammatory products

Inflammatory cell recruitment

Release of digestive enzymes by the cells & toxins by bacteria

Tissue destruction(rapid & irreversible Photoreceptors damage)

Post-operative Endophthalmitis• Cataract surgery is by far the most frequently performed intraocular surgery

• Approximately 90% of postoperative endophthalmitis cases develop after cataract surgery(0.08-0.7%)

• Since the introduction of clear cornea incisions the incidence of endophthalmitishas risen from 0.109% (1963-1999) to 0.265% (2000-2003)

• Endophthalmitis can also complicate other ocular surgeries and procedures such as

Intravitreal injections(IVTA-0.87%,anti-VEGF-0.02-0.08%)

Penetrating keratoplasty (0.2-0.4%)

Trabeculectomy (0.2-9%,increases with rising use of antifibrotic )

Glaucoma drainage device implantation(delayed onset)

Pars Plana Vitrectomy (0.03-0.05% & sutureless > sutured,Staph)

• Types of Post surgical endophthalmitis- 3 forms

1. Fulminant: Occurs within 4 days caused by Bacillus cerus, Staph. Aureus or streptococci, gram negative bacteria

2. Acute: Develops within 5-7 days caused by Staph. Epidermis, coagulase negative cocci,Fungi (rarely)

3. Chronic: May be bleb related or due to Propionbacterium Acnes, fungi etc

• Source of infection- Airborne, Solution and medications, Tissue, Objects and materials

all causes are preventable

• Typical Signs and Symptoms-

Acute Postoperative Endophthalmitis-

Symptoms -Blurred vision (94%),Red eye (82%),Pain (74% ),Swollen lid (34%), Photophobia,Purulent discharge

Signs- Decreased visual acuity,Lids- edema ,Conjunctiva- congestion

and chemosis,Cornea – edema,ring abscess(Pseudomonas and Bacillus),Anterior chamber- cells and flare,hypopyon(in 75%patients in EVS)

Iris muddy and boggy,Pupil-fibrinous exudate,IOL-may be covered by fibrin Fundus- vitreous exudates,scattered retinal haemorrhages,Periphlebitis,loss of red reflex

Delayed onset Endophthalmitis- Secondary contamination after suture removal

After Nd:Yag capsulotomy due to release of sequestered organisms in the capsule

Symptoms - Photophobia,Blurred vision,Mild pain

Signs- Keratic precipitates in anterior chamber,Vitreous flare and cells

Capsular plaque (in Propionibacterium acnes endophthalmitis after Nd:Yagcapsulotomy),Granuloma formation in the pupillary area or near the section(in fungal endophthalmitis)

Bleb Associated Infectious Endophthalmitis- (0.2-9.6%)

Most common causative organisms are streptococcus spp(25%) and haemophilus influenza(18%)

May range from blebitis to frank endophthalmitis

Severe blebitis may cause scleral necrosis and fistula at the site of bleb

Clinical signs- infected white bleb,Vitritis, Hypopyon

Risk Factors for Acute Endophthalmitis following Cataract Surgery• Age – older individuals (≥85 years)

• Male gender

• Extra- or intracapsular cataract extraction (ECCE / ICCE)

• A clear corneal incision - a strong risk factor

• Without intracameral cefazolin (1 mg in 0.1 ml solution)

• Without intracameral cefuroxime (1 mg in 0.1 ml solution)

• Posterior capsular rupture (PCR)

• Silicone IOLs

• Intraoperative complications

Post-traumatic endophthalmitis• The risk for developing endophthalmitis after sustaining open globe injuries is

estimated at about 7%.

• Increasing risk factors for endophthalmitis after ocular injury are

dirty wound,

lens capsule rupture,

older age,

Initial presentation with a delay of more than 24 hours, and the presence of intraocular foreign bodies.

• The incidence of endophthalmitis in cases of

penetrating ocular trauma: 3% to 30% and

after intraocular foreign body: 1% to 61%.

• Bacillus and Streptococcus are common species found in penetrating trauma with an intraocular foreign body

• Other species isolated include

S. epidermidis,

Propionibacterium acnes,

Pseudomonas and

Gram-negative organisms,

fungi and mixed pathogens

• Bacillus species are associated with more aggressive infection and are especially common in intraocular foreign bodies with organic composition

Endogenous Endophthalmitis• Resulting from intraocular colonization of the infectious agents with an exudation into

the vitreous cavity• Accounts for approximately 5% to 10% of endophthalmitis cases• Types :- Bacterial Endogenous endophthalmitis(k1 k.pneumonia)

Fungal Endogenous endophthalmitis(candida > aspergillus, other cryptococcus)Rarely parasites

• Etiology:- Predisposing factors1. Immunocompromised status2. Prolonged alimentation3. IV drug abuse (aspergillus)4. Risk factors- Indwelling catheters, systemic antibiotics, major surgery,

malignancies, diabetes mellitus, chronic alcoholism, liver disease, organ transplantation, corticosteroid therapy, puerperal sepsis• Because of the higher blood flow, choroids and ciliary body are the primary focuses of

infection in the eye with secondary involvement of the retina and vitreous

• Liver abscesses have been reported as the most common infectious origin, followed by pneumonia, endocarditis, soft tissue infection, urinary tract infections, meningitis, septic arthritis, and orbital cellulitis

• Localized epiretinal infiltrates of fluffy creamy white appearance in Candida endophthalmitis

Bacterial endogenous endophthalmitis• Rarest form of endophthalmitis

• very severe, extremely rapid progression,dismal visual prognosis

• Causative organisms -

Gram-positive bacteria (two-thirds)> Gram negative (32%)

Asia - Gram negative (80-90%), K1 subtype of k.pneumonia associated with hepatobiliary infection in 48-77%

• Clinical presentation :- Bilateral in 25% cases

Classification given by Greenwald and colleagues

Four classes

1. Anterior focal: excellent prognosis

2. Posterior focal

3. Anterior diffuse

4. Posterior diffuse: very poor prognosis; can progress into no PL with CRAO and may progress into a fulminant and life threatening panophthalmitis

• Symptoms:- decreased vision, Pain, Photophobia, Redness of eyes, Swollen eyelids, Discharge, Fever

• Critical signs:- vitreous cells & debris, anterior chamber cell & flare and/or a hypopyon

• Other signs: Iris microabscess, absent red fundus reflex, retinal inflammatory infiltrates, flame shaped retinal haemorrhages with or without white centres, corneal edema, eyelid edema,chemosis, conjunctival injection

Fungal endophthalmitis• Fungi are eukaryotic organisms that are ubiquitous in nature

• 3 classes of fungi are important ocular pathogens:

Moulds-Aspergillus, Fusarium, Cephalosporium,Penicillium species and Mucor

Yeasts-Candida and Cryptococcus

Diphasic fungi- Histoplasma, Blastomyces, and Coccidioides

• The most common -in cataract surgery include Candida species and molds such as Aspergillus and Fusarium species

• In India, fungi were isolated in 22% of culture-proven endophthalmitis

• Moulds have a worse outcome than yeasts

• The visual outcome of Aspergillus endophthalmitis usually is poor - preferred macular involvement

• Causes- the less common endogenous infections and the more common exogenous infections

- delayed post-operative endophthalmitis

- endogenous endophthalmitis in immunocompromised patients

• Indolent course becoming evident 2 or more weeks after surgery

• Minimal pain, mild external ocular involvement

• Progressive iridocyclitis, Vitritis ( string of pearl )

• Yellow white choroidal lesion single or multiple

Candidal endophthalmitis• The two most characteristic clinical signs are

Creamy white, well-circumscribed chorioretinal lesions ,Mc in the posterior pole

yellow or white fluffy vitreous opacities.

They may be connected by strands of inflammatory material, producing what has been called a string-of-pearls appearance

• Focal vitreous opacities (composed of inflammatory cells and often contain Candida organisms)from the chorioretinal inflammatory lesions broken through into the vitreous

Aspergillus endophthalmitis• Endogenous Aspergillus endophthalmitis have acute or subacute ocular

symptoms results in rapid onset of pain and visual loss

• The organism initially affects the posterior segment, forming a yellowish macular infiltrate

• Frequently involves the macula, and this probably accounts for the rapid onset of visual loss in many cases

• A hypopyon can develop in the subretinal or subhyaloidal space

• Retinal hemorrhages present in all retinal layers, retinal vascular occlusions, and full-thickness retinal necrosis may occur

• A dense vitritis and variable degrees of cells, flare, and hypopyon in the anterior chamber

• Lesions are histologically angiocentric

Diagnosis of endophthalmitis• Early recognition is critical.

• High index of suspicion to be maintained.

• A complete ocular and medical history is essential

• Search for septic foci.

• Thorough ophthalmic examination performed.

• Presence of hypopyon and vitreous exudates is usually diagnostic of endophthalmitis

• Slit lamp examination –

AC reaction on first post operative day or later

Presence of hypopyon

Presence of corneal edema, White Bleb,Suture abscess

Focal infiltrates, Pupillary membrane

Presence of KP’s

Posterior capsular opacity

Wound abnormalities, Vitreous wick

• Distant Direct ophthalmoscopy for fundus glow

• Indirect ophthalmoscopy- Vitreous haze and fundus glow

ULTRASOUND• Helpful in anterior segment media opacity

• Commonest feature is presence of variable echoes in vitreous cavity

vitreous membrane and opacities

• Thickening of choroid

• Choroidal and retinal detachment

• Retained lens remnants and in the posterior segment

• Intraocular foreign body in post traumatic cases

Microbiological investigations• Aqeous tap

• Vitreous tap (culture positivity >than with aqeous-EVS)

• Corneal scrapings Can be used in case of Corneal infiltration

• Conjunctival Swab

• Postsurgically explanted Intraocular lens can also be cultured

• Cultures: blood, urine, indwelling catheters,and i.v. lines with gram stain of any discharge.

A lumbar puncture is indicated when meningeal signs are present

Culture of suture from suture abcess or infected suture tract

Aqueous tap & Vitreous tap • An anterior chamber Paracentesis is performed using

26 or 30 gauge needle

Tuberculin syringe

0.1 ml of aqeous material is aspirated

• Vitreous tap – 2 ways to collect the vitreous specimen

Aspiration directly by a 22/23 g needle

dry due to formed vitreous

danger of causing a retinal detachment

Vitreous biopsy – best method to obtain a vitreous sample

obtained by attaching a tuberculin syringe to the suction line of the cutter

0.2 to 0.3ml of specimen.

• Specimen Processing –

Smears- Gram’s stain , Giemsa stain , KOH preparation, Calcoflour staining

Culture –

Standard Media - Blood agar ( most aerobic bacteria)

Chocolate agar (aerobic , Neisssseria , Haemophilus )

Thioglycolate broth & Robertson’s cooked meat broth (anaerobic bacteria)

Sabourad’s Dextrose Agar ( fungi)

Specialized Media - Lowenstein –Jensen ( mycobacterium , nocardia)

Non- nutrient agar E.coli enriched

• Culture Interpretation –

Culture is defined positive –

if same organism grows in more than one medium or

There is confluent growth on one or more solid media at inoculation site

Consider equivocal if growth only in one liquid medium or scanty growth in solid media

• Repeat Culture – clinical response not good despite apparently correct Antibiotic administered

• Newer techniques such as DNA microanalysis and polymerase chain reaction (PCR) testing

• CT Scan – not much useful

to detect IOFB

• ERG –

grossly abnormal - poor prognosis

slightly subnormal - slight better

• Systemic investigations –

Routine investigations

CBC( raised TLC),blood sugar(diabetics),KFT, Serum electrolytes,ESR

Conjunctival smear ( existing organisms in adenexae)

Chest x-ray, ECG and echocardiography

Abdominal ultrasound

Other like HIV

BASELINE RISK FACTORS FOR DECREASED VISUAL ACUITY OUTCOME• Older age (≥85 years)

• Diabetes

• Corneal infiltrate or ring ulcer

• Posterior capsule not intact

• Intraocular pressure less than 5mm and more than 25mm Hg

• Afferant pupillary defect

• Rubeosis irides

• Absent red reflex

• Visual 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

PREVENTION OF ENDOPHTHALMITIS• Preoperative preparations-

a) Preexisting conditions e.g.blepharitis, conjunctivitis , dacryocyctitis,, infected contra- lateral socket,Systemic Active infective foci.

b) Topical antibiotic - ofloxacin or moxifloxacin four times a day 3 days before surgery

c) Patient on previous artificial tears, glaucoma drops- fresh bottle of drops at least a week before surgery

d) povidone iodine ( BETADINE 5%)- Periorbital area painted left for 2 minutes,

Instilled in the conjunctiva in 2 forms- Drops – 2 drops for 2-3 minutes

Or Irrigating the conjuntival surface with large volume of povidine iodine

e)Systemic antibiotic prophylaxis in high risk cases

f) meticulous draping

• Intra-Operative- Avoid Wound leak,PCR,Phaco Burn,Vitreous wick

Intracameral antibiotics - cefuroxime 1 mg in 0.1ml intracameraly at the end of the surgery, Vancomycin as 10 ml of ringer lactate is injected in vial of 500mg, 0.2ml injected in 500 ml of BSS, moxifloxacinpreservative free moxifloxacin drops (0.1ml)

Irrigation of IOLS before insertion

Minimum exposure time of IOL

• Post –Operative – Postoperative instillation of topical 2.5 % , 5% povidone iodine solution

Antibiotic drops

Closer postoperative follow-up for patients in diabetes,prolonged surgery, vitreous loss

anterior sub-tenon antibiotic / sub conj. antibiotic

• Bleb related

early diagnosis and treatment of conjunctivitis

wearing of contact lens should be discouraged

treatment of associated periocular infections

• Traumatic

safety goggles

timely and appropriate management of ocular trauma

• Endogenous

adequate and timely management of systemic illness

intravenous drug abuse reduction

control of all predisposing factors

• No prophylactic technique received the highest of three possible clinical recommendations (A, crucial to clinical outcome)

Preoperative povidone-iodine preparation received the intermediate clinical recommendation (B, moderately important to clinical outcome)

All other reported prophylactic interventions –

Postoperative subconjunctival antibiotic injection,

Preoperative lash trimming,

Preoperative saline irrigation,

Preoperative topical antibiotics,

Antibiotic-containing irrigating solutions,

The use of intraoperative heparin

Received the lowest clinical recommendation (C, possibly relevant but not definitely related to clinical outcome)

ENDOPHTHALMITIS MANAGEMENT• The Triad of management of acute post-operative endophthalmitis

Diagnosis+Intravitreal drugs (antibiotics+steroids)+Vitrectomy

• GOALS – Retention of useful vision

Minimize the infection with antimicrobial agents

Limit the inflammation

Symptomatic relief

• 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

Acute infectious endophthalmitis is an ophthalmic emergency-requires prompt therapy

Medical Therapy• Utilizes mainly Antibiotics & Steroids

• Characteristics for ideal drugs –

Bactericidal properties

Broad spectrum of coverage

Excellent therapeutic ratio (activity/toxicity) after intravitreal injection

Good therapeutic ratio after IV injections

Favorable pharmacokinetic properties

Route Of Administration• TOPICAL –

Frequent instillation of topical antibiotics and steroids penetrate cornea and reach anterior segment

Also uses topical cycloplegics e.g Atropine and AGM( IOT-Mc Fungal )

Fortified drug Percent. Conc. Mg/ml

Cephazolin 5% 50

Ceftazidime 5% 50

Vancomycin 5% 50

Tobramycin 1.3% 13.6

Amikacin 2% 20

• SUBCONJUNCTIVAL –

have no advantage over topical and is more painful

• INTRACAMERAL INJ –

not indicated as frequent topical instillation reach significant levels of drugs in anterior chamber (except inj of vanco. In capsular bag in suspected P.acneInfections with little or no posterior segment involvement )

• SYSTEMIC ADMINISTRATION –

IV antibiotics are administered in endogenous endophthalmitis , in posttraumatic endophthalmitis

Role of systemic antibiotics has been severely questioned by Endophthalmitis Vitrectomy Study

Currently pred. e/d from time of diagnosis & Oral or IV Pred. for 6 wk’sday after Vitreous Biopsy / Vitrectomy & intravitreal Antibiotics

Recent publication encourages use of systemic antibiotics even in delayed postoperative infection & fungal etiology

• INTRAVITREAL –

most accepted mode of delivery of drugs to the posterior segment & main treatment strategy according to EVS

Assessment before Intravitreal Injection

The wound integrity

Any infected sutures or suture abscess

Status of lens

IOP - preferably with non contact tonometry

USG should be performed to rule out choroidal or retinal detachment

Drugs of Choice – 2 drugs are given which cover both gram positive and gram negative bacteria

Injection Vancomycin: 1mg in 0.1ml + Injection Ceftazidime: 2.25mg in 0.1ml

Or Injection Amikacin: 400µ in 0.1ml

COMPLICATIONS OF THE PROCEDURE –

i. Elevated intraocular pressure

ii. Intraocular hemorrhage including hyphema

iii. Drug induced retinal toxicity

iv. Retinal detachment

v. Risk of cataract in phakic eyes due to inadvertent contact by the needle

INDICATIONS FOR VITRECTOMY AFTER INTRAVITREAL INJECTION –

i. Worsening despite a proper injection

ii. No response to two repeat intravitreal injections

iii. Development of complications like Retinal detachment

iv. Inadequate drug dosage due to faulty preparation

NUMBER OF INJECTIONS –

2, at the most 3 repeated after 48hrs

Dexamethasone acetate may be added as a third drug depending on the extent of inflammation, Avoided in Fungal endophthalmitis as enchance growth

Fungal endophthalmitis is suspected then Amphotericin B should be given

Follow up of a patient who has been given an intravitreal injection –

Any worsening after intravitreal: Immediately refer to a V-R surgeon for a pars plana vitrectomy

No worsening: - Follow up for 24 to 48 hours

If there is improvement

Medical treatment in form of fortified drops and cycloplegics is continued

If there is no improvement - Repeat intravitreal or refer the patient for a V-R surgeon’s opinion

Specific Antibiotic therapy for treatment of bacterial endophthalmitis

Organism Intravitreal

Staphylococcus Cefazolin, Vancomycin (MRSA)

Streptococcus Vancomycin

Haemophillus Cholramphenicol

Pseudomonas Amikacin, Ceftazidime

Bacillus Clindamycin, Vancomycin, Amikacin

Moraxella Ceftazidime

Enterococcus Vancomycin

E. Coli Amikacin

Proteus Amikacin, Cefazolin

Corynebacterium Vancomycin, Cefazolin

Recommended Doses of IVAb’sName of Antibiotic Safe Dose (mg/0.1ml) Frequency of Repeat Inj.

(Hrs).

1)Cefazolin 2-2.25 24

2)Ceftazidime 2.0 24

3)Clindamycin 0.45-1.0 1 week

4)Daptomycin 0.2 Single dose

5)Dalfopristine/Quinopristine 0.4

6)Imipenem 0.1-0.5

7)Piperacillin/Tazobactam 0.25

8)Linezolid 3.0

9)Vancomycin 1.0 72

10)Amikacin 0.4 24-48

11)Gentamycin 0.1 72-96

12)Clarithromycin < 1 12

13)Ciprofloxacin 0.1 12

14)Moxifloxacin 0.05 12

15)Chloramphenicol 2 24

16)Aztreonam 0.1 12

Preparation of Intravitreal Antibiotics InjectionsAgent Availability Initial

Diluent(ml)

InitialConc.(mg/ml)

Aliquot(ml)

Final Diluent(ml)

Final Conc.(mg/ml)

FinalIntravitrealDose (in 0.1 ml )

Amikacin 500mg/2ml ---- 250 0.1 6.15 4 400 microgram

Ampicillin 1gm 4 250 0.3 1.2 50 5 mg

Cefazolin 500mg 2 225 0.1 0.9 22.5 2.25mg

Chloramphenicol 1gm 10 100 0.1 0.4 20 2mg

Clindamycin 300mg/2ml --- 150 0.1 1.4 10 1mg

Gentamycin 80mg/2ml --- 40 0.1 1.9 2 200 microgram

Kanamycin 500mg/2ml --- 250 0.1 6.15 4 400 microgram

Tobramycin 80mg/ml --- 40 0.1 1.9 2 200 microgram

Vancomycin 500mg 10 50 0.2 0.8 10 1mg

• Gentamycin is more toxic to Retina than Amikacin

• Intravitreal Amikacin in Conc. Of 400 microgram in 0.1 ml is non-toxic to Retina

• Retinal toxicity of Intravitreal Amikacin occurs only in Dose 1500 microgram compared to 400 microgram in Gentamycin & 800 microgram in Tobramycin

• Most endophthalmitis cases recover with single intravitreal antibiotic administration with or without vitrectomy

• Repeat antibiotic injections are required in only few circumstances, termed as Persistent Endophthalmitis & known to have worse outcome

Role Of Steroids• Indications

recent onset after rule out of fungus.

• Contraindication

Late onset endophthalmitis

fungal endophthalmitis

• Mechanism- reduce inflammation clinically and histopathologically , so limit ocular damage

• Routes –

Intravitreal → dexamethasone 0.4 mg in 0.1ml

Subconjunctival → dexamethasone 1mg (0.25ml) OD for 5-7 days

Topical dexamethasone (0.1%) or predacetate (1%) used frequently

Systemic → Oral corticosteroids should preferably be started after 24 hours of intensive antibiotic therapy. Prednisolone (1mg/kg daily) tapered over 6 wk’s

DRUG VIAL SIZE

INITIAL DILUENT (ml)

INITIAL CONC. OBTAINED (mg/ml)

ALIQUOT (ml)

DILUENT (ml)

FINAL CONC. (mg/ml)

FINAL DOSE ORDERED

Dexamethasone acetate

8mg in 2ml

- 4 - - 4 0.4mg/0.1ml

Anti-inflammatory

Anti-fungal• Indication of Intravitreal antifungal

1) pre-existing fungal keratitis endophthalmitis

2) fungal endogenous endophthalmitis ( culture +)

3) After a positive culture is obtained or if there is a strong suspicion of fungal infection

• Commonly used medications –

Intra-vitreal Amphotericin B- 5microgm/0.1ml

Intravitreal voriconazole is used for resistant fungal endophthalmitis

voriconazole - Intravitreal -50 microgm/0.1ml

oral- 200 mg bd

Intravenous- 6 mg/kg bd 2 doses

oral fluconazole / ketoconazole ( better vitreal penetration)

• Amphotericin has been considered the gold standard in antifungal therapy

After IV there are significant systemic complications, including renal toxicity

• Vitrectomy and oral fluconazole have been reported to treat Candida endophthalmitis successfully, with fewer side-effects

• Voriconazole - broad spectrum of action, including Aspergillus species, Candida species

• Systemic antifungals –

For 6 wk’s

LFT- at initiation and

at interval of 2 wk’s

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

Better dispersion of antibiotics

Removal of vitreous scaffolding by which tractional retinal detachments may occur

• Immediate vitrectomy –

Post surgical endophthalmitis where eye has not responded to intravitreal OR vision less than HM

Earlier aqueous/vitreous tap microbiology shows gram negative organisms

Post traumatic endophthalmitis, with retained intraocular foreign body

Bleb related infection

Fungal endophthalmitis

• Deferred vitrectomy – to address late complications of endophthalmitis

1. Opaque membranes in vitreous interfering patient‘s vision

2. Chronic endophthalmitis with low virulence organisms

3. Cyclitis and hypotony

4. Recurrent uveitis, low grade inflammation, cystoid edema of macula

5. Toxic anterior segment syndrome

6. Posteriorly dislocated Intraocular lens, metallic or glass foreignbodies

7. Rhegmatogenous retinal detachment

• should have a fair trial of intravitreal vancomycin, amikacin, dexamethasone preceeding twelve hours before actual start of vitrectomy

• Anterior and central vitreous is removed first, followed by posterior central vitreous

• At the conclusion of surgery one tenth dilution of intravitreal doses of amikacin (40micro gram) and one fifth dilution of vancomycin (200microgram) are injected after closure of all the sclerotomy ports

• Complications –

Failure to achieve control of infection and inflammation ( may required revitrectomy)

Post surgical hypotony and pthysis bulbi

Rubeosis

Iatrogenic retinal tears and retinal detachment which may be difficult to manage (RD - as after infection control PVR is high require resurgery as revision vitrectoy + internal tamponade with gas or silicon oil)

EVISCERATION• Evisceration as an end stage procedure may be required in –

Uncontrolled infection and loss of light perception

In cases of panopthalmitis

Cluster Endophthalmitis• Defined as the occurrence of two or more than two infections at a time, or the

occurrence of repeated postoperative infections under similar circumstances, i.ewith the one surgeon, same staff, same operation theatre, same equipments, etc

• Generally exogenous in origin

• Depending on the number of cases, Green/ Amber/or Red Alert is sounded

• Green Alert :- One case of endophthalmitis is noted, one in > or equal to 100 cases, or two in > or equal to 600 cases

• Amber Alert:- One case in 75 cases, 2 cases in 300-500 cases, 3 cases in 700-800 cases

• Red Alert:- 2 cases in < or equal to 200 cases, 3 cases in < or equal to 600 cases, 4 cases in < or equal to 800 cases

Endophthalmitis Vitrectomy Study (EVS)• Multicenter randomized trial carried out at 24 centres in U.S. (1990-1994)

• 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

• Patients :- N = 420 patients having clinical evidence of POE within 6 weeks of cataract surgery or secondary IOL implantation

• 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 for eyes that did poorly

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

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 planavitrectomy

In patients with initial light perception-only vision, vitrectomy produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold better chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP

• Limitations of EVS:-

1) Only for acute post -operative endophthalmitis after cataract surgery or secondary IOL implantation

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

- post –traumatic

-chronic post operative

-endogenous endophthalmitis

3) The systemic antibiotics used in EVS were amikacin and ceftazidime

4) Potential study subjects with significant opacification of the anterior chamber or without light perception were excluded

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