Oculi Dextra Endoftalmitis Egidius Ian Andrian 102012346 Kelompok : B1 Fakultas Kedokteran Universitas Kristen Krida Wacana 2012 Jalan Arjuna Utara No.6, Jakarta 11510 Telp : 021-56942061 Fax : 021-5631731 E-mail : [email protected]I. Pendahuluan : Endophthalmitis merupakan kegawatdaruratan dalam bidang oftalmologi yang didefinisakan sebagai inflamasi atau peradangan pada bagian dalam bola mata termasuk rongga orbita yang diisi oleh cairan seperti gel yang bersifat transparan yang disebut Vitreus Humor dan juga mengenai Aqueous Humor. Inflamasi juga melibatkan jaringan disekitarnya yang berpengaruh terhadap fungsi penglihatan. Pada banyak kasus, penyebab dari inflamasi ini adalah infeksi (dapat oleh bakteri, jamur, virus ataupun parasit). Selain itu, infeksi bakteri endophthalmitis terbanyak adalah post operasi mata, seperti operasi katarak atau glaukoma. Bakteri juga dapat masuk bila terjadi trauma yang menembus pada mata. Yang jarang terjadi adalah penyebaran infeksi dari darah yang dapat menuju ke mata disebut hematogenous endophthalmitis. 1 II.Anamnesis
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Oculi Dextra Endoftalmitis
Egidius Ian Andrian102012346 Kelompok : B1
Fakultas Kedokteran Universitas Kristen Krida Wacana 2012Jalan Arjuna Utara No.6, Jakarta 11510 Telp : 021-56942061 Fax : 021-5631731
Antibiotik spektrum luas intravena termasuk vancomycin, aminoglikosid, atau
sefalosporin generasi ke-3. pertimbangkan penggunaan clindamycin secara
intravena jika ditemukan infeksi Bacillus spesies.
Antibiotik periokular
Antibiotik intravitreal
Siklopegik (misalnya : atropin)
Steroid topikal mungkin dapat diberikan. Atau pemberian steroid injeksi langsung
ke mata untuk mengurangi inflamasi dan mempercepat penyembuhan.
Vitrectomy mungkin diperlukan pada organisme yang virulen., atau pada infeksi
yang parah.
Gambar 7 : Endophthalmitis Bacterial
Penatalaksanaan Candida endophthalmitis
Sarankan pasien untuk dirawat di rumah sakit.
Fluconazole oral
Amphotericin B intravena atau intavitreal meungkin dapat dipertimbangkan
Siklopegik mungkin diperlukan.
Pada postoperative endophtahlmitis, terapi secara parenteral biasanya tidak dianjurkan kecuali
infeksi sudah menyebar diluar mata. Pada jenis endophtahlmitis yang lain, pemberian antibiotik
spektrum luas dilakukan bila telah didapatkan hasil dari kultur. Ophthalmologist biasanya
menggunakan terapi secara injeksi intravitreal atau subconjungtiva.
Dibawah ini dilampirkan obat-obat yang biasa digunakan untuk kasus Endophthalmitis.
Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive and should
cover all likely pathogens in the context of the clinical setting.
Drug Name
Vancomycin (Vancocin) -- Empiric coverage for gram-positive organisms including B cereus. DOC for both intravitreal and systemic administration; excellent gram-positive coverage and has added advantage of providing better coverage against resistant organisms; bactericidal against most organisms and bacteriostatic for enterococci; inhibits cell wall biosynthesis, interfering with cell-membrane permeability and RNA synthesis.After systemic administration, drug penetrates most tissues including vitreous, especially if the blood-ocular barrier is compromised. Use creatine clearance to adjust dose in patients with renal impairment.
Adult Dose1 g IV, infused over 1 h; repeat q12hIntravitreal dose: 1 mg in 0.1 mL
Pediatric Dose 10 mg/kg IV q6h
Contraindications Documented hypersensitivity
Interactions
Synergistic with aminoglycosides against B cereus, S aureus, enterococci, S viridans, and Streptococcus faecalisAminoglycosides increase risk of nephrotoxicity, requiring careful monitoring; risk of erythema and histaminelike flushing in children may occur when administered with anesthetic agents; increases neuromuscular blockade when used concurrently with nondepolarizing muscle relaxants
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsCaution in impaired renal function or previous hearing loss; red man syndrome may occur when administered too rapidly (rare when vancomycin is given over 2 h)
Drug Name
Gentamicin (Gentacidin, Garamycin) -- Empiric coverage for gram-negative organisms including P aeruginosa. First choice aminoglycoside for systemic gram-negative coverage; bactericidal inhibitor of protein synthesis (30S ribosomal subunit). Dosing regimens are numerous; adjust dose based on CrCl.
Adult Dose Normal renal function: 2 mg/kg load infused IV over 30-60 min, then 1.7
mg/kg IV q8h or 3-6 mg/kg/d IV divided q8h; adjust dose for renal function prn
Pediatric DoseNormal renal function (adjust dose prn):Infants and neonates: 7.5 mg/kg/d IV divided q8h >1 year: 6-7.5 mg/kg/d IV divided q8h
Increases nephrotoxic potential when administered with other aminoglycosides, cephalosporins, penicillins, or amphotericin B; increases effect of neuromuscular blocking agents when used concurrently Ototoxic effects may increase when administered with loop diuretics; monitor hearing in patients receiving aminoglycosides as damage may be irreversible
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsMay cause nephrotoxicity and ototoxicity; caution in premature infants and neonates
Drug Name
Ceftazidime (Fortaz, Ceptaz) -- Third-generation cephalosporin with broad gram-negative coverage but decreased efficacy to gram-positive organisms; gram-negative coverage includes Enterobacter, Citrobacter, Serratia, Neisseria, Providencia, and Haemophilus species. Cephalosporins bind to one or more of the penicillin-binding proteins and prevent cell wall synthesis inhibiting bacterial growth.
Adult Dose 2 g IV q12h
Pediatric DoseNeonates: 30 mg/kg IV q12h<12 years: 100-150 mg/kg/d IV divided q8h; not to exceed 6 g/d>12 years: Administer as in adults
Contraindications Documented hypersensitivity
InteractionsNephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal impairment
Drug Name
Ceftriaxone (Rocephin) -- Third-generation cephalosporin that crosses blood brain barrier. Active against resistant bacteria including gonococci, H influenzae, and other gram-negative organisms.Used in suspected hematogenous source for endophthalmitis in combination with vancomycin while cultures are pending. Cephalosporins bind to the penicillin binding protein and prevent cell wall synthesis, which inhibits bacterial growth.
Adult Dose2 g IV q24hIntravitreal dose: 2 mg in 0.1 mL
Pediatric Dose 50-100 mg/kg/d IV divided q12-24h; not to exceed 4 g/d
Contraindications Documented hypersensitivity
InteractionsProbenecid may increase ceftriaxone levels; concurrent use of furosemide and aminoglycosides may increase nephrotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal impairment; caution in breastfeeding women
Drug Name
Cefotaxime (Claforan) -- Third-generation cephalosporin that has broad gram-negative coverage but lower efficacy for gram-positive organisms. Cephalosporins bind to one or more of the penicillin-binding proteins and prevent cell wall synthesis inhibiting bacterial growth.
Adult Dose 2 g IV q4h
Pediatric Dose 100-200 mg/kg/d IV divided q8h; not to exceed 12 g/d
Contraindications Documented hypersensitivity
InteractionsProbenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
PrecautionsAdjust dose in severe renal impairment; has been associated with severe colitis; caution in breastfeeding women
Drug Name Clindamycin (Cleocin) -- Use in IV drug abusers or penetrating trauma with soil contamination for suspected B cereus infection. Semisynthetic antibiotic
that inhibits bacterial protein synthesis by interfering with peptide bond formation at the 50S ribosomal subunit; has both bacteriostatic and bactericidal activity.
InteractionsIncreases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in severe hepatic dysfunction; may be associated with severe and possibly fatal pseudomembranous colitis Hypotension or cardiopulmonary arrest may occur (rare) after too rapid IV use; anaphylaxis, Stevens-Johnson–like syndrome, agranulocytosis, and aplastic anemia may occur
Drug Category: Antifungal -- For suspected candidal or Aspergillus infection. Indicated in patients who are immunosuppressed, who have indwelling venous catheters, or who are currently taking broad-spectrum antibiotics.
Drug Name
Amphotericin B (AmBisome) -- Fungistatic or fungicidal depending on concentration attained in body fluids; polyene antibiotic produced by a strain of Streptomyces nodosus. Changes permeability of fungal cell membrane by binding to sterols, which causes fungal cell death as intracellular components leak out.
Adult Dose 3 mg/kg/d IV for 14 d; infuse over 2-6 h
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
Interactions Concurrent administration of antineoplastic agents may potentiate bronchospasm, hypotension, or renal toxicity
Monitor potassium levels closely when administered with thiazides or digitalis as potassium depletion may increase, leading to hypokalemia or digitalis toxicityCoadministration of cyclosporin increases risk of nephrotoxicity; administered with aminoglycosides, additive nephrotoxicity and/or ototoxicity possible
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions
Frequently monitor renal function, serum electrolytes (magnesium and potassium), liver function, blood counts, and hemoglobin concentration; neutropenic patients receiving amphotericin B and leukocyte transfusions may experience pulmonary reactions, such as hypoxemia, acute dyspnea, or interstitial infiltratesSeparate the time of amphotericin B infusion as far as possible from time of leukocyte transfusion if transfusion is to be given
Sumber : Department of Emergency Medicine, Massachusetts Genera Hospital, Harvard Medical School.
1. Gentamicin
200µg in 0.1ml1. Take 0.5ml from a vial of gentamicin containing 40mg/ml2. Make up to 10mls with normal saline or balanced salt solution (BSS) in a syringe.3. 0.1ml of this solution=200µg
NB Minims of gentamicin are unpreserved and contain 3000µg per ml. These may be used.
2. Amikacin
0.4mg in 0.1ml1. Reconstitute one vial - 500mg - and make up to 10ml with BSS2. Withdraw 0.8ml (using 1ml syringe) and make up to 10ml with BSS3. Withdraw 0.1ml of this - 0.4mg
3. Cefuroxime or Vancomycin
1000µg in 0.1ml1. Reconstitute a 250mg vial with 8mls of saline or BSS2. Withdraw entire contents and make up to 10mls with saline or BSS3. Inject 2mls back into vial and make up to 5mls in the vial with saline or BSS4. 0.1ml of this solution - 1mg (1000µg)
For smaller doses adjust the volumes accordingly.
4. Amphotericin
5µg in 0.1ml1. Reconstitute a 50mg vial with 10mls of saline or BSS2. Withdraw 0.1ml of this and make up to 10mls in a syringe.3. 0.1ml of this = 5µg
Alternatively inject entire contents of a 50mg ampoule into a 1 litre bag of Ringer-Iactate and 0.1ml of this contains 5µg.
5. Clindamycin
1000µg in 0.1ml1. Draw up the contents of a 2ml ampoule (300mg) and make up to 3ml in a syringe with normal saline or BSS2. Withdraw 1ml of that and make up to 10ml in another syringe with normal saline or BSS3. 0.1ml of that contains 1000µg
Intravitreal Drugs
NB The intravitreal dose is given in 0.1ml except when combination therapy is used and 0.2ml are given. In emergencies it may be necessary to prepare drugs for intravitreal injection without the assistance of the pharmacist. Avoid solutions or preparations containing preservatives. The quantities for intravitreal injection may be drawn up in 1ml syringes, and injected with a 25 or 27 gauge needle. Make sure to fill the dead space with antibiotic solution.
Sumber : The Royal College of Ophthalmologists 17 Cornwall Terrace, London NW1 4QW
Injeksi antibiotik intravitreal dengan dosis terapeutik yang tepat dan tidak toksik terhadap
jaringan mata terutama retina efektif untuk mencegah komplikasi-komplikasi yang dapat terjadi.
Antibiotik sistemik tidak dapat menjangkau agen patogen di intravitreal dikarenakan oleh tidak
terlampauinya konsentrasi maksimal karena adanya blood retinal barrier. Injeksi secara
intravitreal dapat melewati barrier sehingga tercapai konsentrasi terapeutik yang dapat
menghancurkan mikroorganisme. Kadang penggunaan dosis tunggal sudah cukup memadai.
Selain itu perlu diperhatikan jumlah/dosis dari antibiotik yang diinjeksikan mengingat
batas keamanan antara dosis terapeutik dengan dosis toksik terhadap retina sangat sempit.
Sebagai contohnya, Gentamycin yang sangat efektif melawan infeksi organisme gram negatif
seperti pseudomonas dapat menyebabkan infark makula bila tidak diberikan sesuai dengan dosis
yang telah ditetapkan.
Tidak jarang juga ditemukan infeksi sekunder oleh organisme komensal oleh karena itu
diperlukan dua macam antibiotik : satu untuk melawan organisme gram negatif dan yang lainnya
untuk melawan organisme gram positif. Antibiotik yang digunakan untuk melawan organisme
gram negatif misalnya : Ceftazidine, Amikacin, Gentamycin, untuk gram positif : Vancomycin
dan Cefazoline. Sedang yang digunakan untuk infeksi jamur yaitu : Amphotericin B.7
Pada kasus-kasus yang sudah berat biasanya diperlukan penatalaksanaan secara operatif
seperti :
1. Vitrectomy
Vitrectomy adalah prosedur operasi dimana dilakukan pengeluaran cairan Vitreus dari
rongga orbita.
2. Enukleasi bulbi
Enukleasi bulbi merupakan tindakan pembedahan mengeluarkan bola mata
dengan melepas dan memotong jaringan yang mengikatnya didalam rongga
orbita. Jaringan yang dipotong adalah seluruh otot penggerak mata, saraf optik
dan melepaskan conjungtiva dari bola mata. Enukleasi bulbi biasanya dilakukan
pada keganasan intraokular, mata yang dapat menimbulkan oftalmia simpatika,
mata yang tidak berfungsi dan memberikan keluhan rasa sakit, endophthalmitis
supuratif dan pthisis. Biasanya pasien setelah enukleasi bulbi diberi mata palsu
atau protesis.
Gambar 8 : enukleasi bulbi
3. Eviserasi bulbi
Eviserasi bulsi merupakan tindakan mengeluarkan seluruh isi bola mata seperti
kornea, lensa, badan kaca, retina dan koroid. Setelah isi dikeluarkan maka limbus
kornea dieratkan dan dijahit. Eviserasi bulbi dilakukan pada mata dengan
panophthalmitis dan endophthalmitis berat.8
X. Preventif
Jika anda pernah mengalami riwayat operasi mata seperti operasi katarak, anda dapat
menurunkan resiko infeksi dengan mengikuti seluruh intruksi dokter setelah operasi dan
melakukan pemeriksaan reguler (follow-up) yang teratur.
Untuk mencegah endophthalmitis karena trauma, gunakan pelindung mata saat bekerja dan
pada saat olahraga. Kacamata atau helm dapat membantu melindungi dari debris industri
yang dapat menembus mata.
XI. Kesimpulan
Endoftalmitis merupakan peradangan berat bola mata akibat infeksi bakteri, jamur dan
virus setelah trauma, operasi, dan endogen karena sepsis. Yang di tandai dengan rasa
sakit yang sangat, kelopak merah dan bengkak, kelopak sukar dibuka, konjungtiva
kemotik dan merah, kornea keruh, bilik mata depan keruh yang kadang kadang disertai