Ординатура / Офтальмология / Английские материалы / Ocular Traumatology_Kuhn_2008
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2.17 Endophthalmitis |
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Fig. 2.17.2 Ring ulcer in Bacillus endophthalmitis. A ring-like peripheral corneal infiltration is typical of an endophthalmitis caused by Bacillus species. It is extremely unlikely that an eye with such an advanced infection can be saved
Fig. 2.17.3 Loss of retinal details in an eye with preserved red reflex in endophthalmitis (Courtesy of V. Mester, Abu Dhabi, U.A.E.)
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Fig. 2.17.4 Colonization of a nondetached posterior cortical vitreous in endophthalmitis. This intraoperative photograph shows a forceps carefully detaching the posterior hyaloid face in an eye that has had endophthalmitis for over a week. Despite the long duration of the infection, no spontaneous PVD has occurred, and the cortical vitreous is heavily colonized by bacteria, as shown here by the numerous white dots
tain multiple colonies of bacteria in the form of white-yellowish dots (a; Fig. 2.17.4).
•Endophthalmitis retinopathy (a), characterized by perivascular infiltration (periphlebitis), stress hemorrhages, areas of edema, exudative retinal detachment, and necrosis.
•Panophthalmitis (a), characterized by proptosis and fever.
Fungi may cause a clinical picture that is in many ways similar to that described above, but usually such an infection:
•Has a history of soil contamination
•Is caused by an organic IOFB
•Shows a more chronic course
The retina is rarely seen until vitrectomy is performed and the cloudy media have been cleared.
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•Demonstrates “snowball” or “string of pearls” appearing opacities in the vitreous [14].
2.17.3.4Culturing
The bacterial spectrum is different if the endophthalmitis is trauma related and not postoperative. The organisms involved are typically more virulent and multi-organism infections are also more common. Frequently encountered bacteria causing traumatic endophthalmitis with poor prognosis include Bacillus species ([2], Clostridium perfringens [1], and Gram-negative rods [3].
Culturing is important to identify the organism and determine the invitro antimicrobial profile; initiation of the therapy, however, must not be delayed until the lab report is received. Multiple culture media should be used (blood and chocolate agar, Sabouraud’s, thioglycollate broth, anaerobic blood, as well as various stains (Gram, Giemsa, fungal), but the most accurate and rapid identification comes from polymerase chain reaction [20]. Bactec broth is another medium with a high and fast yield [9].
2.17.4Treatment
A two-pronged attack is necessary for eyes with traumatic endophthalmitis: surgery and medications.
ZPearl
Traumatic endophthalmitis is a surgical indication; pharmaceutical treatment is to be employed in addition to, not instead of, vitrectomy.
Vitrectomy for endophthalmitis, especially if it is of traumatic origin, is technically one of the most challenging indications. The difficulty is due to the often hazy media and to the intricacy in distinguishing between yellowish layers of vitreous, which may have blood streaks mimicking retinal
Even though the in-vivo sensitivity may be different.
Bactec Peds Plus F, Becton Dickinson, Sparks, Maryland.
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blood vessels, and a detached, necrotic, nonperfused retina, which may not bleed when injured. It is mandatory for the surgeon to take a slow, cautious approach, similar to that described in Chap. 2.12. The surgical steps are outlined in Table 2.17.2.
Table 2.17.2 Vitrectomy for traumatic endophthalmitis: surgical steps
Surgical step |
Comment |
Scrape the corneal |
Most of the corneal edema resides in the epithelium; removing |
epithelium |
this layer is alone sufficient to dramatically increase visibility |
Drying the corneal |
If the stroma is also hazy, applying a shield wetted with 40% |
stroma |
glucose for a few minutes usually reduces the edema (see |
|
Chap. 2.9 for further options) |
Cleaning of the AC |
An AC maintainer is necessary to prevent hypotony. Gentle |
|
aspiration through a paracentesis is sufficient to remove |
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white and red blood cells and most of the debris. The angle |
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should also be irrigated. In the vast majority of eyes a fibrinous |
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membrane is covering the angle, iris, and lens; this must be re- |
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moved, using forceps, or aspiration with a blunt cannula or the |
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vitrectomy probe. Irrigation of the AC may have to be repeated |
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during surgery because the inflammatory debris may reaccu- |
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mulate. The fibrinous membrane may also reform, especially in |
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children; this must be removed as often as needed |
Enlarging the pupil |
Unless the sphincter has been damaged, the pupil is small; if |
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not dilated, visibility of the posterior segment remains poor, |
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even if wide-angle viewing is employed. If adrenaline does not |
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achieve dilatation, iris retractors must be used (see Chap. 2.9) |
Preparing |
These are made using the standard method.1 The infusion must |
the sclerotomies |
not be opened until the cannula’s proper location is confirmed. |
|
A long cannula2 should be considered |
1 Currently it is not recommended to use small-gauge vitrectomy for traumatic endophthalmitis.
2 6 or even 7 mm
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Table 2.17.2 (continued) Vitrectomy for traumatic endophthalmitis: surgical steps |
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Surgical step |
Comment |
|
Dealing with the lens |
Even if uninjured, the lens may have to be extracted to allow |
|
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unhindered vitrectomy.3 If an IOL is present, a large posterior |
|
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capsulectomy should be created to allow irrigation of the bag. |
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The surfaces of the IOL may have to wiped repeatedly |
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Performing vitrec- |
A careful antero-posterior approach is used, keeping the vit- |
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tomy |
rectomy probe close to the visual axis4 but nasal to it. Very slow |
|
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progression is necessary, and it is crucial to go deep before |
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going wide (see Chap. 2.12) |
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The posterior hyaloid should be separated from the retina if |
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possible.5 If the retina is necrotic or if the vitreous is very adher- |
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ent, this surgical goal must be abandoned |
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The peripheral vitreous is carefully shaved, but a complete |
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vitreous removal must not be attempted since this significantly |
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raises the risk of creating a retinal break |
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Consider using |
Organisms do not proliferate in the oil [13]. Silicone oil use, |
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silicone oil tampon- |
however, is not a must; it should be preserved for those cases |
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ade |
with major retinal pathology such as a break, detachment, or |
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widespread necrosis, and then only if the vitreous cavity has |
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been adequately cleaned.6 Antibiotics and corticosteroids |
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should be placed into the infusion fluid (Table 2.17.3) and the |
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vitreous/capsular bag/AC irrigated, then silicone oil injected |
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3 The capsules may be “dirty” from debris that settled on their surface; their “vacuuming” with the vitrectomy probe may be impossible without causing a capsular break.
4 i.e., not close to the eye wall/retina
5 Even in eyes with endophthalmitis persisting for several days, a vitreoschisis is more likely to be present than a true PVD. Leaving vitreous on the retinal surface increases the risk of macular injury from the organism’s toxins, enzymes, and the body’s inflammatory/immune response.
6 All pus and vitreous, except in the periphery, have been removed.
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ZCave
A methodical, anterior-to-posterior sequence must be followed during vitrectomy for endophthalmitis; any attempt to bypass a step threatens with decreased visualization and thus increases the risk of iatrogenic retinal damage. If visibility is so poor as to make tissue identification impossible, surgery must be stopped.
If the cornea is in such poor shape that it does not allow visualization of deeper structures, the surgeon has three options:
•Foregoing surgery until the cornea clears. More than likely this results in loss of vision and probably even loss of the eye.
•EAV (see Chap. 2.20). It is a technically difficult surgery, and one of its major advantages, the complete cleansing of the vitreous base, should not be utilized; however, EAV does reduce the amount of pus in the eye and alleviates the need for PK.
•TKP vitrectomy (see Chap. 2.15). Currently, this appears to be the most effective, albeit complex, option. Even in these highly inflamed eyes, the graft rejection rate is very low.
Silicone oil (Table 2.17.2) can be employed if the retina is injured and detachment is present or threatens. It has the following advantages:
•It maintains retinal attachment.
•It prevents pus reaccumulation.
•It maintains a clear retinal view even in the early postoperative period.
The details of pharmaceutical treatment are shown in Table 2.17.3. It must be mentioned that the efficacy of subconjunctival antibiotics has not been proven [17]. Recently there is an increase in the resistance of the organisms to vancomycin [21]. If an eye is filled with silicone oil, one-quarter of the
R. Morris, Birmingham, Alabama, unpublished data
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Endophthalmitis |
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Table 2.17.3 Pharmacotherapy for eyes with bacterial traumatic endophthalmitis |
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||
Route of application |
Drug |
Dose |
|
Intravitreal injection |
Ceftazidime |
2.2 mg/0.1 ml |
|
|
Vancomycin |
1−2 mg/0.1 ml |
|
|
Dexamethasone |
0.4 mg/0.1 ml |
|
Vitrectomy infusion fluida |
Ceftazidime |
2.2×25 mg/100 ml |
|
|
Vancomycin |
25 mg/100 ml |
|
|
Dexamethasone |
0.4×25 mg/100 ml |
|
Subconjunctival |
Ceftazidime |
100 mg in 0.5 ml |
|
|
Vancomycin |
25 mg/0.5 ml |
|
|
Dexamethasone |
15 mg/1 ml |
|
Topical |
Fortified topical antibiotics |
Hourly |
|
|
(e.g., ciprofloxacin [15]) |
|
|
|
Prednisolone acetate |
1%, several times a day |
|
Oralb |
Moxifloxacin |
400 mg/day |
|
Intravenous |
Ceftazidime |
1 g/12 h |
|
|
Vancomycin |
1 g/12 h |
|
The initial (“blind”) choice; must be modified as resistance test results become available from culturing
a The drug concentrations are identical to those of an intravitreal injection
b Because of its excellent penetration into the eye, oral moxifloxacin is usually sufficient; if not, intravenous therapy can be chosen
normal dose of the intravitreal regimen (Table 2.17.3) can be injected into the oil at the conclusion of surgery [8].
In addition to the treatment described above, the patient must be constantly reminded not to be in the supine position. The patient should stay in bed as little as possible, but if he does, he should turn to either side. Such posturing helps to prevent settling of the pus on the macula.
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2.17.5Prophylaxis
There is no consensus in the literature regarding the type of prophylactic antibiotics in eyes with open globe injury. Oral, topical, and subconjunctival antibiotics are always recommended. Whether intravitreal antibiotics should be used in every case of open globe injury or just in high-risk eyes [11] is an individual decision the surgeon has to make.
Z
DO:
•always think about the possibility of endophthalmitis if the eye sustained an open globe injury, and especially if the risk is high (e.g., IOFB, soil contamination, lens injury)
•proceed with as complete as possible vitrectomy and proper pharmaceutical therapy as soon as possible
DON’T:
•perform vitrectomy as if the condition of the eye were similar to a postoperative endophthalmitis; intraocular injuries make this operation, which is not an easy one even in the postoperative setting, even more complex and difficult
•leave infected vitreous behind unless visualization is poor and cannot be improved by a meticulous anterio-posterior approach; cleansing of the vitreous cavity should be as complete as possible
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Summary
Endophthalmitis is one of the most dreaded complications of an open globe injury. Recognition is not as straightforward as in most cases of postoperative endophthalmitis, due to masking by the injury. The selection of treatment for a posttraumatic endophthalmitis, however, is
noncontroversial: prompt vitrectomy with intravitreal, systemic, and topical antibiotics offers the best prognosis. Corticosteroids should also be employed to reduce the deleterious effects of the accompanying inflammation.
References
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