1. Endophthalmitis is an inflammatory reaction within the eye resulting from bacterial, fungal, or parasitic colonization. It can be exogenous (post-operative, post-traumatic) or endogenous. 2. Microbial endophthalmitis occurs in three phases - incubation, acceleration, and destructive. The incubation phase lasts at least 16-18 hours as bacteria multiply. The acceleration phase sees inflammation spread from the anterior chamber to the posterior chamber within 7 days. The destructive phase involves inflammatory mediators recruiting white blood cells to directly destroy ocular tissues. 3. Risk factors for post-cataract endophthalmitis include wound leakage, capsular defects, vitreous

1. ENDOPHTHALMITIS 1/2
Nawat Watanachai
Ramathibodi 2008

2. DeFiNiTiOn
Definition
dEfInItIoN
 Inflammatory reaction as a result of
intraocular colonization by bacteria, fungi or
parasites
 Can be
 Exogenous (postop, post traumatic)
 Endogeous

3. NuM3Er5
‘N’
ThE0R1eS
 29-43% of cat Sx, contamination
occurs with pathogenic bacteria without
the development of endophthalmitis
 Immune previlage of the eye
 Compromised by capsular defect/vit
loss -->14X

4. Microbial
Endophthalmitis
: 3 phases
 Incubation
 Accelleration
 Destructive

5. Microbial Endophthlmitis
: 3 phases
 Incubation phase
 Last at least 16-18 hrs
(aq. Barrier)
 Depend on
 Generation time of bacteria
 S.aureus, S.epidermidis 10 min
 Propionibacterium > 300 min
 Toxin production

6. Microbial Endophthalmitis : 3
phases
 Accelleration phase
 Inflam in AC, followed by inflam in PC within 7
days
 Pathogen-spf AB +ve in 3 days --> can produce
negative culture but severe inflammation
 Destructive phase
 Inflam mediators esp cytokines
 --> recruit WBC
 --> direct destruction/ proliferation

7. Microbial Spectrum
: post cataract





CNS
S.aureus
BHS/S.pneumo/AHS
GNB
Fungi
33-77%
10-21%
9-19%
6-22%
<8%
 Late onset : P.acne, Corynebacteria, fungi

8. Microbial Spectrum
: post glaucoma
 Early : CNS 67%
 Late
 Strepttococci
 GNR eg
H.influenza

9. Microbial Spectrum
: post trauma
 Single pathogens
 Mixed




62-65%
12-42%
CNS
16-44%
Bacillus
17-32%
GNB
10-18%
Strep, fungi, corynebacterium, clostrigium

10. postcataract
endophthalmitis
Incidence of
 1910 : 10%
 1970-90
 ECCE
 US
0.072%
 EURO 0.12%
 1990-2000
 PE : 0.015-0.5%

11. Risk Factors for endoph following
cataract surgery : Techniques
-
Incision Site (Talban 2005)
-
-
3.14M cataract cases (ECCE-PE) 0.128%
- 70s
0.327%
- 80s
0.158%
- 90s
0.087%
- 2000-2003
0.265% !?!
- PE : IIOP?
During ‘92-’03
- CCI
0.189%
- CSI
0.074%

12. Risk Factors for endoph following
cataract surgery : Techniques
- Wallin et al 2005
- 27 endoph compared with normal 1525 PE
- Cohort control
- Main factors
- Wound leak on the 1st PO day (P<0.001)
- Capsular/ zonular cpx (P<0.001)
- Use on topical ABO started on the day afer Sx
(P<0.001)

13. Risk Factors for endoph following
cataract surgery : Techniques
- Wound dehiscence : CCI>CSI
- Germany
- Canada
0.1% vs 0.07%
0.13% vs 0.05%
- CCI : prospective randomized
multicenter study 11,595 eyes
- Temporal
- Superior
5X
1X

14. Risk Factors for endoph following
cataract surgery : Techiniques
- ESCRS study : Endophthalmitis
- CCI
- CSI
5.88X
1x
- Caution : only 2/24 centers do the CSI
routinely
- The risk in CCI may be reduced by
suturing

15. Risk Factors for endoph following
cataract surgery : IOL selection
- Sweden(‘94-’00)
- Case-control study
- Silicone >> heparincoated PMMA
- ESCRS
- Prospective
- Silicone
- Acrylic/ others
3.13x
1x

16. Risk Factors for endoph following
cataract surgery : IOL selection
 IOL design
 S.epidermidis : Polypropylene>PMMA
 Staph : less with hydrophilic heparincoated lenses
 Foldable IOL via injector --> lower the
incidence of endoph

17. Risk Factors for endoph following cataract
surgery : Summary from ESCRS
Risk factors
Odds ratio
Intracameral cefuroxime -/+
4.92
CCI/ CSI
5.88
Suture -/+
1
IOL insertion forceps/ injector
1
IOL material silicone/others
3.13
DM +/-
1
immunosuppressed +/-
1
Equipment reuse/disposable
1
Complication +/-
4.95

18. Endophthalmitis and other
surgeries : Glaucoma
 Incidence
 Early
 Late
0.1%
0.2-0.7%
 Germs : Strept, GNB including
Moraxella
 Risk factors
 Antimetabolite : 5-FU
 Bleb location : inferior > superior

19. Endophthalmitis and other surgeries :
 Incidence
 Risk factors
0.08-0.2%
 Contamination of donor tissue
PKP

20. Endophthalmitis and
other surgeries
PPV
:
 Incidence
 Cohen et al 1995
0.05-0.14%
 12,216 PPV in 8 centers
 9 cases of endophthalmitis = 0.07%

21. Endophthalmitis and DM
 14-21% of all PO endophthalmiis are
diabetes
 Poorer prognosis esp when DR is
present preOP
 Higher percentage of GNB bacteria
(compared to nonDM), CMI?

22. Endophthalmitis and
Immunosuppression
 Montan et al, Ophthalmology
1998
 Topical/ systemic
immunosuppressants -->
signif higher risk of
endophthalmitis
 Change in local preop flora?
 Change in spectrum of
causative organisms?

23. PROPHYLAXIS
 1. Operating theatre
 2. Antiseptic
 3. Antibiotics





Preop
Systermic ABO prophylaxis
Irrigation of lacrimal passage
Covering the periorbital area
Intraop prophylaxis
 Irrigating solution
 Intracameral
 Subconj
 Postop

24. Prophylaxis : Operating theatre
 Air flow design
 20 air change per hour (like ECCE)?
 Ultraclean air system (like hip replacement Sx)?
 Equipment- sterilization and single-use
 Prefer single-use of tubing and other
equipments, if cost allows
 Wet areas are easily contaminated with
P.aeruginosa

25. Prophylaxis
: Antisepsis
 Goal : reduce the likelihood of wound
infection by reducing the total bacterial
count in the wound area
 Periorbital skin antisepsis
 Povidone iodine solution 5-10%
 contact time>3 min
 reduce bacterial count 90-99%
 Chlorhexidine 0.05%
 Both ABO can become contaminated
with P.aeruginosa***

26. Prophylaxis : Antibiotics
 Preop
 Topical ABO drop : fluoroquinjolone, chloram,
aminoglycosides, fusidic acid,
polymyxin/neomycin
 Reduce bacteria in conjunctival sac
 --> not proven to reduce rate of PO endoph
 Retrospective analysis : topical ofloxacin
gives lower endop rate compared with topical
ciprofloxacin

27. Prophylaxis : Antibiotics
 Preop
 Randomised placebo controlled
prospective multicenter ESCRS sstudy
 Levofloxacin 0.5%
 1 hr before Sx
 0.5 hr before Sx
 3 drops in 5 min intervals immediately
after Sx
 Result : appear to be some benefit,
but not signif.

28. Prophylaxis : Antibiotics, topical
 20,013 cases with Gatifloxacin 0.3%,
Moxifloxacin 0.5%
 x3/ 1 hr preop
 Qid postop
 Gatifloxacin 0.06%
 Moxifloxacin 0.1%
 --> comparable with others
 --> use older fluoroquinolone, keep these newers
for frank infection

29. Prophylaxis :
Antibiotics, oral and topical
 Combining of oral ABO (3 days preop)
with topical ABO
 --> provider higher ABO level in AC
 --> effect on intraocular bacterial
contamination?

30. Prophylaxis :
Antiseptic and Antibiotics
 Mino de Kasper et al, AmJO 2007
 Topical levofloxacin
 x4 on the day before Sx
 3 drops/1he before Sx
 With 5% povidone ipdine
 highly effective in reducing bacterial conjunctival
flora (compared to povidone-iodine alone)
 Endophthalmitis rate?

31. Prophylaxis : systemic ABO
 IV ABO
 not use and not proven to be of benefit for
elective surgical cases
 Open globe injury : 2 recent studies (narang
2003, Traumatic Endophthalmitis research
group, Archives 2007)
 Bacillus, CNS, S.aureus, Clostridium
 Intravitreal Ceftazidime 2.25 mg+ Vanco 1
mg
 Intracameral Genta 40 mcg+ Clinda 45 mcg
 Oral ABO
 Oral quinolones
 not for usual caseas
 May be useful in severe atopic cases (S.aureus)

32. Prophylaxis :
irrigation of lacrimal passage
 Preop irrigation of lacrimal passage
 No signif effect on the contamination of
investigated aqueous (Amon 1991)
 Should not do immediately before Sx

33. Prophylaxis : lashes
 Lashes cutting : not
associated with
reduction of the risk
(Schmidtz,
Ophthalmology1999)
 Taping back the
lashes :
recommendable

34. Prophylaxis :
ABO in Irrigating Solution
 Normally use Vanco, Genta
 Various in countries
 Germany
60%
 US
35%
 New Zealand 16%
 England
8.5%
 AUS
8%

35. Prophylaxis :
ABO in Irrigating solution
 NOT support by any
prospective casecontrol study
 Risk of overdose?
 Developing
resistance?

36. Prophylaxis :
Intracameral ABO Injection
 Intracameral Cefuroxime 1 mg/ 0.1 ml at the
end of Sx
 Developed in Sweden, data from >400,000 Sx
 Proven by the prospective, randomised controlled
multicenter ESCRS study
 Very active against
 Staph, Strept (except MRSA, MRSE, E.faecalis)
 GNB (except P.aeruginosa)
 P.acnes

37. Prophylaxis :
Intracameral ABO Injection
 Intracameral Cefuroxime (ESCRS)
 Significantly reduce PO endophthalmitis for 5x
 P=0.001 for presumed endophthalmitis
 P=0.005 for proven endophthalmitis
 The lowest rate of infection is in the group who had
intracameral injection and preop topical Levofloxacin :
but not sig.
 1 case report of severe anaphylactic reaction
 Intracameral vanco?, Clinda?, Genta?

38. Prophylaxis :
Subconj ABO Injection
 Has been much used for 30 yrs
 Little prophylactic effect?
 Not proven by any prospective case-control
study
 Give small amount of ABO level in AC :
Cefuroxime
 Subconj 125 mg --> AC level 20 mcg/ml
 Intracameral 2.25 mg --> AC level 3,000 mcg/ml

39. Prophylaxis :
Postop ABO drops
 Recommend for 2 weeks :)
 But not proven
:(
 Choices
 Quinolone drop
 Chloramphenicol
 Polymyxin/Bacithracin/Neomycin

40. Prophylaxis : Conclusion
 Topical ABO 1-2 days before Sx and/or
topical ABO 1-2 drops within 1 hr before Sx
 5% Povidone-iodine in the conjunctival sac/
periorbital area
 Washes surgeon hands with povidone-iodine
or chlorhexidine
 Sterile drape/ gown/ gloves
 Tape the eyelashes

41. Prophylaxis : Conclusion
 PE, consider foldable IOL with injector
 Intracameral Cefuroxime 1 mg/ 0.1 ml
saline
 Topical quinolone/ABO at the end of
Sx
 Postop ABO drop qid
 1 wk for CSI/ CCI with suture
 2 wks for CCI without suture

42. 2 B Continue….
I’ll be
back!

43. Endophthalmitis 2/2
Nawat Watanachai
Ramathibodi 2008

44. Diagnosis
 Early endoph : within 2 weeks PO
 Late endoph : > 2 wks PO

45. Diagnosis : endophthalmitis
Signs and symptoms
early
late
74-85%
21-70%
90+%
80+%
75-86%
67%
Red eye
80+%
50-74%
Lid swelling
35%
<10%
69-72%
48%
Pain
Reduced vision
Hypopyon
Corneal edema

46. Diagnosis : endophthalmitis






Conjunctival discharge
Corneal infiltration/ abscess
APD
AC/ PC cell+flare+fibrin
Absent red reflex
Plaque in the capsular bag
(40-89% in P.acne cases)

47. Differential diagnosis
uveitis
 Toxic anterior segment syndrome (TASS)
 Acute inflammation in the AC after cataract Sx
 may related to the irrigating solution, medications,
materials that gain access to the eye during sx, factors
related to cleaning/ sterilisation of instruments
 Rarely occurs in 1 pt only
 Common : blurred vision, marked AC inflammation
(including hypopyon, fibrin), corneal edema (lumbus-tolimbus)
 Presented in 12-48 hrs PO
 Always gram stain & culture –ve
 Response well with intense topical steroid

48. Management





AC tap
Vitreous tap
Intravitreal ABO
Intravitreal dexamethasone 0.4 mg/0.1 ml?
PPV?
 Gram stain
 Culture
 PCR
 Others?

49. Management :
AC/PC tap, PPV for
Gram, culture, PCR
 Timing : Gold standard
 Perform AC/PC tap and do ivABO within 1 hr of
clinical dx
 To save vision is
 To stop acute bacterial process
 To minimize the acute inflammation
 Unpreserved Dexa 0.4 mg/0.1 ml (Peyman, Lee&
Seal; Endophthalmitis 2004)

50. Management :
AC/PC tap, PPV for
Gram, culture PCR
 Timing : Silver standard
 Perform AC/PC tap and do ivABO within
3 hr of clinical dx
 Or the visual prognosis will becomes
worsen
 Portable vitrector

51. Management :AC/PC tap,
PPV for Gram, culture, PCR
 vitreous material
 Vx
 Syringe and needle (no. 20-23)?
 Aqueous material
 Conjunctival swap
 Corneal swap
 Lid swap

52. Management :
AC/PC tap, PPV for Gram, culture, PCR
 PPV in the OPD, Jager et al, ARVO 2000
 Safe to perform if use with povidone iodine
 No statistical difference in acquired
endophthalmitis rates after Vx between OT
and OP

53. Management :AC/PC tap,
PPV for Gram, culture, PCR
 Neb, ophthalmologe 2000; Mino de
casper, ophthalmologe 1993
 Inoculate the specimen in the media in
the theatre
 Transportation of material on cotton bud
will reduce the detection rate for 90%

54. Management :AC/PC tap,
PPV for Gram, culture, PCR
Results
 Gram+microscopic : 1 hr
 Pathogen culture : 24 hrs
 Abo sensitivity : 48-72 hrs
 ABO sensitivity with RAST method : 6-10
hrs
 PCR
 high sensitivity, low specificity
 Chronic endopthalmitis

55. Surgical Management
 Gold standard for acute PO endophthalmitis
 Immediate complete 3-port PPV by VR surgeon
(T.T)
 Step 1
 Insert the infusion port and KEEP IT CLOSE
 Insert the vitreous cutter
 Attach the handheld syringe to the asperating line
 The assistant aspirates when the surgeon
activates the cutter
 Stop when the eye softens/ the cutter is
disappearing from view
 Should get 1-2 ml of infected UNDILUTED vitreous

56. Surgical Management
 Step 2
 Connect the cutter to the machine
 Std 3-port PPV is performed within the limits of
visualization
 Posterior capsulectomy
 Aspirate pus/fibrin from AC when needed
 Note : NO aggressive Sx, iatrogenic RD in
endophthalmitic eye is catastrophic

57. Surgical Management
 Step 3
 Inject ivABO with needle 25-30G in
separate needles slowly
 Reduce the dose by 50% if a full PPV has
been performed
 Preservative free dexa is then injected
(option)

58. BUT!!!
 Sometimes, it is not possibel to do the gold
standard things

59. Surgical management
 Silver standard
 Vitreous biopsy
 Needle
 Vitreous cutter eg Visitrec vitrectomy system
5100, Intrector --> 23G probe
 ivABO injection

60. Surgical Management
 Silver standard (no PPV)
 Advantage
 Time (>completeness)
 Permit earlier injection of Abo, microbiology
 Easier to perform
 Cons
 Much more vitreous left in the eye
 Provide smaller sample

61. Intravitreal ABO
 Intravitreally inject and repeat as
necessary EVERY 48-72 hrs
 Do it accurately, cuz low safety margin
 Genta 200 mcg --> effective
 Genta 400 mcg --> macular infarction

62. Intravitreal ABO
 First choice :
 Vanco 1 mg + Ceftazidime 2 mg
 Second choice :
 Vanco 1 mg + Amikacin 0.4 mg
 Dexa 0.4 mg
 All in 0.1 ml solution

63. Intravitral ABO
 In eyes after complete vitrectomy
 Reduce dose by 50%
 Inject more frequent

64. Intravitreal ABO :
Gram +ve Bacteria
ABO
Group
Use for
Vancomycin
glycopeptide GPB esp
1
MRSA,MRSE
48-72
Cefazolin
1st Ceph
2
16
Clindamycin
Lincosamide GPB, MRSA,
anaerobe
1
16-24
GPB
Dose
(mg)
Duration
(hrs)
Erythromycin Macrolide
GPB
0.5
24
Ampicillin
GPB, H.flu
2
24
B-lactam

65. Intravitreal ABO :
Gram -ve Bacteria and fungus
Drugs
Group
Use for
Dose
(mg)
Duration
(hrs)
Ceftazidime
3rd Ceph
GNB>G 2
PB
Amikacin
Aminoglycoside GNB
0.4
24-48
Gentamicin
Aminoglycoside GNB
0.2
48
16-24
Amphotericin Polyene
Fungus
5-10 mcg 24-48
Miconazole
Fungus
5-10 mcg 24-48
Imidazole

66. New ABOs
 Linezolid
 Daptomycin
 Etc….

67. Systemic ABO
 Acute purulent ABO
 Intravitreal ABO
 Systemic ABO
 should be the same drug, Peyman 2004
 Penetrate into the inflam eye
 Maintain effective intravitreal level

68. Systemic ABO
 Use HIGH dose unless toxic
 Vanco --> monitor plasma drug level
 Oral probenecid (500mg q 12 hrs) -->
retard outward transport of penicillins,
cephalosporins, fluoroquinolones
across the retinal capillary endothelium

69. Systemic ABO and EVS
 Systemic Abo do not appear to have any
effect on the course and outcome of
endophthalmitis
 The study design used different drugs
systemically (amikacin, ceftazidime) to those
used intravitreally (vanco and ceftazidime)
 38% of endophthalmitic eyes demonstrated
GPC (limited activity with ceftazidime,
whereas vanco would have been much more
effective)

70. Systemic ABO
 May modified after
24-48 hrs
according to
 clinical response
 ABO sensitivity
profiled of the
cultured organism

71. Anti-Inflammator therapy
 In order to
 Limit tissue destruction by infiltrating leukocytes
 Stem the effect of antigens and highly inflammatory cell
walls released by bacterial disintegration after
administration of ABO
 Diminish the toxic effect of intraocular cytokines
 Intravitreal dexa 0.4 mg/ 0.1 ml
 Oral pred 1-2 mkd, start on the next day after
ABOinjection/PPV
 (do not show any -ve effect, EVS, Archieves 1995)

72. Thank you
It’s over for now,
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