NW2008 Endopthalmitis

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)

Thank you

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