ppt by dr mazhar

1. DR MAZHAR ALI PANHWER
CIVIL HOSPITAL KARACHI
Endophthalmitis
Etiology, classification
and clinical approach

2. DEFINITION
 Intraocular inflammation involving ocular
cavities(vitreous cavity and /or anterior
chamber) & their adjacent structures which
is either infectious or non – infectious .

3. CLASSIFICATION
 Endophthalmitis can be classified according to the
• Infectivity – Infective / non infective ( sterile)
• Mode of entry – exogenous / endogenous
• Type of etiological agent

4. Classification
Infectious Sterile (Infectivity)
Exogenous Endogenous ( Mode of entry)
Post –trauma Post-operative Blebitis
(PEI-IOFB)
Fulminant Acute Chronic

5. Cont.
 Etiological agent
5
Bacterial Fungal viral Parasitic
Endophthalmitis

6. Gram positive bacteria
75%-85%
Gram negative bacteria
10%-15%
Fungi
3%
Staphylococcus
epidemidis (43%)
Pseudomonas (8%) Aspergillus
Streptococcus spp
(20%)
Proteus (5%) Fusarium
Staphylococcus aureus
(15%)
Haemophilus
influenzae (1%)
Cephalosporium spp.
Propionibacterium
acnes
Klebsiella( 0-1%)
Bacillus cereus (1%) Coliform spp (0-1%)

7. Exogenous Endophthalmitis
 Vitreous and aqueous – primary site of involvement
 Retina and uvea –secondary involvement
 Basically 3 types
1) post operative
2) post traumatic
3) Blebitis
 Source of infection is from exterior
 Maily bacterial

8. 1)Post-op Endophthalmitis
Surgery Bascom Palmer Eye
Institute (1984-1994)
Katten et al
(1984-1989)
ECCE with and without
PCIOL
0.08% 0.072%
Secondary PCIOL 0.37% 0.3%
PPV 0.05% 0.05%
PK 0.18% 0.11%
Glaucoma filtration
surgery
0.12% 0.06%
Incidence: 0.05%
MC among all types: 49-76%

9. Source of infection
Airborne
respiratory origin, air condition in O.T
Solution and medications
irrigating solutions, drops and ointment
skin antiseptic, viscoelastic and silicon oil
Tissue
periocular skin ,lid margin and lashes
conjuctival sac, Lacrimal sac
nasal mucosa, corneal graft
Objects and materials
surgical instruments, gloves, masks, IOL
Clinical Importance- all causes are preventable

10. Risk Factors
Preoperative risk factors
blepharitis , active conjunctivitis
Lacrimal drainage system infection or obstruction ,
contaminated eye drops.
Operative risk factors
wound abnormalities, PC rent ,vitreous loss ,prolonged
surgery & contaminated irrigation solutions

11. Types Of Presentations

 Fulminant Acute Chronic
(<4 days) (4-7days) (>4 weeks)
-gram –ve -staph.epidermidis
-staph.aureus -coag.-ve cocci
-streptococci delayed delayed
entry onset
bleb P.acne
related fungi
S.epidermids

12. 2)Post traumatic
 Incidence-2-7%(unsterile conditions & contaminated objects)
 Contributes to 17-40% of all cases
 Penetrating ocular trauma is main culprit
 Causative organisms
fulminant: acute: chronic:
B. cereus S.epidermidis(MC) fungi:
Streptococcus Gram.-ve fusarium
 Bacillus cerus isolated in 50% of culture positive cases
causes fulminante Endophthalmitis

13.  Difficult to diagnose early.
 Rapid worsening of symptoms and inflammation
should be suspected as Endophthalmitis until proved
otherwise.
 Ring corneal infiltrate & ring abscess is typical of
Bacillus. also assoc.with proptosis,chemosis & severe
orbital pain in 24hrs
 Commoner in rural setting due to retained IOFB.
 Removal of IOFB with in 24 hr.reduces risk.

14. 3)Bleb related endophthalmitis
 4-18% of all cases
 After glaucoma filtration surgery
 May occur at any time (months- years )after surgery
 Most of the time through intact bleb via conjuctival flora
 Poor prognosis as org. are more virulent
 Causative organism
streptococci(MC)-faecalis,viridans,pneumoniae
H.influenzae
staph. are rare
 Clinical signs
infected white bleb
Vitritis
Hypopyon

16.  Risk factors: use of antimitotic agents,inferior
blebs,conjunctivitis,contact lens,periocular
infections
 Should be differentiated from BLEBITIS
 Blebitis
- low virulence organism
- mild intraocular inflammation
- no Vitritis

17. Endogenous(Metastatic) Endophthalmitis
 2-15% of all cases
 Hematogenous spread of organism from distant source
 Retina and choroid primarily involved due to high
vascularity.
 Fungi> bacteria
Candida(MC)>Aspergillus
 Predisposing factors
- Diabetes
- immunosuppresion(AIDS,malignancies medications)
- recent major abdominal surgery
- prolong indwelling catheter ( intravenous , TPN)
- intravenous drug abuser
- distant infection ( endocarditis, meningitis, septicemia etc)
 no structural defect in globe

18. Clinical Approach
Symptoms: Decreased or blurred vision
( sudden / severe – acute)
( slowly / mild—chronic)
Pain
Photophobia
Redness of eyes
Swollen eyelids
Discharge
White lesion in black part of the eye
Floaters
Fever

19. Signs
 Initial visual acuity ( prognostic significance)
 Ocular motility ( sign of orbital inflammation)
 Eyelid swollen , blepharospasm
 Conjunctiva
hyperemia, chemosis, bleb examination if present
 Cornea
edematous, opacification , DM folds
keratic precipitate, infiltrates, occult penetration
 Anterior chamber
cells, flare , fibrinous exudates and Hypopyon
 Iris – muddy,boggy,resistant to dilatation,post.synechiae

20.  Pupil-absent or sluggish reaction to light
 Lens - Membrane , exudates around IOL
 Vitreous - Vitritis , exudates , yellowish appearance
 Fundus examination
Absent red reflex and no fundal view
Papilitis
White lesion in retina and chorioid
Retinal hemorrhage and periphlebitis
 IOP- usually low,may be high in early cases
 Signs of penetrating injury and Intraocular foreign
body
 Wound dehiscence

22. Fungal Endophthalmitis
Caused by – Candida albicans, Aspergillus, Fusarium
etc.
 Causes
- delayed post-operative endophthalmitis
- endogenous endophthalmitis in
immunocompromised patients
 Minimal pain, mild external ocular involvement
 Progressive iridocyclitis, Vitritis ( string of pearl )
 Yellow white choroidal lesion single or multiple

23. Diagnosis
 A) Clinically
 B) Laboratory
AC Tap (0.1ml)
Vitreous tap (0.2 ml)
Standard Media
Gram’s stain Blood agar ( most aerobic bacteria)
Giemsa stain Chocolate (aerobic , Neisssseria , Haemophilus )
Culture Thioglycolate broth ( aerobic ,anaerobic bacteria)
SDA ( fungi)
Specialized Media
Lowenstein –Jensen ( mycobacterium , nocardia)
Non- nutrient agar E.coli enriched
PCR

24. 1) Ultrasound-vitreous membrane and opacities
anatomical status of the retina
extent of inflammation
choroidal detachment
IOFB presence and localization
retained lens material
2) CT Scan – not much useful
to detect IOFB
3) ERG
grossly abnormal - poor prognosis
slightly subnormal - slight better

25. For endogenous endoph.:
Complete blood count ( signs of infection)
ESR ( malignancy ,chronic infections, rheumatic
diseases)
Cultures ( for detection of source of infection)
blood culture
urine culture
throat swab
CSF
stool
indwelling catheter’s tip
Chest X-ray
Other
like HIV

26. Treatment
GOALS
1) Retention of useful vision.
2) Minimize the infection with antimicrobial agents.
3) Limit the inflammation.
4) Symptomatic relief.

27. For bacterial endoph.
 Prompt therapy is critical
 Modalities
MEDICAL
1) Antibiotics
Intravitreal, periocular, topical , systemic
2) Anti-inflammatory (steroids)
topical ,periocular , systemic
( not for chronic Endophthalmitis)
3) Supportive – Cycloplegic,AGM
SURGICAL
vitrectomy

28. Medical treatment
 Intravitreal injection
- preferred route in all types of endophthalmitis.
- direct administration in vitreous
- by passes Blood Ocular Barrier.
Intravitreal injection
 Vancomycin ( 1.0 mg in 0.1 ml )
 Amikacin ( 400ug in 0.1 ml)
Or
 Ceftazidime (2.25mg/0.1ml)
Subconjunctival injections
 Vancomycin (25mg in 0.5ml)
 Amikacin (25mg in 0.5ml)

29.  Systemic : 1) penetrating ocular injury from
contaminated objects.
2) Endogenous bacterial endophthalmitis.
 For Post-Op Endophthalmitis:
- no role due to MIC in vitreous
-Quinolones ( ciprofloxacin) can be tried
 Rapid bacterial proliferation make even the
Quinolones concentration inadequate to
prevent the growth of organisms.
Ideal duration - at least 2-4 week

30. Drugs Doses
Vancomycin 1 gm iv.12 hrly
(10-30 mg/kg)
Ceftazidime 2 gm iv. Bd
Amikacin 250 mg iv. Tid
(15mg/kg)
Gentamycin 80 mg iv tid
(3-5mg/kg)
Ciprofloxacin 750 mg po.bd
Ofloxacin 200 mg 12 hrly

31. Role Of Steroids
Indications
recent onset after rule out of fungus.
Contraindication
Late onset endophthalmitis
fungal endophthalmitis
Mechanism- reduce inflammation clinically and
histopathologicaly
limit ocular damage
Routes - Intravitreal(dexa400mgm in 0.1ml),systemic, sub-
conjuctival(1 mg in 0.25ml), topical

32. Treatment in Fungal Endoph.
 Indication of Intravitreal antifungal
1) pre-existing fungal keratitis endophthalmitis
2) fungal endogenous endophthalmitis ( culture +)
 Commonly used medications
intra-vitreal Amphotericin B- 5microgm/0.1ml
oral fluconazole / ketoconazole ( better vitreal penetration)
 Voriconazole
Intravitreal -50 microgm/0.1ml
oral- 200 mg bd
intravenous- 6 mg/kg bd 2 doses
 Steroids in any form C/I

33. Systemic antifungals

34. Vitrectomy
Advantages ( DIAGNOSTIC / THERAPEUTIC)
 1) more material for culture esp. fungus.
 2) removal of inflammatory mediators /organisms /toxins.
 3) removal of source of infection.
 4) better dispersion of antibiotics in the vitreous
.
 5) clears the media and better posterior segment visualization
 6) removes vitreous membrane which may be a source of late
traction and subsequent detachment.
guided by Endophthalmitis vitrectomy study
(EVS)

35. Complications
 Retinal necrosis
 Retinal detachment
 Retinal necrosis
 Vitreous tap
 Vitrectomy
 Increased intraocular pressure
 Retinal vascular occlusion
 Optic neuropathy
 Panophthalmitis
 Hypotony
 Ciliary body shut down
 Leaking wound
 Retinal detachment
 Cyclodialysis cleft
 Medication

36. Prevention
1 ) PRE-OPERATIVE
a) preexisting conditions e.g.blepharitis, conjunctivitis ,
dacryocyctitis,, infected contra- lateral socket
b) povidone iodine ( BETADINE) drops
c) meticulous draping
d) topical antibiotic
2) INTRA-OPERATIVE
irrigation of A/C with vancomycin
3) POST –OPERTAIVE
anterior sub-tenon antibiotic / sub conj. antibiotic

37. Bleb related
1) early diagnosis and treatment of conjunctivitis.
2) wearing of contact lens should be discouraged.
3) treatment of associated periocular infections.
Traumatic
1) safety goggles.
2) timely and appropriate management of ocular
trauma.
Endogenous
1) adequate and timely management of systemic
illness.
2) intravenous drug abuse reduction.
3) control of all predisposing factors.

38. THANK
YOU

39. Endophthalmitis Vitrectomy Study(EVS)
 Multicenter randomized trial carried out at 24 centres in
U.S. (1990-1994)
Purpose : To determine
 The role of IV antibiotics in the management of POE
 Role of initial vitrectomy in management.
Patients : N = 420 patients having clinical evidence of POE
within 6 weeks of cataract surgery
Intervention
Random assignment to immediate vitrectomy (VIT) or
vitreous biopsy (TAP). They were also randomly assigned to
treatment with IV or no IV.

40. Study medications : After initial VIT or TAP, all patients
received I/V injection of amikacin (0.4 mg) + vanco(1 mg)
 Vanco(25 mg in 0.5 ml), Ceftazidime (100 mg in 0.5 ml),
 Dexamethasone (6 mg in 0.25 ml) administered
subconjunctivally.
 IV treatment: ceftazidime (2 g every 8 hrs) + amikacin
(6mg/kg every 12 hrs) for 5-10 days

41. Main outcome measures
 Evaluation of visual acuity and clarity of ocular
media at 3, 9, 12 months
 No difference in outcome between PPV followed by I/V
group compared to vitreous tap and I/V if vision better
than light perception
 No difference in final visual acuity or media clarity
whether or not EVS systemic antibiotic( Amikacin ,
Ceftazidime) were employed
 Vision with light perception or worse ,much better
results in immediate PPV

42.  Limitations of EVS
1) only for acute post -operative endophthalmitis
after cataract surgery
2) doesn’t mention the outcome of vitrectomy in
other forms of endophthalmitis like;
- post –traumatic
-chronic post operative etc
-endogenous endophthalmitis