Endophthalmitis course by Prof Dr Fadel AbouSHousha

1. Endophthalmitis
in
The New Millennium
Prof. Fadel Abou Shousha
Alexandria University

2. Endophthalmitis
• Postoperative
• Acute
• Delayed onset
• Bleb associated
• Post-traumatic
• Endogenous

3. Endophthalmitis following
intraocular surgery
• Cataract (with & without IOL)
• Secondary IOL implantation
• Glaucoma
• Penetrating keratoplasty
• Vitreoretinal procedures

4. Incidence by surgical category
• Cataract: 0.08%
• Secondary IOL: 0.37%
• PPV: 0.05%
• Glaucoma: 0.12%
• PK: 0.18%

5. Mean VA after treatment
• Secondary IOL implant: 20/40
• Glaucoma: 20/80
• Cataract: 20/133
• PK: 2/200
• PPV: NLP

6. Intraocular organisms
• Gram positive bacteria 94%
• Gram negative bacteria 6%

7. Intraocular isolates
• Coag. negative staph. 70%
• Staph. aureus 10%
• Strept. Species 9%
• Other Gram + 3%
• Enterococcus 2.2%
• Gram negative 6%.

8. Antibiotic susceptibility EVS
• 100% of G+ susceptible to
vancomycin
• 90% of G - susceptible to Amikacin
and Ceftazidime

9. Late onset endophthalmitis
• Propionobacterium acnes
• Staph. epidermidis
• Fungi (Candida)

10. Source of organisms
• Bacteria from patient’s eyelids and conjunctiva
• Confirmed by DNA fingerprinting (pulsed- field
elctrophoresis)
• Organisms introduced into the eye at the time of
surgery
• Small inocula usually eradicated by the immune
system.

11. Virulent organisms =
poor outcome
• Streptococci
• Pseudomonas aeruginosa
• Klebsiella pneumoniae
• Other gram negative rods
• Staph. aureus

12. Virulent organisms
• If :
– Rapid presentation
– Relative afferent pupillary defect
– Hypopyon > 1.5 mm
– Loss of red reflex

13. Clinical presentation
• Pain ( 75 % )
• Conj. Injection
• Lid oedema (33%)
• Note that low virulence organisms may
present without pain or external
inflammation

14. Clinical presentation
• Loss of vision
• Pupillary membranes
• Vitreous opacification
• Hypopyon
• Retinal Hges
• Ultrasonography!!!

15. Diabetes and Endophthalmitis
• 14% are diabetic
• Worse VA on presentation
• Worse final VA

16. Diagnosis
• Early diagnosis is crucial and
requires high index of suspicion in
patients with postoperative
inflammation greater than
expected.

17. Time of presentation
• 1-3 days: Staph. aureus
• Strept species
• Gram negative
• One week: Staph. epidermidis.
• 3-4 weeks: Late onset

18. Differential diagnosis
• TASS ( Toxic anterior segment syndrome ) !!!
• Within the first 24 hours
• No pain
• Limbus to limbus corneal edema
• Non-reactive dilated pupil
• Moderate to severe anterior chamber reaction with
cells , flare , hypopyon and especially fibrin
• Responds to steroids
• Negative culture

19. Work-up
• Both aqueous and vitreous taps
• Send to an understanding lab.

20. Diagnostic stains
• Gram stain (5 min)
• Giemsa stain
• Acridine orange stain (2min)

21. Modern molecular
diagnostic tests
• Used in both clinical and
experimental settings
• Polymerase chain reaction ( PCR )
• Specific DNA probes

22. Method of specimen acquisition
• Aqueous specimen
• 27 – 30 G needle attached TB syringe
• 0.1 ml required

23. Method of specimen acquisition
• Vitreous undiluted specimen
• Vitreous needle tap
• Mechanized vitreous biopsy

24. Vitreous needle tap
• 22 G needle attached to syringe
• Pars plana location
• 0.1 – 0.3 ml required
• Dry tap convert to vitreous biopsy

25. Mechanized vitreous biopsy
• 20 G pars plana sclerostomy
• Vitreous cutter attached to syringe
• 0.1 – 0.3 ml
• Manual aspiration

26. Mechanized vitreous biopsy
• Visitrec Vitrectomy System
• 23 G guillotine cutter
• One-step sclerostomy, cutting, aspiration
• Suture closure not required

27. Vitrectomy cassette fluid
• 3 - port vitrectomy
• Specimen may be suction filtered or
centrifuged

28. EVS
• EVS HM visual acuity
• Required 4-5 hand
presentations at 2 feet with
the light source from behind
the patient

29. Intravitreal injection of antibiotics
• Antigram negative Ceftazidime
• Antigram positive Vancomycin

30. Intravitreal injection of antibiotics

31. Intravitreal injection of antibiotics

32. Intravitreal injection of antibiotics

33. EVS: Additional procedures
• Guidelines for early additional
procedures
• VA <5/200
• No red reflex or worse media
clarity
• Growth from initial culture
• At least one of these:
• 1mm increase in hypopyon
• Corneal infiltrate
• Increasing pain

34. Corticosteroids
• Intravitreal
Recommended dosage 0.4 mg/0.1 ml
• Topical & subconjunctival
Essential in EVS
• Oral
Used in EVS ( 30 – 60 mg prednisolone )
for 10 days

35. Treatment derived from EVS
• Topical antibiotics & steroids
• Oral steroids
• Culture/sensitiivty & gram stain

36. Treatment derived from EVS
• No IV antibiotics
• No hospitalization
• Pre-op B-scan if retina not seen
New Modality
Moxifloxacin 400mg daily
Reach vitreous in therapeutic
concentraction

37. Delayed onset Endophthalmitis
Treatment Strategies
• P acnes
– Topical Antibiotics ( moxifloxacin , gatifloxacin ,
Levofloxacin , Vancomycin )
– Intravitreal Vancomycin
– If no response
PPV with or without capsulectomy
with or without IOL exchange
Oral Klacid ( clarithromycin 500mg BD x 1-2 wks )

38. Delayed onset Endophthalmitis
Treatment Strategies
• Fungal
– Topical antifungal ( Amphotericin 0.15% or
Fluconazole )
– Intravitreal Amphotericin
– Oral antifungals ( Fluconazole or Itraconazole )
– Intravenous Amphotericin
– If no response PPV with or without capsulectomy
with or without IOL exchange

39. Bleb Associated Endophthalmitis

40. Difficulties during vitrectomy

41. Difficulties during vitrectomy

42. Parsplana approach

43. Pseudophakic endophthalmitis

44. Pseudophakic endophthalmitis

45. Fundus Changes
after treatment of endophthalmitis

46. Fundus Changes
after treatment of endophthalmitis

47. Fundus Changes
after treatment of endophthalmitis

48. Fundus Changes
after treatment of endophthalmitis

49. Thank you