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Endophthalmitis in The New Millennium
- 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
- 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