Post Cataract Endophthalmitis

Endophthalmitis
• It is an inflammation of internal coats of the eye with exudates in the vitreous. • Classification : Endogenous: Entry through vascular system Exogenous: Entry through cornea or sclera
 Post traumatic  Post surgical

INTRODUCTION
• Endophthalmitis is a catastrophic complication of cataract surgery • Its incidence was 10% at the beginning of 19th century • After popularization of aseptic techniques, a sharp decline occurs so that its incidence reduced to 1% up to 1950 • Currently its incidence is around 0.072%

Comparison of incidence of post surgical endophthalmitis
S.No. 1 2 3 4 5 6 Procedure Extracapsular Cataract extraction Intracapsular cataract extraction Secondary IOL implantation Penetrating keratoplasty Filtering surgery for glaucoma Pars plana viterectomy Incidence of culture positive endophthalmitis 0.072 % 0.093 % 0.30 % 0.11 % 0.061 % 0.051 %

Sources of infection
 Airborne contaminants
• Respiratory origin • Surface origin (skin, clothing etc) • Air conditioning system

 Tissues
• Skin of hands and operating field • Lid margins and eyelashes • Conjunctival sac • Lacrimal sac • Nasal mucosa • Corneal grafts • Vitreous implants • Fellow eyes

 Solutions and medications
• Saline for irrigation and other purposes • Instruments • Skin antiseptics

 Objects and materials
• • • • • • • • • Optical instruments Surgical instruments Tonometers Cotton balls, swabs, drapes, dressings, masks and gowns Rubber gloves, bulbs, droppers Glass syringes, bottles, irrigating tips Plastic tubings, sheeting, retractors Intraocular lenses Sutures

 Miscellaneous
• Patient with poor hygiene, health or nutrition • Active periocular infection • Prolonged duration of surgery • Viterous loss • Rough handling of tissues • Prolonged hospitalization and crowded wards

Risk factors
 Patient factors
 Ocular conditions
• Ocular surface infections • Nasolacrimal duct obstruction / infection • Ocular prosthesis

 Surgical factors
 IOLs with polypropylene haptics  Vitreous communication  Wound abnormalities  Use of silk suture for wound closure  Contaminated irrigating solutions

 Systemic conditions
• Active infection (URTI, skin, soft tissue) • Diabetes • Immune compromise

Microbiology
 Bacteria  Gram negative  Gram positive • Pseudomonas • Staphylococcus aureus aeruginosa • Staphylococcus epidermidis • Proteus species • Streptococcus pneumoniae • Kiebsiella • Streptococcus haemolyticus • E.coli • Streptococcus viridians • Enterobacter • Bacillus subtilis aerogenes • Bacillus megaterium • Other coliforms • Clostridium perfringes • N.catarrahalis  Fungi • Actionmyces species • Sprotrichum schenkii • Candida species • Fusarium species

Insulting agent / specific organism
Vascular changes •Vasodilatation •Increased capillary permeability •Increased fluid exudation •Cellular infiltration Release of digestive enzymes and toxins

•Inadequate inoculums of organism •Less virulent organism •Good host immunity

•Adequate inoculums of organism •Virulent organism •Poor host immunity Progressive infection with secondary manifestation

Limits further organism reproduction

Types
Endogenous

Surgical endophthalmitis

Infective

Noninfective Exogenous Acute ( 5 – 7 days )

Fulminant ( within 4 days )
•Gram negative bacteria •Streptococci •Staph aureus

•Staph epidermides •Coagulase negative cocci

Chronic (more than 4wks ) Delayed entery
•Viterous wick syndrome •Bleb related

Delayed onset
•Fungi •P.acne •Staph epidermidis

Non infective
 Phacoanaphylactic :
• Cotton and fluffy retained lens material in vitreous

 Foreign material;
• Like particulate debris, irritating chemicals • Sections of such globe if enucleated reveal evidence of particulate contamination in middle of granulomatous reaction

 Endogenous
• By haematogenous route • Delayed presentation usually because of indolent course • Anterior segment typically lacks behind the posterior segment inflammation • Risk factors :
– – – – – – – – – Indwelling catheters Prolonged antibiotics Major surgery Malignancy Diabetes mellitus Chronic alcoholism Liver disease Intravenous drug abusers Prolonged corticosteroid therapy

• Foci of colonization beneath internal limiting membrane

Acute presentation
 Symptoms :  Signs: • Exaggeration of usual inflammatory signs • Prominent visual • Marked lid edema loss • Increased ciliary congestion and chemosis • Painful red eye • Corneal edema • Photophobia • Limbal ring abscess, suture abscess,wound • Purulent dehiscence discharge • Anterior chamber reaction • Frequent o Presence of cells and flare headaches
• o Turbid o Hypopyon Iris o Muddy and boggy o Tendency to form posterior synechiae Pupillary response either absent of sluggish Reterolenticular flare Viterous reaction o Viterous exudate o Loss of red reflex

• • •

Grading of clearity of media in endophthalmitis (as adopted by Endophthalmic Viterectomy Study • Grade I: >6/12 view of the retina • Grade II: Second order retinal vessel visible • Grade III: Some vessel visible but not second order • Grade IV: No retinal vessel visible • Grade V: No red reflex

)

Delayed presentation
• Classic clinical picture may be delayed for weeks or months • Infective organisms may enter eye at the time of surgery or sometime after surgery • There are four kinds of delayed postoperative endophthalmitis grossly

Mycotic
• Uneventful until 2 – 3 wks • Hypopyon may appear, usually transient • Whitish stringy exudative strands, extending from the anterior vitreous across the iris to the bottom of the anterior chamber

Bacterial
• Classic signs and symptoms may be delayed 4 – 8 wks postoperatively • Organism: Staphylococcal epidermidis, Propionibacterium acnes
Propionibacterium acne Organism grow slowly Sequester in capsular bag

Out of reach of host defences

Organism may get entery to eye after Stimulate immunologic reactio Nd YAG capsulotomy Persistent inflammation

• Viterous wick syndrome
o A postoperative rupture of anterior hyaloid membrane with incarceration of viterous in wound occurs o Necrosis at site of suture permitting viterous to prolapse slightly

• Postoperative filtering bleb associated
o Type of bleb
 Thin walled  Cystic  Positive Siedel’s test

• Sterile inflammation Parameter Focal infiltrate Fundus glow Viterous cavity Colour of exudates IOP

Differential diagnosis
Enophthalmitis Commonly present Poor/absent Haze ++ Yellowish Low Sterile inflammation rare Ok/mildly poor Clear/mild haze White normal

• Corneal edema due to raised IOP

Diagnosis
 Proper history  Clinical picture  B scan: helps to rule out other condition that mimic endophthalmitis
o o o o o Retinal detachment Choroidal detachment Dislocated lens / nucleus Parasite infestation RIOFB

 Microbiologic investigations:
 For identification of organisms  To find the source of infection: materials and solutions used during operation are sent for microbiological diagnosis

Identification of organisms
 Specimen collection:  Anterior chamber tap: • About 0.1ml of aqueous is aspirated with 25-guage needle attached to tuberculin syringe • 36 – 40 % possibility of isolating organisms • May come out to be negative in presence of endophthalmitis  Vitreous tap: • About 0.1ml is aspirated from mid vitreous with 23-guage needle attached to tuberculin syringe through pars plana approach just before injecting intravitreal antibiotics • 56 – 70 %possibility of isolating organism • Risk of vitreous traction specially if vitreous is formed and may lead to retinal detachment

Viterous biopsy:
• Limited anterior vitrectomy using automated vitrectomy instrumentation (no irrigation) • Full posterior vitrectomy (with irrigation ) • Advantage :prevents vitreous traction by cutting the strands rather then pulling on it

Microbial detection
 Smears:
            Gram’s stain Giemsa’s stain KOH stain Gomori’s methenamine stain Celluflour & calcoflour white stain Blood agar plate (25 & 37 degree Celsius) Chocolate agar ( 37 degree Celsius ) Thioglycolate broth ( 37 degree Celsius ) Robertson cooked meat media Brain heart infusion Blood culture bottles Membrane filter system

 Culture:

Prophylaxis
 Preoperative:  Treatment of any ocular surface or systemic infections  Topical antibiotics:
 Decrease bacterial counts on ocular surface  Usually quinolones and tobramycin eye drops are given  Qid for 3 -4 days preoperatively are used

 Systemic antibiotics
 May be considered in high risk cases
• • • • Secondary IOL implantation Vitreoretinal procedures In immunocompromised patients Prolonged cataract surgery complicated by vitreous loss

 Preperation of patient
 Trim eyelashes a night before surgery  Patient should take bath, properly clean his face and hairs, and comb hair properly at the day of surgery  Placing povidone iodine 5% in conjunctival sac for few minutes before surgery decreases microbial count

 Intraoperatve:  Sterilization of OT and sterile irrigating fluids  Doctors / nurses:
 No one with URTI should be allowed in OT  Clean laundried clothes should be weared  Effective scrubbing of hands by surgeon  Sterile disposable cap, mask, and gloves  Sterile /disposable OT gowns

 Patient
 Painting of periocular skin with 10% povidone iodine  Cover with sterile eye towel drapping to exclude eyelids from operative field  Antibiotics use in infusion fluid  Irrigate IOL before insertion to remove adherent bacteria  Minimize duration of exposure of IOL to operating room environment  Careful wound closure  Minimizing duration of surgery  Subconjunctival antibiotics at the end of surgery

 Postoperative :
Postoperative antibiotics eye drps and ointment Patient with prolonged surgery, viterous loss, diabetes, immunocompromised individuals consider close follow up Careful suture removal

Treatmentof endophthalmitis

Medical therapy

Surgical therapy

Definitive

Supportive Vitrectomy Enucleation

 Antibiotics / Antifungal •Intravitreal injections •Subconjunctival injections •Topical therapy •Systemic therapy Corticosteroids

Cycloplegic IOP lowering drugs

 Objectives   Primary • Control / erradication of infection • Manage complications • Restoration of vision  Secondary • Symptomatic relief • Prevent panophthalmitis • Maintain integrity of globe

Determinants  Time duration  Virulence and load of infecting organisms  Pharmakokinetics and spectrum of activity of the intraviteral drugs

Medical therapy
 Intraviteral antibiotics: Check list:
• • • • • • • Informed consent Vision status Echography results Wound integrity Suture abscess Lens status Intraocular pressure

Combination of antibiotics should be given emperically to cover gram positive & negative organisms in bacterial endophthalmitis and antifungal agents in fungal endophthalmitis

Bacterial endophthalmitis
First choice Inj. Vancomycin 1000 microgram in 0.1ml Inj. Ceftazidime 2.25 mg in 0.1ml Second choice Inj. Vancomycin 1000 microgram in 0.1ml Inj. Amikacin 400 microgram in 0.1ml Third choice Inj. Vancomycin 1000 microgram in 0.1ml Inj. Gentamycin 200 microgram in 0.1ml

Fungal endophthalmitis:

•Amphotericin B : 5 – 10 microgram in 0.1ml •Fluconazole : 25 microgram in 0.1ml

• Quinolones group are under evaluation and is not much effective due to there short half life • Single injection is sufficient to sterlize the eye • Persistent infection occur in case of virulent & slowly growing organisms • Complications:
• • • • Increase intraocular pressure Intraocular hemorrhage Retinal toxicity Retinal detachment

 Intravenous antibiotics  Intraocular infection disrupt the blood aqueous barrier & increase intraocular penetration of drugs, still MIC of the drug is not achieved  It is just additive to intravitreal injection  Disadvantage :
• Cost effectiveness • Systemic side effects of drugs • Drug resistance

Vancomycin Ceftazidime Ceftriaxone Cefazolin Amikacin Tobramycin Gentamycin Amphotericin B Fluconazole

1gm IV/ 12 hr 2gm IV/ 8hr 2gm IV/ 8 hr 1.5gm IV/ 6hr 240mg IV/12 hr 1gm IV/ 12 hr 1gm IV/ 12 hr 0.7-0.1mg / kg / day IV 200mg/day

 Topical antibiotics
 Combination of two drugs covering gram positive and negative organism is given  EVS prefer: Vancomycin 50mg/ml + Amikacin 20mg/ml

Subconjuncival antibiotics:
Vancomycin Gentamycin Cephaloridine Methicillin Tobramycin Gentamycin 25mg /0.5ml 25mg /0.5ml 25mg /0.5ml 25mg /0.5ml 25mg /0.5ml 25mg /0.5ml

 Corticosteroids:
• Act by decreasing inflammation, tissue destruction and tend to preserve retinal tissue function • Contraindicated in fungal endophthalmitis • Intraviteral injection disadvantage: o Reduce ability of eye to sterlize inoculum of organisms o Retinal necrosis o Corneal opacification Intravitreal dexa 0.4mg in 0.1ml Subconj dexa 1mg in 0.25 ml

 Supportive therapy:  Cycloplegics:
• Relieve ciliary spasm • Prevent synechiae formation • Mydriasis o Better clinical evaluation o Asset if need for performing vitrectomy

 IOP lowering drugs:
• Actazolamide • Timolol eye drops

Vitrectomy
 Indications : Severe case of endophthalmitis
• • • • • • • Gram negative smear confirmed Total absence of red reflex Inaccurate projection of rays Afferent pupillary defect Corneal ring infiltrate Patient worsening 24 – 48 hrs after intravitreal injection Lack of response after two intravitreal injection

 Needed at two stages:
• Primary : acute infection • Secondary : resolving phase for vitreous opacification and membranes

 Advantages:
 Decrease infectious, toxic &inflammatory response  Adequate undiluted viterous specimen  Increase antibiotic concentration within eye  Removing media opacities enable a more rapid visual recovery

 Disadvantages:
 Iatrogenic complications:
• Retinal hole • Retinal detachment • Choroidal hemorrhage

 Decrease half life of intraviterally administered drugs

Reasons for treatment failure
 Late presentation  Highly virulent organisms  Drug resistance  Inadequate drug concentration  Comlications ( retinal detachment )  Failure to give timely intraviteral injections  Failure to recognize nidus  Faulty diagnosis

Endophthalmitis viterectomy study (EVS)  Primary objective:
EVS was a multicentric study undertaken in United States on 420 patients who developed bacterial endophthalmitis within 6wks of cataract surgery or secondary IOL implantation Comparison of role of early pars plana viterectomy with intraviteral injections and to identify role of systemic treatment

 Conclusions

 If initial vision is HM or better then no difference in final visual outcome between viterectomy and intraviteral inj  If initial vision is only PL then final visual acuity and media clearity are substantially better with viterectomy  No difference in final visual acuity by the use of systemic antibiotics  Viterous is richer source of lab confirmed growth  Gram stain should not determine the choice of antibiotics  Viterectomy with culture of viterectomy cassette fluid did not produce significantly more positive cultures  Secondary or anterior chamber IOL implantation was associated with possible shift in spectrum of organismsto gram positive  Vancomycin effective against gram positive organisms  Amikacin and ceftazidime have equivalent activity against gram negative organisms  Poor visual outcome with gram negative and coagulase negative organisms

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