Endophthalmitis PacEYES 2012a.pptx

(1)

(2)

Outline



Presentation and differential



Causes and sources



The Endophthalmitis Vitrectomy Study



Goals and approach to treatment



Outcomes



Key points

(3)

Post-op

endophthalmitis



Cataract surgery is the most common

intraocular procedure worldwide



Post-op endophthalmitis is a rare but

dreaded complication

(4)

(5)

Presentation of post-op

endophthalmitis

 _Symptoms

 _Pain

 _Photophobia  _{Reduced vision}

 _Signs

 _{Profoundly reduced VA}

 _RAPD

 _{Lid swelling}

 _{Conjunctival injection}  _{Corneal oedema}

 _{AC inflammation, fibrin,}

hypopyon

(6)

Classification and differential

 Classification

 Acute (less than 4 weeks post-op)

 _Mild

 Severe

 Chronic/delayed (4 weeks or more after surgery, or months to years later)

 _{Gradual onset; good vision; minimal pain; mild vitritis; hypopyon less common}

 Bacteria or fungus, including P. acnes, S. epidermidis, Candida

 Can rarely be triggered by Nd:Yag laser capsulotomy

 Differential diagnosis

 Vitreous haemorrhage

 _{Excessive inflammation post op}

 Retained lens material  sterile inflammation

 _{Toxic anterior segment syndrome (TASS) due to contaminated irrigating fluid or}

viscoelastic

 _{Always limited to AC}

 _{Gram stain negative}

 _{Improves with steroids}

(7)

How does it happen?

 _{The eyelids and conj are the primary source of}

infection

 _{Other sources of contamination include:}

 _{Secondary infection from other sites eg. lacrimal}

system

 _Blepharitis

 _{Contaminated eyedrops}

 _{Contaminated surgical instruments, intraocular lenses}

or irrigation fluids

 _{Other agents introduced into the eye}

(8)

Potential sources

 _Airborne

contaminants

 _{Respiratory origin}  _{Surface origin (e.g.}

skin of lids, lashes)

 _Optical instruments  _Surgical instruments  _Tonometers  _Magnets  _Hypodermic needles, blood lancets

 _{Cotton balls,}

swabs, drapes, dressings, masks and gowns

 _{Rubber gloves,}

bulbs, droppers

 _{Glass syringes,}

bottles, irrigating tips

 _{Plastic tubing,}

sheeting, retractors

 _{Contact lenses}  _{Orbital implants}  _{Intraocular lenses}  _Sutures

(9)

Other factors



Complicated surgery



Surgeon experience



Clear corneal incision

(10)

Strategies for

prevention

 _{Pre-operative management of external diseases}

 _{Dacryocystitis, blepharitis, chronic conjunctivitis,} lagophthalmos, ectropion, entropion and tear film abnormalities

 _{Pre-op topical fluoroquinolone}

 _{Pre-op povidone-iodine}

 _{10% for skin; 5% on ocular surface}  _{Reduce bacterial load}

 _{For 3 minutes?}

 _{Draping / taping of lashes}

 _Asepsis

 _{Intracameral antibiotics}

(11)

The Aravind approach to

prevention

 _{Very high volume}

 _{Phaco/ECCE/SICS}

 _{Range of surgeon}

experience

 _{Cipro eye drops day}

before and on day

 _{Pre- and post-op}

povidone iodine

 _{No intracameral}

antibiotics

(12)

Endophthalmitis Vitrectomy

Study



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

(13)

Endophthalmitis Vitrectomy

Study

 _{Patients were randomized to one of two standard}

treatment strategies for the management of bacterial endophthalmitis:

 _{(1) initial pars plana vitrectomy with intravitreal}

antibiotics, followed by retap and reinjection at 36-60 hours for eyes that did poorly as defined in the study or

 _{(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}

(14)

Endophthalmitis Vitrectomy

Study



Study end points:

 _{Visual acuity and clarity of ocular media, the latter}

assessed both clinically and photographically

 _{Each patient’s initial end point assessment}

occurred at 3 months, after which procedures to improve vision, such as late vitrectomy for

nonclearing ocular media, were an option

 _{The final outcome assessment occurred at 9}

months

 _{Multiple centers cooperated by enrolling 420 eyes}

(15)

Results of the EVS

 _{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 plana vitrectomy

 _{However, vitrectomy tripled (33% v 11%) the frequency of achieving 20/40}

or better acuity; approximately doubled (56% v 30%) the chance of

achieving 20/100 or better acuity; and decreased by more than one-half (20% v 47%) the frequency of severe visual loss in the subgroup of patients who presented with VA of PL only

 _{Initial management for patients who meet EVS entry}

criteria should include 3 port pars plana vitrectomy if patients present with vision worse than hand motions

 _{But an initial vitreous tap/biopsy should generally be}

sufficient if presenting vision is hand motions or better

 _{Systemic antibiotics were not of benefit although all}

(16)

Goals of treatment



Identify the causative organism if possible



Preserve vision/the eye by:



Sterilizing the eye

(17)

Identify the organism

 _{Samples from anterior chamber and vitreous}

 _Aspiration

 _{Deliver to the pathologist, or}  _{Inoculate media (don’t dilute)}

 _{Drop onto:}

 Slide (gram and giemsa)

 _{Blood agar, choc agar, sab’s, thioglycolate broth}

 _{Mechanical vitrectomy}

 _{Yields and complications the same (EVS)}

 _{Negative cultures do not absolutely rule out infection}_

(18)

Sterilizing the eye



Most bugs are in the vitreous



Topical, subconj, systemic don’t reach high

enough concentrations (except cipro)



Need direct injection to vitreous



Shoot first, ask questions later



If doing tap, then inject (or it may be too late)

(19)

Sterilizing the eye

 _{Which antibiotic?}

 _{Used to be gentamicin and cefazolin (before 1986)}

 _{But gentamicin is toxic to retina}

 _{And vancomycin has better coverage of gram positives}

 _{EVS used amikacin (0.4mg) and vancomycin (1mg)}

 _{In Australia:}

 _{Ceftazidime (2.25mg)}

 Covers most Gram negatives including P. aeruginosa

 _{Vancomycin (1mg)}

(20)

Treatment of fungal

endophthalmitis



Can inject amphotericin B (0.005 to 0.01mg

in 0.1ml)

(21)

Role of systemic

antibiotics

 _{EVS shows that IV amikacin/ceftazidime or IV}

amikacin/ciprofloxacin made no difference to VA outcomes comparing treated and untreated groups

 ₄th generation oral gatifloxacin and moxifloxacin is

shown to achieve MIC90 after 2 x 400mg doses, and has broad spectrum coverage for S. aureus, Strep, Enterococcus, Proteus, E. coli, P. acnes

 _{But neither covers}_{Pseudomonas aeruginosa}

 _{Could be considered as adjunctive treatment, but}

(22)

Role of steroids

 _{Corticosteroids may be}

given as topical, subconjunctival, intravitreal

(dexamethasone or triamcinalone) or oral

 _{May diminish the}

destructive intraocular inflammatory response to endophthalmitis

 _{Timing and use is}

controversial

 _{Should be withheld if a}

fungal pathogen is suspected

 _{Evidence is limited so}

clinical judgement is important

 _{Topical and subconj}

steroid are acceptable but intravitreal

corticosteroid is more controversial

 _{Systemic steroid 30mg}

bd for 5-10 days, followed by a rapid

taper has been used in EVS, but the benefits were not evaluated

 _{No prospective}

(23)

Topical

fluoroquinolones



Third gen (cipro) v. fourth gen



Better gram positive cover

(24)

Intracameral antibiotics

 _{South India eye camps in}

1977

 _{Peyman et al. in BJO}  _Gentamicin

 _{ESCRS study (2003-2006)}

 _Cefuroxime

 _Barcelona

Endophthalmitis Group  _Cefazolin

 _{Rates of endophthalmitis}

– up to 0.35%

 _{Cefuroxime (second gen)}  _{Cefazolin (first gen)}

 _{Better coverage of gram} positives

 _{Cefotaxime (third gen)}

 _{Broad cover}

 _{Preparing the solution}

 _Sterility

 _{Concentration}

 _{1mg in 0.1ml through}

(25)

Initial treatment

 _Tap

 _Inject

 _{Intensive topical steroids}

 _{1% Atropine bd}

 _{Intensive topical antibiotics}

 _{Systemic antibiotics}

 _{Ciprofloxacin 750mg bd po}  _{Moxifloxacin 400mg daily po}

(26)

Subsequent

management



Depends on cultures and response to treatment



Signs of improvement

 _{Look for contraction of fibrin clot}

 _Continue



Signs of worsening

(27)

Outcomes

 _{Visual loss results from damage caused by:}

 _{Toxins and proteases produced by the infectious organisms and}  _{Host’s inflammatory response to the infection}

 _Sequelae:

 _{Direct injury to retina, anterior segment structures}  _{Tractional or rhegmatogenous RD}

 _{Ciliary body damage}  _Hypotony

 _{Phthisis bulbi}

 _{Worse visual outcomes in more virulent organisms that produce} endotoxins, exotoxins and proteases eg. S. aureus, Strep, Bacillus, Pseudomonas, Serratia marcescens, Proteus

 _{Less virulent organisms eg.}_{S. epidermidis}_and_{P. acnes}_{have a} more indolent course and are associate with better visual

(28)

Outcomes



EVS:



Correlated with presenting VA, and

organism

 _Strep_sp_._and_enterococci_{worst final VA}



At 3 months:

 _{41% achieved 6/12 or better}  _{69% achieved 6/30 or better}



At 9-12 months:

 _{53% achieved 6/12 or better}  _{74% achieved 6/30 or better}

 _{15% achieved worse than 5/200}



At final follow-up:

(29)

Key points



Maintain high standards of care



Warn the patient



Recognise the signs



Tap and inject



Carefully watch response and micro



Retreat if indicated

(30)

Preparation of

antibiotics

 _{Find out what’s}

available

 _{Look up the dose}

 _{Do your calculations}  _{Plan the dilutions}  _{Stick them on the}

wall

 _{Use aseptic}

technique

(31)

Tapping and injecting

 Best done in the OT

 Povidone-iodine 5%; drape; speculum

 Anaesthetic: sub-Tenon’s or peribulbar

 _{AC tap}

 _{Limbal paracentesis}

 25G needle on a tuberculin syringe

 _{Take 0.1 ml}

 _{Vitreous tap}

 _{23G needle on a 2 ml syringe}  3.5 mm from limbus

 _{Mid-vitreous cavity}  Take 0.2 ml

 Inject 0.1 ml of each antibiotic

(32)

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