Endophthalmitis

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Pathogens

  • Acute postoperative (< 6 weeks, in 90% manifestation within the 1st postoperative week):
    • Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus, Pseudomonas.
  • Delayed postoperative/ chronic low grade infections:
    • Propionibacterium acnes, fungi
  • After trauma:
    • Bacillus, S. epidermidis, streptococci, S. aureus, gram-negative germs
  • Endogenous:
    • Candida
  • Sterile
    • if within 24 h after surgery: TASS?

Symptoms / findings

  • Progressive pain, red eye and decreased visual acuity
  • Eyelid swelling, conjunctival injection, corneal oedema, anterior chamber cells/flare, hypopyon +/- fibrin, vitritis, retinitis

Management

  • Vitreous tap/biopsy (Gram preparation, culture, consider PCR, resistance testing) + consider anterior chamber tap/irrigation
  • and earliest possible pars plana vitrectomy (PPV)
    • according to ESCRS Guidelines (2013):
      • immediate PPV is favoured over puncture!
    • according to EVS (Endophthalmitis Vitrectomy Study, 1995):
      • old study
      • visual acuity: light perception: ppV
      • visual acuity: hand movements or better: only “tap & inject” (vitreous tap/biopsy + antibiotics intravitreally)
  • Intravitreal administration of broad-spectrum antibiotics
    • e.g. Vancomycin 0.1ml (1.0mg/0.1ml) + ceftazidime (2mg/0.1ml)
    • alternative: vancomycin 0.1ml (1.0mg/0.1ml) + amikacin 0.1ml (0.4mg/0.1ml)
  • Additional antibiotic therapy:
    • local: e.g. ceftazidime/ofloxacin half-hourly or ofloxacin + gentamycin half-hourly
    • Systemic: e.g. Ciproxin 400mg i.v. every 12h, taper to p.o. 500mg 2x/d (for a total of 7-14 days)
      (no profit according to the Endophthalmitis Vitrectomy Study, recommended according to ESCRS Guidelines)
  • Cycloplegics
    • e.g. atropine 2x daily
  • Steroid therapy (controversial):
    • intravitreal (dexamethasone) / subconjunctival
    • local (e.g. Pred forte gtt (prednisolone) 6x/d, Ultracortenol ointment (prednisolone) at night) or
    • systemically (Spiricort (prednisolone) e.g. 60mg, 40mg, 30mg, 20mg, 10mg daily for 3 days each)
  • If fungus is suspected: additional antimycotic therapy (e.g. voriconazole AT + systemic therapy)

Sources

  • EyeWiki Endophthalmitis
  • ESCRS Guidlines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery (2013)
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski‚Äôs Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)