nw2008 endopthalmitis
DESCRIPTION
endophthalmitis, a serious kind of eye infection, in briefTRANSCRIPT
ENDOPHTHALMITIS 1/2
Nawat Watanachai
Ramathibodi 2008
DeFiNiTiOnDefinitiondEfInItIoN
Inflammatory reaction as a result of intraocular colonization by bacteria, fungi or parasites
Can be Exogenous (postop, post traumatic) Endogeous
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
Microbial Endophthalmi
tis : 3 phases
Incubation Accelleration Destructive
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
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
Microbial Spectrum: post cataract
CNS 33-77% S.aureus 10-21% BHS/S.pneumo/AHS 9-19% GNB 6-22% Fungi <8%
Late onset : P.acne, Corynebacteria, fungi
Microbial Spectrum : post glaucoma
Early : CNS 67% Late
Strepttococci GNR eg
H.influenza
Microbial Spectrum : post trauma
Single pathogens 62-65% Mixed 12-42%
CNS 16-44% Bacillus 17-32% GNB 10-18% Strep, fungi, corynebacterium, clostrigium
Incidence of postcataract endophthalmitis
1910 : 10% 1970-90
ECCE US 0.072% EURO 0.12%
1990-2000 PE : 0.015-0.5%
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%
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)
Risk Factors for endoph following cataract surgery :
Techniques- Wound dehiscence : CCI>CSI
- Germany 0.1% vs 0.07%- Canada 0.13% vs 0.05%
- CCI : prospective randomized multicenter study 11,595 eyes- Temporal 5X- Superior 1X
Risk Factors for endoph following cataract surgery :
Techiniques- ESCRS study : Endophthalmitis
- CCI 5.88X- CSI 1x
- Caution : only 2/24 centers do the CSI routinely
- The risk in CCI may be reduced by suturing
Risk Factors for endoph following cataract surgery : IOL
selection- Sweden(‘94-’00)
- Case-control study- Silicone >> heparin-
coated PMMA
- ESCRS- Prospective- Silicone 3.13x- Acrylic/ others 1x
Risk Factors for endoph following cataract surgery : IOL
selection IOL design
S.epidermidis : Polypropylene>PMMA Staph : less with hydrophilic heparin-
coated lenses Foldable IOL via injector --> lower the
incidence of endoph
Risk Factors for endoph following cataract surgery : Summary from
ESCRSRisk 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
Endophthalmitis and other surgeries : Glaucoma
Incidence Early 0.1% Late 0.2-0.7%
Germs : Strept, GNB including Moraxella
Risk factors Antimetabolite : 5-FU Bleb location : inferior > superior
Endophthalmitis and other surgeries : PKP
Incidence 0.08-0.2% Risk factors
Contamination of donor tissue
Endophthalmitis
and other surgeries : PPV
Incidence 0.05-0.14% Cohen et al 1995
12,216 PPV in 8 centers 9 cases of endophthalmitis = 0.07%
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?
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?
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
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
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***
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
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.
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
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?
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?
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)
Prophylaxis : irrigation of lacrimal passage
Preop irrigation of lacrimal passageNo signif effect on the contamination of
investigated aqueous (Amon 1991)Should not do immediately before Sx
Prophylaxis : lashesLashes cutting : not
associated with reduction of the risk (Schmidtz, Ophthalmology1999)
Taping back the lashes : recommendable
Prophylaxis :ABO in Irrigating SolutionNormally use Vanco, GentaVarious in countries
Germany 60%US 35%New Zealand 16%England 8.5%AUS 8%
Prophylaxis : ABO in Irrigating solution
NOT support by any prospective case-control study
Risk of overdose?Developing
resistance?
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
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?
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
Prophylaxis : Postop ABO dropsRecommend for 2 weeks :)But not proven :(Choices
Quinolone dropChloramphenicolPolymyxin/Bacithracin/Neomycin
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
Prophylaxis : Conclusion
PE, consider foldable IOL with injector Intracameral Cefuroxime 1 mg/ 0.1 ml
salineTopical quinolone/ABO at the end of SxPostop ABO drop qid
1 wk for CSI/ CCI with suture2 wks for CCI without suture
2 B Continue….
I’ll be back!
Endophthalmitis 2/2
Nawat Watanachai
Ramathibodi 2008
Diagnosis
Early endoph : within 2 weeks POLate endoph : > 2 wks PO
Diagnosis : endophthalmitis
Signs and symptoms early late
Pain 74-85% 21-70%
Reduced vision 90+% 80+%
Hypopyon 75-86% 67%
Red eye 80+% 50-74%
Lid swelling 35% <10%
Corneal edema 69-72% 48%
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)
Differential diagnosisuveitis 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-to-limbus) Presented in 12-48 hrs PO Always gram stain & culture –ve Response well with intense topical steroid
Management
AC tap Vitreous tap Intravitreal ABO Intravitreal dexamethasone 0.4 mg/0.1 ml? PPV?
Gram stain Culture PCR
Others?
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)
Management : AC/PC tap, PPV for Gram, culture PCR
Timing : Silver standardPerform AC/PC tap and do ivABO within
3 hr of clinical dxOr the visual prognosis will becomes
worsenPortable vitrector
Management :AC/PC tap, PPV for Gram, culture, PCRvitreous material
VxSyringe and needle (no. 20-23)?
Aqueous materialConjunctival swapCorneal swapLid swap
Management :AC/PC tap, PPV for Gram, culture,
PCR
PPV in the OPD, Jager et al, ARVO 2000Safe to perform if use with povidone iodineNo statistical difference in acquired
endophthalmitis rates after Vx between OT and OP
Management :AC/PC tap, PPV for Gram, culture, PCRNeb, ophthalmologe 2000; Mino de
casper, ophthalmologe 1993 Inoculate the specimen in the media in
the theatreTransportation of material on cotton bud
will reduce the detection rate for 90%
Management :AC/PC tap, PPV for Gram, culture, PCR Results
Gram+microscopic : 1 hrPathogen culture : 24 hrsAbo sensitivity : 48-72 hrsABO sensitivity with RAST method : 6-10
hrsPCR
high sensitivity, low specificityChronic endopthalmitis
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
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
Surgical Management
Step 3 Inject ivABO with needle 25-30G in
separate needles slowlyReduce the dose by 50% if a full PPV has
been performedPreservative free dexa is then injected
(option)
Sometimes, it is not possibel to do the gold standard things
BUT!!!
Surgical management
Silver standardVitreous biopsy
NeedleVitreous cutter eg Visitrec vitrectomy system
5100, Intrector --> 23G probe
ivABO injection
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
Intravitreal ABO
Intravitreally inject and repeat as necessary EVERY 48-72 hrs
Do it accurately, cuz low safety marginGenta 200 mcg --> effectiveGenta 400 mcg --> macular infarction
Intravitreal ABO
First choice : Vanco 1 mg + Ceftazidime 2 mg
Second choice : Vanco 1 mg + Amikacin 0.4 mg
Dexa 0.4 mgAll in 0.1 ml solution
Intravitral ABO
In eyes after complete vitrectomyReduce dose by 50% Inject more frequent
Intravitreal ABO : Gram +ve Bacteria
ABO Group Use for Dose (mg)
Duration (hrs)
Vancomycin glycopeptide GPB esp MRSA,MRSE
1 48-72
Cefazolin 1st Ceph GPB 2 16
Clindamycin Lincosamide GPB, MRSA, anaerobe
1 16-24
Erythromycin Macrolide GPB 0.5 24
Ampicillin B-lactam GPB, H.flu 2 24
Intravitreal ABO : Gram -ve Bacteria and fungus
Drugs Group Use for Dose (mg)
Duration (hrs)
Ceftazidime 3rd Ceph GNB>GPB
2 16-24
Amikacin Aminoglycoside GNB 0.4 24-48
Gentamicin Aminoglycoside GNB 0.2 48
Amphotericin Polyene Fungus 5-10 mcg 24-48
Miconazole Imidazole Fungus 5-10 mcg 24-48
New ABOs
LinezolidDaptomycinEtc….
Systemic ABO
Acute purulent ABO Intravitreal ABOSystemic ABO
should be the same drug, Peyman 2004Penetrate into the inflam eyeMaintain effective intravitreal level
Systemic ABO
Use HIGH dose unless toxicVanco --> monitor plasma drug level
Oral probenecid (500mg q 12 hrs) --> retard outward transport of penicillins, cephalosporins, fluoroquinolones across the retinal capillary endothelium
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)
Systemic ABO
May modified after 24-48 hrs according toclinical responseABO sensitivity
profiled of the cultured organism
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)
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