Management of endophthalmitis

1. Acute post-operative
endophthalmitis-Management
Dr Haitham Al Mahrouqi
Oman Medical Specialty Board

2. Outline
 Recap
 Treatment step by step
 Discussion

3. Classification
 According to onset:
 Acute (Mostly within 1 week)
 Chronic (>6 weeks)
 According to origin:
 Endogenous: From blood stream
 Exogenous: Post-operative (Cataract, glaucoma..etc), or post-
traumatic

4. Incidence post traumatic endophthalmitis
 Range from 1-20%, increased with retained foreign body and dirty
wounds from rural settings. (safneck, 2012)
Incidence of endophthalmitis
Post-op Traumatic
<1% >1% (average 5-10%)

5. Clinical features
 Symptoms (within 1 week for acute)
 Decreasing vision along with “Eye ache”
 Later, severe redness, pain, photophobia.
 Often afebrile
 Signs

6. How to take culture samples
 Should be kept for at least 14 days to culture slow growing organisms.
 Prepare patient as if intra-ocular surgery, full draping.
 Topical + peribulbar anaesthesia. If severe endophthalmitis (e.g. abscess), resistant to local
anaesthesia. Therefore general anaesthesia might be necessary.
 Conjunctival swabs: Can be helpful if –ve tabs
 Aqueous tab: 0.1-0.2mls aspirated using 25g needle
 Vitreous tab (More likely to yield +ve results): 0.2-0.4mls aspirated using 23g needle or better using disposable
vitrector (scleral tunnelling)
 Videos
http://simulatedocularsurgery.com/simulation/intraocular-injections/

7. Microbiology
Post op cataract Post-op Blebitis Post-op IVI Post traumatic
Acute:
Coagulase negative
staph
Chronic:
P.Acnes
Corynebacterium
Early onset:
Coagulase negative
staph
Delayed:
Strep/staph
- Coagulase negative
staph
- Streptococcus
-Coagulase negative
staph
- Bacillus
- Streptococcus
Always think about
fungi
Endogenous endophthalmitis: Many organisms, think about fungi in immunocompromised.
Exogenous Endophthalmitis

8. Prevention
 The only evidence currently:
 Povidone iodine
 Intra-cameral cefuroxime
No evidence does not mean absence of evidence

9. Treatment
 Things to consider:
1) Intravitreal antibiotics
2) Vitrectomy
3) Adjunct topical and systemic antibiotics

10. Intravitreal antibiotics
 Empiric
 Vancomycin 1 mg plus either :
 Ceftazidime 2.25 mg OR
 Amikacin 0.4 mg
 Ceftazidime is preferred over amikacin due to aminoglycodie retinal toxicity and infarction.
 Antibiotics last for an average of 48hrs. May need repeat injections. Do not inject amikacin twice!
 Silicone oil and gas-filled eyes require a substantial dose reduction (1/4-1/10 of the standard dose has
been suggested) taking into account the reduced fluid distribution volume that remains in the eye

11. Landmark study: Endophthalmitis
Vitrectomy Study (EVS) 1990-1995
 Purpose:
 To investigate the role of initial pars plana vitrectomy in the managment of postoperative bacterial endophthalmitis
 Determine the role of intravenous antibiotics in management;
 Determine which factors, other than treatment, could predict outcomes in postoperative bacterial endophthalmitis.
 Random Allocation:
1) Vitrectomy + intravenous antibiotic (Ceftazidime and amikacin)
2) Vitrectomy, no intravenous antibiotics
3) Tap-biopsy + intravenous antibiotic
4) Tap-biopsy, no intravenous antibiotic
All patients received intravitreal amikacin, vancyomycin + subconj vancomycin, ceftazidime and dexamethasone.

12. Landmark study: Endophthalmitis
Vitrectomy Study (EVS) 1990-1995
Results
 Vitrectomy:
patients presenting with hand motion acuity or better showed NO benefit from
immediate vitrectomy, however;
patients presenting with light-perception-only VA had substantial benefit from
immediate vitrectomy, with:
3-fold greater frequency of achieving 20/40 vision or better
Twice the frequency of achieving 20/100 or better
Decrease by one-half in frequency of severe visual loss to < 5/200.
 Debate!

13. Landmark study: Endophthalmitis
Vitrectomy Study (EVS) 1990-1995
 IV antibiotics (Amikacin and ceftazidime):

14. ? Systemic antibiotics
 Most studies after the EVS are retrospective and not conclusive.
 Recommended by experts:
 Ceftazidime, vancyomycin or linozolid.
 Use similar to the IVI antibiotics

15. ? Topical
 Still theoretical
 No evidence

16. Treatment: Dexamethasone
 Dexamethasone (preservative-free) is often given by intravitreal injection (dose = 400
μg in 0.1ml volume, using the commercial preparation containing 4 mg/ml)
 Conflicting evidence from –ve to neutral to +ve effect.
Gan 2005, Shah 2000, Das 1999

17. After 48hrs
 If no improvement:
 Re-inject IVI OR
 Vitrectomy

18. Treatment
ESCRS
guidelines
2013

19. Consideration in other endophthalmitis
syndromes
 Post IVI: same approach as post cataract
 Chronic: Systemic antibiotics are not indicated
 Endogenous, Post traumatic and Bleb related endophthalmitis:
 Recommend 3 step approach: IVI, Vitrectomy and systemic antibiotics.
 UpToDate: Bacterial enodphthalmitis. Accessed 25/12/15

20. My recommendation (as supported by
evidence)
 Prevention:
 Povidone
 Intra-cameral cefuroxime
 Post op antibiotic for 1 week.
 Treatment:
 Tap and inject (Vancomycin and ceftazidime)
 Immediate vitrectomy if vitreoretinal surgeon available for VA LP
 IV antibiotics for severe cases (Vancomycin/Linozlid and ceftazidime)

21. Thanks you

22. References
 Shah GK, Stein JD, Sharma S, et al. Visual outcomes following the use of intravitreal steroids in the treatment of postoperative endophthalmitis. Ophthalmology 2000;107:
486 – 489
 Das T, Jalali S, Gothwal VK, Sharma S, Naduvilath TJ. Intravitreal dexamethasone in exogenous bacterial endophthalmitis: results of a prospective randomised study. Br J
Ophthalmol 1999;83:1050 –1055
 Gan IM, Ugahary LC, van Dissel JT, et al. Intravitreal dexamethasone as adjuvant in the treatment of postoperative endophthalmitis: a prospective randomized trial. Graefes
Arch Clin Exp Ophthalmol 2005;243:1200 –1205