endophthalmitis traetment

1. Vitrectomy in
endophthalmitis

2. Disease entity
• Post operative (62%)
• Bleb associated (25%)
• Post trauma (10%)
• Endogenous (<4)
• Post intravitreal injection (<1%)

3. Acute endophthalmitis
• < 6 weeks
• Infective, TASS, lens indused, reactivation of uveitis
• flora colonizing the lids and lash
• Staph (35%)(epidermidis or aureus), strepto spp.(35%), p. acnes (5%)

4. Chronic post operative endophthalmitis
• >6 weeks
• P. acne (41.2%), Staph. Epidermidis, corynebacterium spp., fungi

5. Therapy
• In the past, topically, subconjunctivally, by IV, and by IM injection
• 1980s - intravitreal antibiotics were accepted and recommended
• PPV - significant amount of material obtained for culture
Removal of infected vitreous - reduces bacterial load and toxins.
Media opacities are cleared
more rapid restoration of visual function

6. Antimicrobial Therapy
• role of subconjunctival and systemic antibiotics is more controversial
• Intravitreal – emperic
MIC - only 36–48 hours
• 1. Vancomycin 1 mg/0.1 mL
• 2. Cefazolin 2.25 mg/0.1 mL
• 3. Amikacin 0.2–0.4 mg/0.1 mL
• 4. Ceftazidime 2 mg/0.1 mL
• In select cases with severe vitreous inflammation consider:
• • Dexamethasone 4 mg/0.1 mL
• In traumatic endophthalmitis with vegetable matter consider:
• • Amphotericin B 5 μL/0.1 mL

7. Endophthalmitis vitrectomy study 1995
• Purpose –
• role of IV antibiotics and
• necessity of immediate PPV(within 6 hours of presentation) in post op.
endophthalmitis within 6 weeks

8. • Four treatment groups
• two groups underwent a three-port PPV, with or without IV
antibiotics
• two groups underwent a vitreous tap again with or without IV
antibiotics.
• All patients in the four treatment groups received systemic steroids

9. EVS drug regimen
• vancomycin 1 mg/0.1 cc and
• amikacin 400 mcg/0.1 cc.
• no intravitreal steroids
• Topical drops included vancomycin, amikacin, cycloplegics, and
corticosteroids

10. • Systemic medications were used for 5–10 days
• They were prednisone (PO) 60 mg,
• amikacin (IV) 50 mg/kg every 12 hours, and
• ceftazidime (IV) 2 g every 8 hours(Oral ciprofloxacin if the patient was
allergic to penicillin)

11. Key points of EVS results
• average onset of signs and symptoms of endophthalmitis was 6 days
after surgery
• 25% were without pain and
• 14% had no hypopyon
• Cultures were positive in only 69% of the cases
• 94% were Gram positive, with the majority being Staphylococcus
coagulase negative (70%), Staphylococcus aureus (10%), and
Streptococcus species (11.5%).
• Only 6% were Gram-negative organisms

12. Conclusions of EVS
• streptococci, Staph. aureus and Gram-negative organisms were more
virulent and more difficult to sterilize in the vitreous cavity
• intravenous antibiotics used at the time showed no additional benefit
• Immediate vitrectomy (up to 6 hours) is of significant benefit to those
who present with LP vision
• when the vision is hand-motion or better, a vitreous tap and
intravitreal antibiotics were as efficacious and recommended
• patients with diabetes mellitus had a better outcome with an initial
strategy of vitrectomy regardless of presenting vision

13. Traumatic Endophthalmitis
• Others effects of the injury
• wider, more virulent spectrum of bacteria
• Bacillus species
• Vitrectomy has been recommended because of
severity of the injuries,
severity of infection, and
more adverse outcome reported in these cases
• retained lens cortex, vitreous hemorrhage, and retinal breaks, as well
as allowing removal of infected vitreous, bacteria, and toxins

14. Chronic post-operative endophthalmitis
• indolent, initially responding to topical corticosteroid
• P. acnes – produces a granulomatous inflammation
characteristically a white plaque on the lens capsule
Cultures should be kept for at least 2 weeks
• fungal (particularly Candida parapsilosis),and
• nonvirulent forms of Staph. Epidermidis
• Surgery
• Recommended antimicrobial - vancomycin for P. acnes and amphotericin
for fungi;
imidazoles, - ketoconazole, fluconazole, or voriconazole may be of
benefit

15. Bleb-Associated Endophthalmitis
• occurs long after the initial surgery and is preceded by irritation and
redness of the eye
• classic initial finding is “white on red”
• Streptococcus is the infecting organism in as many as 60% of these
• initial vitrectomy
• In some (phakic) initial infection may be confined to the anterior
segment (“blebitis”), so systemic and intensive topical antibiotics may
work

16. Endogenous Endophthalmitis
• systemic illness or IV drug use
• Repeated blood cultures and a multidisciplinary approach are often
helpful
• Systemic therapy may be sufficient if the vitreous is not heavily
involved
• If fungal disease is strongly suspected, therapeutic vitrectomy is the
treatment of choice

17. Surgical Techniques
• placement of the infusion cannula
• AC wash
• inflammatory membrane
• in pseudophakic, the lens need not be removed initialyy - attempting
to do so may increase the risk of bleeding
• Removal of membrane over crystalline lens should begin over the iris,
close to the pupillary border, so the lens can be spared
• poor dilation and poor visualization, the lens in phakic eyes removed

18. • In severe cases the cornea and anterior chamber may be totally opaque.
• a temporary keratoprosthesis / open-sky vitrectomy can be used, followed
by a penetrating keratoplastic.
• Pockets of more heavily infiltrated vitreous are sometimes located near the
vitreous base; in the aphakic eye, peripheral depression may be used to
bring these into view
• posterior vitreous detachment
• cutting of vitreous near inflamed/necrotic retina can cause breaks
• If good visibility cannot be obtained, it is better to discontinue the
procedure
• In the end, watertight closure and intravitreal antimicrobials

19. Postoperative Management
• Analgesics
• Topical antibiotics and steroids, cycloplegic
• Systemic steroid
• If the inflammation appears to worsen - repeat tap and injection of
antibiotics
• In the EVS, 35% of all eyes needed some secondary procedure

20. Thank you