DISEASES OF THE UVEA

Prof Suhardjo, MD,M Biomed, Ophth

UVEA

Inflammation Uveitis
Anatomy classification: Anterior uveitis= iridocyclitis Intermediate uveitis Posterior uveitis=choroiditis

Panuveitis=inflammation of
the whole uvea

Epidemiology Uveitis

Adamantiades-Behcets syndrome, and VKH are more common in Japan than in Europe or the United State.Adamantiades-Behcets syndrome seems highly prevalent in Turkey and in China. Tuberculosis remains the main etiology of infectious uveitis in India, Indonesia. Viral uveitis is predominant in the Middle East and in France, followed by Toxoplamosis. Epidemiologic study in northern California: incidence rate 52.4/100,000 person-years. The incidence and prevalence were lowest in the pediatric age groups and highest in those over age 65, women was greater than that man.

Terminology base of: Standardization of Uveitis Nomenclature

Inactive: grade 0 cells (anterior chamber) Worsening activity: 2-step increase in level of inflammation Improved activity : 2-step decrease or decrease to grade 0 Remission: inactive disease for> 3 months after discontinuing all treatments .

Clinical classification: Acute uveitis sudden symptomatic onset and persist for 6 weeks or less Chronic uveitis persists for months or years

Aetiological classification

Exogenous uveitis external injury, invasion microorganisms, other agents to uvea from outside Endogenous uveitis microorganism, other agents within patient

Endogenous Uveitis Associated with systemic disease (ankylosing spondilitis) Infection bacteria (TB), fungi (candidiasis), viruses (herpes zoster), protozoa (toxoplasma), roundworms

(toxocariasis)
Idiopathic specific uveitis entities (Fuchs uveitis syndrome) Idiopathic non-spesific uveitis entities

Pathological classification Granulomatous Non-granulomatous

Clinical Features of Uveitis

Anterior Uveitis

Symptoms Photophobia, pain, redness, decreased vision, lacrimation Sign: Limbus Ciliary injection

Cornea : Keratic precipitates (KP)

Small KP herpes zoster, Fuchs uveitis syndrome Medium KP most types acute and chronic uveitis

Large KP mutton fat granulomatous uveitis

Fresh KP white and round

Mutton fat KP

Iris nodules Koeppe nodules Busacca nodules

Koeppe nodules

Busacca nodule

Anterior chamber: Aqueous cells Sign of active inflammation Graded from 0 to +4: 5-10 cells = +1 11-20 cells = +2 21-50 cells = +3 >50 cells = +4
Aqueous flare Leakage of proteins into aqueous humor through damaged iris blood vessels Faint-just detectable = +1 Moderate-iris details clear= +2 Marked-iris details hazy= +3 Intense-with severe fibrinous exudate= +4

Iris and Pupil : Posterior synechiae Adhesions between the anterior lens surface and iris Anterior vitreous cells

Other signs of anterior uveitis

Hypopyon Fibrin Pupillary miosis Pigment dispersion Synechiae Band keratopathy (seen in longstanding uveitis)

Intermediate Uveitis

Symptoms
floaters, impairment of visual acuity caused by chronic cystoid macular edema Sign Cell infiltration of the vitreous (vitritis), with few, if any, cells in the anterior chamber and no focal inflammatory lesion in fundus

Posterior Uveitis Symptoms floaters and impairment of visual acuity Sign Vitreous change cells, flare, opacities and posterior vitreous detachment Choroiditis Retinitis Vasculitis Three main types: Unifocal (toxoplasmosis, onchocerciasis, cysticercus, Masquerade syndromes) Multifocal (ocular histoplasmosis,sypilis, HSV,VZV,CMV,Candida, Sarcoidosis, Masquerade ) Geographical (CMV retinitis)

Laboratory and Medical Evaluation

Fluorescin angiography; Indocyanine green angiopraphy USG: vitreous opacities, choroidal thickening, retinal detachment, cyclitic membrane formation. OCT: to measure of uveitic CME. Anterior chamber paracentesis: Goldmann-Witmer coefficient is gold standard for diagnosis of Toxoplasmosis in Europe, PCR is valuable tool in case of viral uveitis or retinitis but less sensitive in diagnosing parasitic infecion. Vitreous biopsy Chorioretinal biopsy

Complications of uveitis

Posterior synechiae - 30%

Cataract -20%

Glaucoma due to PAS - 15%

Iris atrophy .Band keratopathy - 10%

Therapy for Uveitis

Medical : Steroid

Immunomodulators: Alkylating agent, antimetabolite, T-lymphocyte modulators,biologic response modifier

Surgical

Uveitis associated with arthritis

Ankylosing spondilitis

Idiopathic, inflammatory arthritis

IgM rematoid factor (-)

HLA-B27

Acute iritis

Ankylosing spondilitis

Reiters syndrome Triad

Urethritis
Conjunctivitis Seronegative arthritis

HLA-B27
Conjuncvtivitis Acute iritis Keratitis

Reiters syndrome

Conjunctivitis

Plantar fasciitis

Urethritis and circinate balanitis

Keratoderma blenorrhagica

Juvenile Chronic Arthritis

Children before the age 16 years

Polyarticular onset
Arthritis > 5 joints 20% 0f cases

Paucyarticular onset
Arthritis < 4 joints

60% of cases

Anterior Uveitis, chronic, non-granulomatous, bilateral in 70%

High risk factors for uveitis

Girls Early onset Paucyarticular onset ANA HLA-DR5

Adamantiades-Behcets Disease

Idiopathic multisystem disorder, typically young men

from eastern Mediteranian and Japan. Now many cases

have found in Indonesia, Malaysia and China.

HLA-B5 as risk factor . Uveitis , with:-Oral ulceration Apthous ulcers Genital ulceration Skin lesion Other thromboplebitis, arthropathy,

gastrointestinal, CNS, cardiovascular lesions

Uveitis in Adamantiades-Behet disease

Acute iritis

Retinitis

Occlusive periphlebitis

Diffuse leakage

Ocular feature:
Recurrent, bilateral, non-granulomatous, intraocular

inflammation.
Acute recurrent iridocyclitis hypopion Posterior segment involvement

Diffuse vascular leakage Periplebitis Retinitis Vitritis

Vogt-Koyanagi-Harada syndrome

Idiopathic multisystem disorder, typically affects pigmented individuals.

Japanese, in whom the disorder is relatively common,

increased prevalence of HLA-DR4 and DW15. Many

cases have reported in china, Indonesia, Malaysia.

Skin and hair change: Alopecia Poliosis

Vitiligo

Neurologic feature:
Vertigo

Encephalopathy
Auditory symptoms Mild meningitis with neck sitffness

Ocular feature Chronic granulomatous iridocyclitis Posterior segment involvement

Signs of Vogt-Koyanagi syndrome

Granulomatous iridocyclitis

Alopecia

Poliosis

Vitiligo

Sympathetic Uveitis

Rare, bilateral, granulomatous panuveitis which occurs after accidental penetrating ocular trauma or intraocular surgery

Traumatized eye exciting eye Develops uveitis sympathizing eye Clinical feature: Anterior segment: inflammation become chronic and severe, Koeppe nodule, mutton fat KP, posterior

synechia

 Posterior segment: small, deep, yellow-white spots corresponding to Dalen-Fuchs nodules

Treatment:
Enucleation Steroid therapy

Immunosupressive therapy

Sympathetic ophthalmitis

Typically follows penetrating trauma

Bilateral granulomatous panuveitis

Granulomatous anterior uveitis

Multifocal choroiditis

Treatment of Uveitis

Mydriatic-cycloplegic : sulfas atropine 1% eye drop/hour Steroid systemic. : topical, subconjunctival, intra vitreal,

Cytotoxic drugs for chronic uveitis: azathioprin, chlorambucil, cyclosporin, cyclophosphamide

Diseases of the LENS

Eyeball

The Lens is a unique structure

Transparent: no blood, no nerve Higher protein content It continues to grow throughout life. New fiber from just beneath the capsule, while the older fibers are compressed towards the centre of the lens

Ageing changes in the Lens

Increase in hardness presbyopia Increase in density more dense (nuclear sclerosis), the power of the lens increases lens induced myopia. Increase in size shallowing of the anterior chamber Increase in opacity: caused by biochemical damage of the delicate protein structure of the lens cells.

LENS DISORDERS
Abnormalities of lens shape

Coloboma

Lenticonus
Small lens

Coloboma

Ocular associations

Coloboma of iris

Coloboma of choroid

Giant retinal tear

Lenticonus
Posterior Anterior

Posterior axial bulge Unilateral - usually sporadic Bilateral - familial or in Lowe syndrome

Anterior axial bulge Associated with Alport syndrome

Small lens
Microphakia Microspherophakia

Small diameter Systemic association - Lowe syndrome

Small diameter and spherical

May be familial (dominant) Systemic association - Weill-Marchesani syndrome

Cataract =Opacification of the Lens

General causes :age, diabetes, chronic renal failure, hypoparathyroidism, Downs syndrome, myotonic dystrophy, steroids, episodes of severe dehydration in early life (osmotic shock, severe dehydrationdamage the lens structure). Local causes: trauma, uveitis, glaucoma,myopia, radiation

Cataract backlog in Indonesia

Prevalence of cataract in Indonesia : 1.02% Incidence of cataract in Indonesia: 0.1% Population in Indonesia: 240.000.000 Ophthalmologist surgical rate of cataract in Indonesia =200, should be 500 to avoid backlog Total ophthalmologist in Indonesia : 1500

Why cataract is so much more common in hot climates

Episodes of severe dehydration in early life (osmotic shock mechanism) Solar radiation:ultraviolet is absorbed by the

lens causing damage to the tissue enzymes and protein molecules. Diet. : The poor people have a higher prevalence of cataract than rich people. Heat: glass-blower

Protective factors

Aspirin low dose (100 mg) Vitamin C Bendazac lysine

Symptoms of cataract

Dazzling , when opacity in the centre. Multiple images (ghosting, or polyopia) caused by poor refraction. Haloes, caused by opacity in the lens split Refractive changes, progressive myopia from nuclear sclerosis .

Signs of cataract

Cortical lens opacities: the most common type of opacities. Nuclear sclerosis: lens hardens at first yellow, then brown, and finally black. Posterior subcapsular lens opacities: less common, often develop in quite young people.

ECTOPIA LENTIS
1. Acquired 2. Isolated familial ectopia lentis 3. Associated with systemic syndromes Marfan syndrome Weill-Marchesani syndrome Homocystinuria

4. Treatment options

Acquired ectopia lentis

Trauma Stretched zonules

Buphthalmos Megalocornea

Anterior uveal tumours

Degenerate eye

Isolated familial ectopia lentis

Autosomal recessive

Pupil may be normal

Pupil may be displaced in opposite direction (ectopia lentis et pupillae)

Systemic features of Marfan syndrome

Autosomal dominant

Limb-trunk disproportion

Arachnodactyly

Pectus excavatum High-arched palate

Aortic dilatation, dissection and regurgitation Mitral valve prolapse

Homocystinuria
Autosomal recessive Defect in cystathio beta-synthase Systemic features Ocular features

Malar flush and fine, fair hair Marfanoid habaitus Increased platelet stickiness Mental handicap

Downward lens subluxation Disintegration of zonule

CONGENITAL CATARACT
1. Important facts 2. Classification

3. Causes
In healthy neonates In unwell neonates

Causes of cataract in healthy neonate

Hereditary
(usually dominant)

Idiopathic With ocular anomalies

. PHPV Aniridia Coloboma Microphthalmos Buphthalmos

Causes of cataract in unwell neonate

Intrauterine infections
Rubella Toxoplasmosis Cytomegalovirus Varicella

Metabolic disorders
Galactosaemia Hypoglycaemia Hypocalcaemia Lowe syndrome

Important facts

33% - idiopathic - may be unilateral or bilateral 33% - inherited - usually bilateral 33% - associated with systemic disease - usually bilateral Other ocular anomalies present in 50%

Classification of congenital cataract

Anterior polar Posterior polar Coronary Cortical spoke-like

Lamellar

Central pulverulent

Sutural

Focal dots

Anterior polar cataract

May be dominant inheritance

Capsular

Pyramid

With persistent pupillary membrane

With Peters anomaly

ACQUIRED CATARACT
1. Classification of age-related cataract
Morphological According to maturity

2. Other causes of cataracts

Diabetes Myotonic dystrophy Atopic dermatitis Trauma Drugs Secondary (complicated)

3. Surgery
Large incision extracapsular extraction Phacoemulsification

Classification of Age-related Cataract According to Morphology

1. Subcapsular
Anterior Posterior

2. Nuclear 3. Cortical 4. Christmas tree

Subcapsular cataract
Anterior

Posterior

Nuclear cataract
Progression

Exaggeration of normal nuclear ageing change Causes increasing myopia

Increasing nuclear opacification Initially yellow then brown

Cortical cataract
Progression

Initially vacuoles and clefts

Progressive radial spoke-like opacities

Classification according to maturity

Immature

Mature

Hypermature

Morgagnian

Other causes of cataract - diabetes

Juvenile Adult

White punctate or snowflake posterior or anterior opacities May mature within few days

Cortical and subcapsular opacities May progress more quickly than in non-diabetics

Other causes of cataract - myotonic dystrophy

Myotonic facies Frontal balding

Stellate posterior subcapsular opacity 90% of patients after age 20 years No visual problem until age 40 years

Other causes of cataract - atopic dermatitis

Cataract develops in 10% of cases between 15-30 years Bilateral in 70% Frequently becomes mature

Anterior subcapsular plaque (shield cataract) Wrinkles in anterior capsule

Causes of traumatic cataract

Concussion

Vossius ring from imprinting of iris pigment

Flower-shaped

Penetration

Other causes
Ionizing radiation Electric shock Lightning

Drugs
Systemic or topical steroids
- initially posterior subcapsular

Chlorpromazine
- central, anterior capsular granules

Other drugs

Long-acting miotics Amiodarone Busulphan

Secondary (complicated) cataract

Posterior subcapsular Glaukomflecken

Chronic anterior uveitis High myopia Hereditary fundus dystrophies

Follows acute angle-closure glaucoma Central, anterior subcapsular opacities

The treatment of cataract is Surgery

Intracapsular extraction : not popular now, impossible to intra ocular implantation. Extracapsular : the posterior capsule and suspensory ligament are left intact, IOL can be implanted. Small Incision Cataract Surgery: the most popular in India. Phacoemulsification : the most popular in the World

Complications of cataract

Acute angle-closure glaucoma: a lens which is swollen makes anterior chamber more shallow. Phacolytic uveitis and glaucoma. Fluid lens protein leaks out through the capsule into anterior chamberacute uveitislens protein is ingested by macrophages and these block the anterior chamber angle phacolytic glaucoma

CATARACT

Anatomi Mata

Pengertian Katarak
proses kekeruhan lensa mata kebutaan yang bisa ditanggulangi indonesia : - penyebab kebutaan no.1 - 1996 : 1,47% (3 juta penduduk) - tiap tahun tambah 200.000

pembagian katarak
1. katarak senilis / ketuaan : - > 40 tahun - karena degenerasi 2. katarak kongenital - sejak lahir - virus rubella 3. katarak traumatika 4. katarak komplikata : infeksi, dm

PENANGANAN KATARAK :
Operasi : - Konvensional / Jahitan - Irisan kecil tanpa jahitan PHACOEMULSIFIKASI Setelah Operasi : - Kacamata + 10 dioptri - Langsung pasang lensa tanam Prosedur Operasi : - Bius lokal

- Bius umum

PERSIAPAN OPERASI :
Pemeriksaan ahli penyakit dalam : DM,
Jantung Pemeriksaan USG mata + ukur lensa

Bius lokal : Tidak puasa

KEBERHASILAN OPERASI :
Sangat tergantung kondisi kesehatan, kooperatif saat operasi Keadaan : DM, Hipertensi, Paska infeksi, Glaukoma dapat memperburuk Perawatan kebersihan paska operasi, batuk sangat penting

Kelainan Mata yang sering dianggap sebagai katarak oleh masyarakat :

Pterygium Kekeruhan di Kornea Kelainan Segmen Posterior mata dengan penurunan visus

Pterigium bukan katarak

Pertumbuhan jaringan fibrovaskular ke dalam kornea Bentuk segitiga pada daerah celah kelopak konjungtiva

Leukoma kornea bukan katarak

Kekeruhan kornea Mata tenang Terlihat iris koloboma jam 10 Pasca iridektomi optik

Katarak Imatur

Uji bayangan iris Bayangan iris pada lensa keruh Terdapat uji bayangan iris positif pada katarak imatur

Katarak Matur

Kekeruhan lensa total Mata tenang Pupil kecil dan dibesarkan dengan midiriatik

Katarak Hipermatur

Katarak Morgagni
Nukleus lensa (warna sedikit coklat) terletak di bagian bawah lensa Terdapat tanda penyulit glaukoma
Kornea keruh
Pupil lebar

Katarak Hipermatur

Katarak hipermatur dengan tanda glaukoma sekunder

Injeksi siliar Edema kornea Pupil lebar Lensa keruh total

Penderita Katarak sering merasa

silau siang hari terik atau malam

hari bila terkena cahaya lampu dan nyaman pada kondisi remangremang misalnya sore hari

Tetap mengeluh kabur walau sudah berulang kali ganti kaca mata

Penurunan Ketajaman Penglihatan Sehat Katarak

Apa saja yang menyebabkan Katarak, dan bagaimana pencegahannya?

1. 2.

3. 4. 5. 6. 7.

Petambahan umur Obat-obatan ( Kortikosteroid, Phenotiazine, Myotic, Amiodrarone) Trauma/kecelakaan Radiasi Infra merah Sinar Ultra violet Gangguan Metabolik Nutrisi

Bagaimana Mengobati Katarak?

Non Operatif
Operatif
Ekstraksi Katarak Ekstra Kapsuler Fakoemulsifikasi

UVEITIS

UVEA

Inflammation Uveitis
Anatomy classification: Anterior uveitis= iridocyclitis Intermediate uveitis Posterior uveitis=choroiditis

Panuveitis=inflammation of
the whole uvea

Clinical Features of Uveitis

Anterior Uveitis

Symptoms Photophobia, pain, redness, decreased vision, lacrimation Sign: Limbus Ciliary injection

Cornea : Keratic precipitates (KP)

Small KP herpes zoster, Fuchs uveitis syndrome Medium KP most types acute and chronic uveitis

Large KP mutton fat granulomatous uveitis

Fresh KP white and round

Mutton fat KP

CORNEAL ULCERS

Keratitis Superfisialis,
radang epitel/ sub epitel dapat disebabkan oleh
infeksi, keracunan, degenerasi, alergi sebagai titik-

titik atau pungtata yang merata, infiltrat dibagian

atas pada trakoma, dicelah mata pada keratitis sika, atau akibat sinar u v, dibag bawah pada blefarokonjungtivitis stafilokokus

Ulkus Kornea Bakteri :

- Sentral ( stafilokok aureus, streptokokus, pneumokok, pseudomonas, moraxella ), yang karena stafilokok biasanya terlokasi, bila karena pneumokok ulkusnya menggaung disertai hipopion, pseudomonas cepat menimbulkan nekrosis dengan eksudat mukopurulen - Marginalis, biasanya karena stafilokok, ada kemungkinan karena reaksi hipersensivitas, ulkus kornea marginalis harus dibedakan dengan ulkus Mooren

- Pemeriksaan laboratorium dilakukan

secara rutin pada ulkus kornea, catnya Gram / Giemsa, mediumnya agar darah, agar coklat atau sabouraud, sensitivity tes perlu dilakukan

Keratitis Virus Herpes Simpleks

a. Keratitis epitelialis, ( keratitis dendritika, keratitis geografika virus menyerang epitel basal

b. Keratitis metaherpetik atau pasca infeksi

bentuk linear tidak teratur sehingga hampir sama dengan keratitis geografika, kesembuhan sangat lambat ( 8-12 minggu) c. Keratitis interstitialis virus

putih seperti keju (nekrosis), ada radang

limbus, harus dibedakan dengan keratitis krn infeksi sekunder atau jamur d. Keratitis diskiformis, kekeruhan bentuk cakram di parenkim kornea yang udem tanpa nekrosis

Keratitis virus Herpes Zoster

Infeksi akut yang mengenai ganglion Gaseri, jarang bilateral, sakit saat awal, timbul vesikula pada kulit dahi, kelopak mata sampai ujung hidung, konjungtiva hiperemi, sensitivitas kornea menurun

Keratitis Jamur
Petani, sukar sembuh, infiltrat abu-abu, kadang ada hipopion, gejala inflamasi berat dimulai dengan ulserai superfisial, disertai infiltrat satelit ditempat lain, ulkus meluas sampai endotel, tepi ulkus tidak teratur ( banyak karena Candida )

ENDOPHTHALMITIS

Endophthalmitis
- An inflammation reaction of intra ocular fluids or

tissues caused by infection of microbial organism

Categories :
Post operative endophthalmitis (70%) * Acute onset * Delayed - onset 2. Post traumatic Endophthalmitis (25%) 3. Endogenous

Incidence :
After ECCE After Penetrating Keratoplasty : 0,072 % : 0,11 %

Secondary IOL
Glaucoma filtering surgery Pars Plana Vitrectomy IVTA Penetrating Trauma

: 0,3 %
: 0,061 % : 0, 051 % & 0,048% : 0,5 % : 10,7 % (10FB) & 5,2 %

(N10FB)

Spectrum of Causative Organism

(AJO 2004; 137:38-42)

8, 6% 11, 8%

78, 5%

Gram + Gram Fungi

Spectrum of causative Organism

(VES, 1995)

13% 18%

Gram +
4% 63%

Gram No growth Equivocal growth

Spectrum of Causative Organism

(AJO 2004; 137:38-42)

- Staphylococcus Epidermidis - Streptococcus viridans

: 27,8 % : 12,8 %

- Other coagulase-negative staphylococci : 9.3%

- Staphylococcus aureus - Propionibacterium acnes : 7.7% : 7.0%

Most Frequent Causative Organism Among Categories (AJO 2004, 137 : 38-42)
-Acute onset post operative -Delayed onset post operative -Delayed onset bleb-associated -Post traumatic : S. Epidermidis (46,9 %) : S. Epidermidis (22,7%) : fastidious gram rods : S. Epidermidis (20 8%)

Clinical Presentation
Determined by : - Clinical category - The infecting organism

- Severity
- The duration since initiation of the infection

Prominent Symptoms
- Ocular discomfort/pain
- Reduced vision

Sign
- Marked intraocular inflammation with hypopion - Chronic iridolytis - Granulomatous KP

Clinical Presentation
Acute Onset Post Operative Typically 2-7 Days After Surgery
-Ocular discomfort and pain -Marked intraocular inflammation with hypopion * Lid edema, corneal edema, marked conjungtival congestion, fibrin in the AC

Chronic/delayed onset post operative :

- Months / years after surgery - Chronic iridocylitis - Granulomatous appearing KP

- Hypopion

Diagnosis :
- Clinical recognition - Microbiologic Confirmation

Obtaining specimen for microbiologic examination :

- Sample of aqueous :
- Local anesthesia

- Partial thickness keratotomy

- 25 or 27 G needle attached to a tuberculin syringe - Aspirates 0,1 ml of aqueous

-Vitreous specimen :
- Needle aspiration - Vitrectomy biopsy procedure - Part of a full therapeutic vitrectomy

Treatment
Goal : Retention of useful vision
Consists of : -Intensive antibiotic administration -The use of anti-inflammatory therapy -Vitrectomy + antibiotic + anti-inflammatory therapy

Antibiotic Treatment :
Delivery : - Intraocular injection - Systemic administration - Periocular injection - Topical Application Antibiotic Agent

Intravitreal injection of antibiotics

- Achieve high intraocular concentration - Should be performed early (at the time of diagnostic sampling) - Recommended antibiotic agent : * Vancomycin (1 mg in 0,1 ml) * Amikacin 0,4 mg/0,1 ml/gentamycin 0,1 mg in 0,1 cc

- Repeated injection is not recommended

Sensitivities of various antibiotics

Gram + Vancomycin Gentamycin Ciprofloxacin Ceftazidime 100 % Gram Ciprofloxacin 94,2 % 80,9 % 80,0 % 75 % 78.4 % Amikacin 68,3 % Ceftazidime 63,6 % Gentamycin

Cefazolin

66,8 %

Topical antibiotics :
- EVS : - Vancomycin HCL 50 mg/ml - Amikacin 20 mg/ml - Smiddy (2005) - Vancomycin - Ceftalzidine - Tobramycin 50 mg/ml 50 mg/ml 9/14 mg/ml
Every 1-4 hours

- Amikacin
- Gentamycin

8 mg/ml
9/14 mg/ml

Costicosteroid Therapy
- EVS : - Dexamethason 6 mg in 0,5 ml sub conjunctivally
- 1 % Predmisolone Acetate Topically - Predmisone, 30 mg 2 x a day orally - Smiddy (2005) - Dexamethason 0,4 m intravitreal - Dexamathason 4 mg sunbconjunctival

Vitrectomy :
-EVS : - Routine immediate vitrectomy not necessary in vision of hand movement or better - Stenberg, 2001 - Aggressive immediate vitrectomy for : - Bleb associated endophthalmitis - Delayed onset endophthalmitis - Traumatic endophtahlmitis

Result of therapy
Depend on : - Virulence of infecting organism (Pseudomonas, Basillus Sp, Staphylococci) - Severity and rapidity of clinical presentation

(include VA)
- The pressure of associated ocular damage

Treatment of fungal endophthalmitis :

- No need to inject antimycotics at the time of the initial
vitreous sampling
- If culture is + for fungal infection : * Amphoterican B 0,005 0,010 mg in 0,1 cc mikonazole 0,025 mg intravitreal * Subconjunctival mikonazole, 10 mg in 1 ml * Avoid the use of corticosteroid

Initial Therapy :
- Intravitreal antibiotics
- Antravitreal dexamethason (if onset is not delayed and fungal etiology is not considered) - System antibiotics * Vancomycin 0,5 % mg 1 mg and ceftazidine 1 g

every 12 hours (intravenous) or

* Oral ciprofloxacin, 750 mg every 12 hours, gatifloxacin 400 mg

Orally

- Topical * Vancomycin 50 mg/ml alternatively with gentamycin

14 mg/ml or ceftazidime 50 mg/ml every hours

* Topical procedure prednisolone acetate 1 % every 2-3 hours

Conclusion
Standard treatment for endophthalmitis - Intravitreal antibiotics - Systemic antibiotic - Vitrectomy

Endoftalmitis post trauma

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