Transcript Endophthalmitis

ENDOPHTHALMITIS
By :
SAAD AL-DAHMASH
Endophthalmitis
The term refers to intraocular
inflammation predominantly
involving the vitreous cavity
and A/C, as a result of
intraocular colonization by
microrganisms.
Pathophysiology
In 29 – 43% of cataract surgery ,
intraocular contamination occurs with
facultative bacteria from ocular
surface without development of
endophthalmitis .
Immune privilege mechanisms are
particularly effective in the anterior
part of the eye.
pathophysiology
Ocular infection with infectious bacterial load /with
impairment of immune privilege of the eye ,leads to
intense destructive inflammatory reaction .
( Bact. Toxins ,proteases + intense host inflammatory
response ---------- injury to retina ,CB, A/S
structures .
Intense inflammatory response ----- negative
microbiological studies .
Classification
1) Endogenous : bacterial / fungal /
parasite.
2) Exogenous :
a) postoperative.
b) post traumatic .
c) Bleb associated .
d) miscellaneous ; e.g. microbial keratitis
,scleritis (infectious)
Incidence
*Post cataract 0.07 – 0.5 %.
*post PKP 0.11%.
*post PPV 0.05 %.
*Bleb related 0.2 – 9.6 %.
*traumatic 2.4 – 8.0 % , up to 40% in rural
areas with IOFB.
Signs and symptoms
*Decrease VA.
*pain.
*A/C reaction +/- hypopyon.
*Vitritis .
*others: lid swelling , discharge ,
C.edema, chemosis.
D.Dx
*TASS.
*Complicated , prolong surgery .
*Preexisting uveitis .
*Retained lens material.
*Associated ocular injury .
NB : presence of significant vitritis =
infectious Endoph. Till proven
otherwise .
Microbial spectrum
Post cataract :CNS 33-77%
Staph. Aurus 10-21%
Streptococci 9-19%
G –ve, fungi 6-22%
Delayed onset (chronic) post cataract:
Prop. Acne ,corynebacteria,fungi.
Post glaucoma Sx: CNS 67% early
Strept, H influ.
Cont.
Post traumatic : CNS 16 – 44 %
Bacillus 17 – 32%
G -ve 10 -18%
Strept. 8 – 21%
Fungi 4 – 14 %
Source of infection
*Mainly eye lids and conjunctiva.
*Other sources : e.g.
- lacrimal drainage syst. Infections.
- Blephritis.
- infected socket in contralateral
prosthetic eye.
Risk factors for Endoph. Post cataract
surgery
*Disruption of the integrity of the barrier 
between A/S and P/S ( post. Caps.tear,zonular
dialysis,vitreous loss).
*clear corneal incision > scleral tunnel.
*wound leakage in the first day post op.
*Silicon IOL > PMMA.
*no difference of incidence between sutureless
and suture technique if no leak.
*No diff. between inpatients and outpatients. 
*No diff. between DM and non DM.
*No diff. between disposable and reusable
instruments.
Prophylaxis
*Antiseptics: 5% povidone – iodine for at
least 3 minutes is the most important
prophylaxis in many studies; decreasing
conj +periorbit.skin flora .
*Single use instruments is always
preferable esp. tubes.

*there has been no randomised controlled studies
of preoperative cutting of eye lashes, available
data in the literature showed no association
with the reduction of the risk of Endoph.
*But taping back of the lashes with adhesive tape
is recommended.
* Treat any underlying predisposing cause e.g.
blephritis.
Antibiotics
Topical antibiotics esp. 4th generation 
fluoroquinolones appears to be very
effective in reducing conj. Flora load ,
achieving high concentrations in the in the
A/C.
But no controlled clinical trial prove their
effect in reducing incidence of Endoph.
Abx
Systemic antibiotics preopertive or post 
op has not proven to be of benefit
against post op Endoph.
In penetrating ocular trauma systemic +/intravitreal Abx shown to have some
protective effects ; two recent studies.
Abx
Adding antibiotics to irrigation 
solution , there was a debate about
there use but there is no study based
evidence showing reduction of Endoph.
Also , risk of endoth. Toxicity not studied .
Abx
Injection of intracameral 1mg/0.1ml of
cefuroxime (3000ug/ml @ a/c ) at the
end of surgery:
It has bee shown the risk of Endoph. with
this regimen reduced by almost 5 folds
(ESCRS ) study
NB: cefuroxime resist.
MRSA,MRSE,Ent.faecalis,pseud.aur.
Abx
Subconjunctival antibiotics:

It is very common practice to inject Abx subconj.
at conclusion of surgery.
*Gentamycin is not effective against Strept.
Species ,prop.acne.
*Subconj.cefuroxime --- 20ug/ml in A/C much
lower than intracameral.
*till now no proven evidence of it’s help.
Abx
*post
op Abx use :
It is recommended to use post op Abx of same
type used preop esp. quinolones for 1 - 2
weeks until the wound is secured ; but this
also not proven to be effective but it is not
harmful.
NB they recommendation to start them in the
first day very frequent (Q2hrs) for one day
then QID to decrease A/C contamination
load.
Diagnosis
*It is mainly clinical.
*Delay in diagnosis is not uncommon
(steroids ,complications ,expected post op
inflam.).
*B-scan is an aid , but some times it is
misleading .
*if doubt, be safe and consider it as
Endoph.,
no body is blaming of over protection but
missing serious irreversibly damaging
pathology is this the situation.
Management of acute post op
Endophthalmitis
*It is a real ophthalmic emergency.
*controversies in management :
Vitreous tap + A/C sampling + intravitreal
Abx&steroids---- in cases VA >=HM (EVS)
VS
Primary Vitrectomy +intravitreal
Abx&steroids in all cases (ESCRS).
Mx
ESCRS recommend Primary Vitrectomy
+intravitreal Abx&steroids as a gold
standard of care :
To: dec. bact. Load , pus , remove most of
the inflammatory destructing cells and
mediators , removing the scaffold
(vitreous)
Mx
EVS recommends :
a) Vitreous tap + A/C sampling + intravitreal
Abx&steroids---- in cases VA >=HM.
b) Vitrectomy +intravitreal antibiotics &steroids in
cases VA < HM.
Why ?
-Comparative results founded ( organism
virulence).
-Avoiding delay vitreous tap + Abx .
-Avoiding vitr. Complications In a fragile retina .
* Inravitreal antibiotics can
be repeated every 48 hours
according to the response
Adjunctive measures
According to EVS systemic Abx do not appear to
have any effect on the course and the outcome
of endophthaalmitis.
But : they use ( amikacin + ceftazidime )
systemically ; and ( vancomycin +ceftazidime )
intravitrealy.
They don’t use same Abx , they don’t take in
consideration of G +ve to be the most common
to be covered.
So, at least in theory; IV Abx of same
type of intravitreal Abx can
contributes towards maintaining
effective Abx level within the eye .
Also , some practitioners will use
topical fortified same Abx for same
principle.
Cont. Adjunctive measures
*As mentioned earlier , the destructive
agent in Endoph. Is the intense
inflammatory response + the bacterial
toxins .
*Systemic (oral) steroids is recommended,
studies does not shown any negative
effect on the infection course in cases of
bacterial endophthalmitis .
*also , topical steroids has same principle.
Chronic (delayed onset) post
operative endophhalmitis
It is very commonly misdiagnosed as uveitis or 
post op. inflammation .
Problems:
a)High rate of recurrence.
b)Difficulty in culturing the organism(mostly
prop. Acne) because it is enclosed in the
synechised capsular bag.
Dx &Mx
*If clinical diagnosis suspected :
1st step:
start systemic Clarithromycin 250mg po BD
for 2/52 ( it is concentrated 200 X more
in macrophages,PMN containing
intracellular bacteria as prop.acne )
If improvement is successful keep close F/U
2nd step : 
If no improvement in step one, consider PPV
+ intravitreal Abx ( vancomycin
+cefazoline ) + posterior capsulotomy .
3rd step:
If no mprovements in step 2 remove IOL
+surrounding bag .
Outcomes of treatment
*in general more virulent organisms as :
staph aureus,strept, bacillus sp,pseud.
Carry the worst visual outcomes.
*low virulent organisms as ( CNS, P acne )
carry better visual outcomes .
Out comes from EVS
@ 3/12 --- 41% had >=20/40.
69% had >=20/100.
@9 – 12/12 ---- 53% had >=20/40.
74% had >=20/100.
15% had < 5/200.
@ final follow up visit 5% had NLP.
Cont.
Chronic endoph. Carries a favorable
visual prognosis , one study
showed final VA >=20/40 in 80%
of cases .
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