Ординатура / Офтальмология / Английские материалы / Glaucoma Surgery_Trope_2005

organisms, and their high susceptibility to antibiotic therapy (1,19). In contrast, late-onset bleb-associated endophthalmitis tends to be caused by more virulent bacteria, (Streptococcus spp. and gram-negative bacteria such as H. influenzae) and is therefore often associated with a poor visual prognosis, occasionally culminating in evisceration or enucleation (1,24,27,29,30). A visual acuity of 20/400 or better is expected in 41% of eyes with bleb-associated endophthalmitis. This drops to 33% of eyes with streptococcal blebassociated endophthalmitis (1,3,24,26,29).

6.1.Treatment

Unlike postcataract endophthalmitis, to date there has been no randomized controlled clinical trial conducted to establish recommended guidelines for the management of bleb-related infections. This is partly due to the fact that bleb-related infections represent a spectrum of disease from localized blebitis to endophthalmitis with different infecting organisms.

Isolated blebitis, without an AC reaction, should be treated aggressively with intensive broad-spectrum topical antibiotics against the pathogens known to be associated with blebitis. Stains and culture results of conjunctival exudates, although equivocal, may help direct further antibiotic therapy (22,23,31). Reynolds et al. conducted a survey to investigate practice patterns in the management of isolated blebitis among members of the American Glaucoma Society (32). Treatment of blebitis varied among glaucoma subspecialists. Out of 319 physicians, 204 responded. Fifty-one percent (104/204) responded that they treat isolated blebitis with a topical fluoroquinolone alone as the primary empirical treatment. Another 23% use a topical fluoroquinolone in combination with one or two other topical antibiotics (half used a combination of an unfortified aminoglycoside or trimethoprim polymixin combination or equivalent, and half used one or two fortified antibiotics). Twenty-one percent preferred a combination of fortified topical antibiotics as initial treatment (half of these used fortified cephalosporins with a fortified aminoglycoside, and half used fortified vancomycin in some combination with another topical agent). Subconjunctival and oral antibiotics were used infrequently (32).

Fourth generation fluoroquinolones such as moxifloxacin, gatifloxacin, grepafloxacin, and trovafloxacin are now available for topical and/or systemic treatment. Their spectrum of activity covers many of the gram-positive and gram-negative pathogens, including bacteria most frequently implicated in blebitis and bleb-associated endophthalmitis (Staph. epidermidis, Staph. aureus, Streptococcus pneumonia, Strep. pyogenes,

H. influenzae). In addition, they have excellent activity against atypical pathogens such as Mycoplasma, Chlamydia species, and anaerobic microorganisms such as P. acnes (33,34). This generation of fluoroquinolones, achieves high intravitreal concentration well above the MIC90 for the specific microorganisms frequently implicated in blebrelated infections, is well tolerated and is reported to achieve excellent bioavailability with oral administration (33,34). Moreover, the intraocular penetration of these antibiotics is higher in eyes that are infected or inflamed (35).

As blebitis may be a precursor to endophthalmitis, aggressive antibiotic treatment at this early stage of the infection is recommended to prevent progression to endophthalmitis (1,21). At least three studies have suggested that oral antibiotics might be effective in preventing the progression of blebitis to bleb-associated endophthalmitis (1,21,26). With the lack of specific evidence-based guidelines, most clinicians (80%) treat blebitis as a precursor of endophthalmitis (32).

Our recommendation for the treatment of isolated blebitis without an AC reaction is the use of the newer topical 4th generation fluoroquinolones such as 0.5% moxifloxacin

or 0.3% gatifloxacin (if not available 0.5% levofloxacin 3rd generation fluoroquinolone can be used) every 15 min for the first hour and then hourly around the clock until clinical improvement is seen. Alternately, fortified cefazolin (50 mg/mL) or vancomycin (25 50 mg/mL) and fortified tobramycin (14 mg/mL) or gentamycin (14 mg/mL) alternating every 2 h can be used (Table 27.1). The patient’s clinical status, especially symptoms of increasing pain or decreasing vision needs to be monitored very carefully over the first 24 h. Oral antibiotics may not be necessary as bactericidal concentrations are obtained with intensive topical therapy (36). Admission to hospital may not be necessary if the patient is compliant with drops and can be seen daily.

In more advanced cases of blebitis, where there is a mild-to-moderate AC reaction, the patient should be treated with intensive topical antibiotic drops around the clock, as described earlier. We recommend the addition of a systemic 4th generation fluoroquinolone, for example, oral gatifloxacin or moxifloxacin 400 mg twice a day as a loading dose for the first day followed by 400 mg daily thereafter (if not available, other fluoroquinolone can be used) (37 39). When a 4th generation fluoroquinolone is not available, intravenous vancomycin (1 g twice daily) combined with intravenous ceftazidime (1 2 g every 8 h) merits consideration, despite the endophthalmitis vitrectomy study (EVS)

finding that adding systemic antibiotic treatment (intravenous amikacin and ceftazidime) to intravitreal antibiotic injections for postcataract endophthalmitis did not improve outcomes when compared with using intravitreal injections alone. This was attributable to the very poor intravitreal penetration of amikacin (1,21,40 42). Vancomycin penetrates the blood-ocular barrier and was not tested in the EVS. Furthermore, ceftazidime provides good coverage for gram-negative organisms that were found to be infrequent in the EVS, but are more prevalent in late-onset bleb-associated endophthalmitis (42 44). Hospital admission is advisable.

Patients where the ocular inflammation progresses, despite the earlier measures, or patients who present initially with blebitis associated with severe AC reaction (i.e., heavy cellular reaction with fibrin) hypopyon and/or vitreous cells should be treated as blebrelated endophthalmitis. Bleb-related endophthalmitis should be treated in a manner similar to acute postoperative endophthalmitis (40). If on presentation, the visual acuity is better than light perception, this is managed by performing a vitreous tap for cultures and stains and simultaneous intravitreal injection of vancomycin (1.0 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) or amikacin (400 mg/0.1 mL). In addition, the patient should be started on topical fortified antibiotic drops on an hourly or half hourly basis [e.g., vancomycin (25 50 mg/mL) or cefazolin (50 mg/mL) combined with an aminoglycoside e.g., tobramycin (14 mg/mL)] (Table 27.2). Patients with vision of light perception or less at the time of diagnosis should have an immediate pars plana vitrectomy, as visualization permits, with injection of intravitreal fortified antibiotics (27).

The use of concomitant topical or intravitreal corticosteroids is controversial. Currently, there is no evidence-based support in the literature which demonstrates their effectiveness in this setting. It is believed that their beneficial effect is to reduce the inflammatory component and the resultant destructive damage to ocular tissue. If the use of topical steroids is considered to reduce inflammation in the bleb, it should be started only after the leak and infection have been treated (36). If intravitreal corticosteroids are given, dexamethasone (400 mg/0.1 mL) is administered (36).

Table 27.2 Bleb Associated Endophthalmitis

6.2.Prevention

In light of the potentially devastating results associated with bleb-related endophthalmitis, it is advisable that patients who have undergone trabeculectomy, with or without antifibrotic agents, should be educated by their ophthalmologists to contact them immediately should they notice the onset of the following symptoms: redness, irritation, photophobia, discharge, or reduced vision. Excessive watering from the eye should be evaluated for a bleb leak. Such leaks should be surgically repaired, if conservative measures fail. Physicians should avoid prescribing prophylactic topical antibiotics for chronic postoperative use (9,14). The chronic prophylactic and subtherapeutic use of antibiotics (especially the fluoroquinolone family) can lead to an increase in antibiotic resistance and the selection of more virulent strains of bacterial and/or fungal infection.

REFERENCES

1.Ciulla TA, Beck AD, Topping TM, Baker AS. Blebitis, early endophthalmitis, and late endophthalmitis after glaucoma filtering surgery. Ophthalmology 1997; 104(6):986 995.

2.Bellows AR, McCulley JP. Endophthalmitis in aphakic patients with unplanned filtering blebs wearing contact lenses. Ophthalmology 1981; 88:839 843.

3.Higginbotham EJ, Stevens RK, Musch DC, Karp KO, Lichter PR, Bergstrom TJ, Skuta GL. Bleb related endophthalmitis after trabeculectomy with mitomycin C. Ophthalmology 1996; 103:650 656.

4.Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF, Flynn HW Jr. Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol 1996; 114:943 949.

5.Wolner B, Liebmann JM, Sassani JW, Ritch R, Speaker M, Marmor M. Late bleb related endophthalmitis after trabeculectomy with adjunctive 5 fluorouracil. Ophthalmology 1991; 98:1053 1060.

6.Akova YA, Bulut S, Dabil H, Duman S. Late bleb related endophthalmitis after trabeculec tomy with mitomycin C. Ophthalmic Surg Lasers 1999; 30:146 151.

7.Shields MB, Scroggs MW, Sloop MW, Simmons RB. Clinical and histopathologic observations concerning hypotony after trabeculectomy in with adjunctive mitomycin C. Am J Ophthalmol 1993; 116:673 683.

8.Mietz H, Brunner R, Addicks K, Konen W. Histopathology of an avascular filtering bleb after trabeculectomy with mitomycin C. J Glaucoma 1993; 2:266 270.

9.Nuyts RM, Felton PC, Pels E, Langerhorst CT, Geijssen HC, Grossniklaus HE, Greve EL. Histopathologic effects of mitomycin C in human glaucomatous eyes with persistent hypotony. Am J Ophthalmol 1994; 118:225 237.

10.Greenfield DS, Parrish RK II. Bleb rupture following filtering surgery with mitomycin C: clinicopathologic correlations. Ophthalmic Surg Lasers 1996; 27:876 877.

11.Belyea DA, Dan JA, Stamper RL, Lieberman MF, Spencer WH. Late onset of sequential multifocal bleb leaks after glaucoma filtration surgery with 5 fluorouracil and mitomycin C. Am J Ophthalmol 1997; 124:40 45.

12.DeBry PW, Perkins TW, Heatley G, Kaufman P, Brumback LC. Incidence of late onset bleb related complications following trabeculectomy with mitomycin. Arch Ophthalmol 2002; 120:297 300.

13.Soltau JB, Rothman RF, Budenz DL, Greenfield DS, Feuer W, Liebmann JM, Ritch R. Risk factors for glaucoma filtering bleb infections. Arch Ophthalmol 2000; 118:338 342.

14.Jampel HD, Quigley HA, Kerrigan Baumrind LA, Melia BM, Friedman D, Barron Y. Glaucoma Surgical Outcomes Study Group. Risk factors for late onset infection following glaucoma filtration surgery. Arch Ophthalmol 2001; 119:1001 1008.

15.Sidoti PA, Lopez PF, Michon J. Delayed onset pneumoccocal endophthalmitis after mitomy cin C trabeculectomy: association with cryptic nasolacrimal obstruction. J Glaucoma 1995; 4:11 15.

16.Burchfield JC, Kolker AE, Cook SG. Endophthalmitis following trabeculectomy with releasa ble sutures (letter). Arch Ophthalmol 1996; 114(6):766.

17.Poulsen EJ, Allingham RR. Characteristic and risk factors of infections after glaucoma filtering surgery. J Glaucoma 2000; 9:438 443.

18.Eifrig CW, Flynn HW Jr, Scott IU, Newton J. Acute onset postoperative endophthalmitis: review of incidence and visual outcomes (1995 2001). Ophthalmic Surg Lasers 2002; 33(5):373 378.

19.Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthalmitis. Review of 36 cases. Ophthalmology 1982; 89:921 928.

20.Olson JC, Flynn HW Jr, Foster RK, Culbertson WW. Results in the treatment of postoperative endophthalmitis. Ophthalmology 1983; 90:692 699.

21.Brown RH, Yang LH, Walker SD, Lynch MG, Martinez LA, Wilson LA. Treatment of bleb related endophthalmitis glaucoma surgery. Arch Ophthalmol 1994; 112:57 61.

22.Chen PP, Gedde SJ, Budenz DL, Parrish RK II. Outpatient treatment of bleb infection. Arch Ophthalmol 1997; 1124 1128.

23.Bellows AR. Complications of filtering surgery, late post operative complications, infection. In: Albert DM, Jakobiec FA, eds. Glaucoma Lids and Orbit Ophthalmic Pathology. Vol. 4. Principles and Practice of Ophthalmology. 2nd ed. W.B. Saunders, 1994:2995 2996.

24.Mandelbaum S, Forster RK, Gelender H, Culbertson W. Late onset endophthalmitis associated with filtering blebs. Ophthalmology 1985; 92:964 972.

25.Forster RK, Abbott RL, Gelender H. Management of infectious endophthalmitis. Ophthal mology 1980; 87(4):313 319.

26.Kangas TA, Greenfield DS, Flynn HW Jr, Parrish RK II, Palmberg P. Delayed onset endophthal mitis associated with conjunctival filtering blebs. Ophthalmology 1997; 104(5):746 752.

27.Song A, Scott IU, Flynn HW Jr, Budenz DL. Delayed onset bleb associated endophthalmitis: clinical features and visual acuity outcomes. Ophthalmology 2002; 109:985 991.

28.Waheed S, Ritterband DC, Greenfield DS, Liebmann JM, Seedor JA, Ritch R. New patterns of infecting organisms in late bleb related endophthalmitis: a ten year review. Eye 1998; 12:910 915.

29.Beck AD, Grossniklaus HE, Hubbard B, Saperstein D, Haupert CL, Margo CE. Pathologic findings in late endophthalmitis after glaucoma filtering surgery. Ophthalmology 2000; 107:2111 2114.

30.Margo CE, McKnight GT. Lens induced granulomatous inflammation. Am J Ophthalmol 1988; 106:1035.

31.Mac I, Soltau JB. Glaucoma filtering bleb infections. Curr Opin Ophthalmol 2003; 14:91 94.

32.Reynolds AC, Skuta GL, Monlux R, Johnson J. Management of blebitis by members of the American Society: a survey. J Glaucoma 2001; 10:340 347.

33.Hariprasad SM, Mieler WF, Holz ER. Vitreous and aqueous penetration of orally administered gatifloxacin in humans. Arch Ophthalmol 2003; 121(3):345 350.

34.Bauernfeind A. Comparison of the antibacterial activities of the quinolones Bay 12 8039, gatifloxacin (AM 1155), trovafloxacin, clinafloxacin, levofloxacin and ciprofloxacin. J Antimi crob Chemother 1997; 40:639 651.

35.Martin DF, Ficker LA, Aguilar HA, Gardner SK, Wilson LA, Meredith TA. Vitreous cefazolin levels after intravenous injection: effects of inflammation, repeated antibiotic doses, and surgery. Arch Ophthalmol 1990; 108:411 414.

36.Lerner SF, Parish RK II. Late complications of trabeculectomy. In: Lerner SF, Parish RK II, eds. Glaucoma Surgery. Lippincott Williams & Wilkins Publishers, 2003:80 90.

37.Keren G, Alhalel A, Bartov E, Kitzes Cohen R, Rubinstein E, Segev S, Treister G. The intra vitreal penetration of orally administered ciprofloxacin in humans. Invest Ophthalmol Vis Sci 1991; 32:2388 2392.

38.Fiscella RG, Shapiro MJ, Solomon MJ, Kurtz RM, Mui S, Labib S. Ofloxacin penetration into the eye after intravenous and topical administration. Retina 1997; 17:535 539.

39.Fiscella RG, Nguyen TK, Cwik MJ, Phillpotts BA, Friedlander SM, Alter DC, Shapiro MJ, Blair NP, Gieser JP. Aqueous and vitreous penetration of levofloxacin after oral administration. Ophthalmology 1999; 106:2286 2290.

40.Endophthalmitis Vitrectomy Study Group. Results of the endophthalmitis vitrectomy study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113:1479 1496.

41.el Massry A, Meredith TA, Aguilar HE, Shaarawy A, Kincaid M, Dick J, Mahmoud MI. Aminoglycoside levels in the rabbit vitreous cavity after intravenous administration. Am J Ophthalmol 1996; 122:684 689.

42.Meredith TA. Antimicrobial pharmacokinetics in endophthalmitis treatment: studies of ceftazidime. Trans Am Ophthalmol Soc 1993; 91:653 699.

43.Schech JM, Alfaro DV III, Laughlin RM, Sanford EG, Briggs J, Dalgetty M. Intravenous gen

tamicin and ceftazidime in penetrating ocular trauma: a swine model. Retina 1997; 17(1):28 32.

44.Aguilar HE, Meredith TA, Shaarawy A, Kincaid M, Dick J. Vitreous cavity penetration of ceftazidime after intravenous administration. Retina 1995; 15:154 159.