Acute post operative endophthalmitis prevention

1. Acute post-operative
endophthalmitis-Prevention
Dr Haitham Al Mahrouqi, MB ChB
Oman Medical Specialty Board

2. Outline
 Definition
 Epidemiology
 Clinical features
 Prevention: Detailed

3. What is endophthalmitis?
 Inflammation of the internal coats of the eye along with vitritis
of an infectious origin. (Ocular infection by Seal)
 Infectious origin: Bacteria or fungal
 If the infectious origin is viral or parasite, called uveitis rather
than endophthalmitis.

4. Classification
 According to onset:
 Acute (Mostly within 1 week)
 Chronic (>6 weeks)
 According to origin:
 Endogenous: From blood stream
 Exogenous: Post-operative (Cataract, glaucoma..etc), or post-
traumatic

5. Incidence post cataract
 Incidence of post cataract endophthalmitis:
 Early 1990s: <0.08 (Javitt et al 1994)
 Late 1990s: 0.15 (Smitz, 1999)
 Mid 2000s: 0.3 (ESCRS study, 2006)
 Attributed to going sutureless

6. Incidence post filtering surgery
 Post filtering surgery (statistics from Bascom Palmer):
 1994: 0.16%
 2002: Around 0.2
 Attributed to the use of anti-fibrotic agents (5-FU and Mit-C)

7. Incidence post vitrectomy
 Post vitrectomy (Wills Eye Institute data):
 1995: 0.04
 2007: 0.23 (statistically significant difference between 20g and 25g
needles: Kunimoto 2007)
 Attributed to use of 25g needles and sutureless incisions.

8. Incidence post intravitreal injections
 0.05 (Fileta et al, 2004)

9. Incidence post traumatic endophthalmitis
 Range from 1-20%, increased with retained foreign body and dirty
wounds from rural settings. (safneck, 2012)
Incidence of endophthalmitis
Post-op Traumatic
<1% >1% (average 5-10%)

10. Risk factors
 YOU: Hand cleaning, proper draping
 PATIENT: Immunocompromised, old age, co-morbidities, local infections/flora
 ENVIRONMENT:
 Surgery related: Leaky wounds, types of IOL, heparinization (bacteria adhere more to polypropylene material, PMMA
compared to acrylic, without heparin), foldable or non-foldable, surgical complications, length of surgery.
 Non surgery related: Sterilised theatre, proper sterilization of equipment.
 Intraocular complications: Posterior capsular rupture
 Up to 40% of eyes have culture positive results from the aqueous humour at the end of cataract surgery
(Dicky et al 1991)
 Mostly staph epidermidis
 However, rarely develop endophthalmitis unless the vitreous was exposed.

11. Generally
 Post-operative endophthalmitis generally increased due to:
 Newer techniques
 Higher number of surgeries
 Larger pool of organisms

12. Clinical features
 Symptoms (within 1 week for acute)
 Decreasing vision along with “Eye ache”
 Later, severe redness, pain, photophobia.
 Often afebrile
 Signs

13. Clinical features
 Investigations:
 High WBC, normal to high ESR/CRP
 B-scan
 Vitreous sample: Negative culture does not
exclude diagnosis

14. How to take culture samples
 Should be kept for at least 14 days to culture slow growing organisms.
 Prepare patient as if intra-ocular surgery, full draping.
 Topical + peribulbar anaesthesia. If severe endophthalmitis (e.g. abscess), resistant to local
anaesthesia. Therefore general anaesthesia might be necessary.
 Conjunctival swabs: Can be helpful if –ve tabs
 Aqueous tab: 0.1-0.2mls aspirated using 25g needle
 Vitreous tab (More likely to yield +ve results): 0.2-0.4mls aspirated using 23g needle or better using disposable
vitrector (scleral tunnelling)

15. Diagnosis
 Endophthalmitis is a clinical diagnosis, confirmed with positive aqueous
or vitreous cultures.
 DDx:
 Toxic anterior segment syndrome
 Severe uveitis
 Retained lens material
 Vitreous haemorrhage

16. Microbiology: Acute
Streptecoccus endo
Courtesy: Wills eye
path lab.

17. Microbiology: Sweden

18. Microbiology
Post op cataract Post-op Blebitis Post-op IVI Post traumatic
Acute:
Coagulase negative
staph
Chronic:
P.Acnes
Corynebacterium
Early onset:
Coagulase negative
staph
Delayed:
Strep/staph
- Coagulase negative
staph
- Streptococcus
-Coagulase negative
staph
- Bacillus
- Streptococcus
Always think about
fungi
Endogenous endophthalmitis: Many organisms, think about fungi in immunocompromised.
Exogenous Endophthalmitis

19. Chronic endophthalmitis
 Indulent course, develops slowly
 > 6 weeks, flares up with reduction of steroids
 Low virulent organisms (e.g P.acnes)
 Form biofilms inside the capsule which are difficult to treat.
 Treatment often involves removal of biofilm and lens.
 Good prognosis.
 BIOFILM: a community of microbes embedded in an
organic polymer matrix, adhering to a surface

20. Management: Prevention
 Prevention is the best cure!
 Pre-operative:
 Treat local infections
 Recognise risk factors: Immunocompromised states, pre-existing ocular infection
 Proper draping hand washing (5 minutes, at least 2 minutes)
 Povidone iodine
 Antibiotics
 Pre-op: 1 week, 1 day, minutes
 Intraop: intracameral, infusate, on the lens!, subconj at the end of surgery
 Post-op: soon vs delayed.

21. Prevention: History of povidone iodine
(Betadine)
 In the 4th century BC, before iodine had been discovered, Theophrastus,
a pupil of Aristotle, recorded that iodine-rich seaweeds could be used to
reduce the pain of sunburn. (Selvaggi et al, 2003)
 The antimicrobial properties of iodine were first demonstrated in 1882 by
Davaine. In the First World War, iodine was found by Alexander Fleming
to reduce the incidence of gas gangrene in the wounds of soldiers when
compared to carbolic acid. (Felming et al, 1919)
 Iodophores (Povidone)developed in 1950s to overcome the toxic nature
of iodine to body tissue. Slow release of iodine.

22. Prevention: Povidone iodine’s (Betadine)
antimicrobial properties
 The action is not well understood but thought to be due to penetration of
cell wall of organisms. Action against bacteria (including mycobacterium),
fungi, protozoa, virsus. (Vs chlorehexidine; less effective against viruses
and mycobacteria).
Sibbald et al, 2011

23. Prevention: Povidone iodine (Betadine),
proper application
 Eyelids and skin
 10%
 Clean eyelashes and eyelid margin first
 Clean surrounding skin
 Conjunctiva:
 5%
 Leave for at least 3 minutes (ESCRS guidelines)
 Studies showed reduction up to 90% of conjunctival flora (Apt 1984)
 Extensive evidence on its effect on reducing endophthalmitis.

24. Prevention: Pre-op antibiotics
 No clear evidence!
 Hariprasad et al, 2005: Moxifloxacin 2h and 6h for 3 days prior to surgery: Although 4th generation
flouroquinolones have good penetration and exceed the MIC of most organisms in the A/C, limited
concentration in the vitreous (better for 2h).
 HOWEVER
 Friling et al (2013): Case control study of all endophthalmitis cases in sweden from 2005-2010 (500,000
operations, 135 cases of endophthalmitis). No role of pre or post op antibiotics when intra-cameral
cefuroxime.
 Moss et al (2009): RCT; 3 day use of moxifloxacin confered no additional reduction in conjunctival flora
over povidone iodine only.
 He et al (2009): No difference in conjunctival flora of 3 days Vs 1 day moxifloxacin.

25. Prevention: Intra-operative prophylaxis
 Surgical technique:
 2 vs 3 plane corneal incision
 Clear corneal vs limbal with suture
 Intra-cameral antibiotic:
 Sweden was a pioneer in this area.
 ESCRS study 2006

26. Prevention
Landmark study: ESCRS study 2006
 16,000 patients, 23 centres
 RCT, 4 groups
 All cases received povidone iodine and post op
levofloxacin for 6 days (started 24hr later).
 Prematurely stopped due to the overwhelming evidence
of the effect of IC cefuroxime in reducing the rate of
endophthalmitis.

27. Prevention
Landmark study: ESCRS study 2006

28. Prevention
Landmark study: ESCRS study 2006

29. Prevention
In support of IC cefuroxime
Berry et al 2006

30. Prevention: Cost-effectiveness study
 Hypothetical study with 100,000 patients.
 The cost-effectiveness ratio for intracameral cefuroxime is $1403 per case of
postoperative endophthalmitis prevented. By comparison, the least expensive
topical fluoroquinolone in our study, ciprofloxacin, would have to be >8 times more
effective than intracameral cefuroxime to achieve cost-effective equivalence. The
most expensive topical fluoroquinolones studied, gatifloxacin and moxifloxacin,
would have to be > or =19 times more effective than intracameral cefuroxime to
achieve cost-effective equivalence. A sensitivity analysis reveals that even in the
worst case scenario for intracameral cefuroxime efficacy and with a 50%
reduction in the cost of 4th-generation fluoroquinolones, gatifloxacin and
moxifloxacin would have to be > or =9 times more effective than intracameral
cefuroxime to achieve cost-effective equivalence.

31. Is it povidone or intracameral antibiotics?

32. Prevention: therefore
 The only evidence currently:
 Povidone iodine
 Intra-cameral cefuroxime
No evidence does not mean absence of evidence

33. Treatment
 If it happens:
 Early recognition
 Optimal treatment

34. References
 Kunimoto DY, Kaiser RS. Incidence of Endophthalmitis after 20- and 25-Gauge Vitrectomy. Ophthalmology;114(12):2133-37.
 Fileta JB, Scott IU, Flynn HW, Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic Surg Lasers Imaging
Retina 2014;45(2):143-9
 Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from
a European multicenter study. J Cataract Refract Surg 2006;32(3):407-10
 Selvaggi G, Monstrey K, Van Landuyt. The role of iodine in antisepsis and wound management: a reappraisal. Acta Chir Belg 2003; 103: 241-7
 Vallin E. Traite des desinfectants et de la desinfectantion. 1882; Paris: Masson.
 Fleming A. The action of chemical and physiological antiseptics in a septic wound. Br J Surg 1919; 7: 99-129.
 Sibbald RG, Leaoer DJ, Queen D. Iodine Made Easy. Wounds International 2011; 2(2): Available from http://www.woundsinternational.com
 Apt L, Isenberg S, Yoshimori R, et al. Chemical preparation of the eye in ophthalmic surgery. III: effect of povidone-iodine on the conjunctiva. Arch Ophthalmol 1984;102:728-729
 Hariprasad SM, Blinder KJ, Shah GK, Apte RS, Rosenblatt B, Holekamp NM, et al. Penetration pharmacokinetics of topically administered 0.5% moxifloxacin ophthalmic solution in human
aqueous and vitreous. Arch Ophthalmol 2005;123(1):39-44
 He L, Ta CN, Hu N, et al. Prospective randomized comparison of 1-day and 3-day application of topical 0.5% mxoifloxacin in eliminating preoperative conjuncctival bacteria. J Ocul Pharmacol
Ther 2009;25:373-8
 Moss JM, Sanislo SR, Ta CN. A prospective randomized evaluation of topical gatifloxacin on conjunctival flora in patients undergoing intravitreal injections. Ophthalmology 2009; 116: 1498-
501
 Safneck JR. Endophthalmitis: A review of recent trends. Saudi Journal of Ophthalmology 2012;26(2):181-89
 B. Carpentier and O. Cerf, Biofilms and their consequences, with particular reference to hygiene in the food industry, J. Appl. Bacteriol. 75(6) (1993), 499–511