Endophthalmitis |
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45.1General Considerations
45.1.1 Etiology
Endophthalmitis may be postoperative,1 posttraumatic, and endogenous; it is mostly caused by bacteria but may also be fungal.
Q&A
Q Can endophthalmitis occur after closed-globe surgery?
AIn principle, no; in practice, yes. The simple explanation for this paradox is accidental perforation of the sclera with the needle during SB or squint operation.
The vast majority of the cases are acute2; the chronic cases are typically caused by fungi or organisms such as Propionibacterium acnes after cataract surgery.
Posttraumatic endophthalmitis is unique in its presentation since the typical signs are often masked by the injury, thus making the diagnosis more challenging. The organism is often more virulent; it is therefore even more important to intervene on an emergency basis and attempt to do a complete surgery (CEVE, see below).
1Including cases associated with filtering blebs.
2This chapter is dedicated to these acute cases. The difference in the management of eyes with chronic endophthalmitis is that the surgery is not urgent and the capsules/IOL complex commonly needs to be removed; it is in the bag where the organisms hide.
© Springer International Publishing Switzerland 2016 |
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DOI 10.1007/978-3-319-19479-0_45
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45.1.2 Clinical Diagnosis
The following are typical signs and symptoms.3
•Drop in visual acuity.
•Pain.
•Corneal edema.
•Hypopyon and fibrin in the AC.
•Small pupil.
•Reduction in, or loss of, the red reflex.
•If the retina is visible at all, it shows tortuous and sheathed blood vessels, stress hemorrhages, and widespread edema.
The diagnosis can be confirmed by obtaining a sample from the AC or via a vitreous tap.4
45.1.3 Timing
There is no other surgical indication in ophthalmology when the initiation of treatment is as urgent as in endophthalmitis.
Pearl
The easiest part of the management of a patient with acute endophthalmitis is timing. Medically and legally, it is very difficult to justify any delay in commencing the treatment, whichever treatment route is chosen.
As part of the management, the ophthalmologist should warn the patient against lying in bed. Being upright reduces the risk of the heavy purulent material settling on the macula.
45.1.4 Treatment Options and Management Philosophy
There are two basic options: medical and surgical.5 In the first case the ophthalmologist chooses the “safe” route and follows an “evidence-based” recommendation6: if the VA is greater than LP, intravitreal and periocular antibiotics are given, but no systemic antibiotics are used and surgery is not performed.
3Not all of these need to be present in a given case. In posttraumatic cases other pathologies may mask the signs of endophthalmitis.
4The question is whether the ophthalmologist chooses to operate or inject first (see below). If the former option is chosen – which is my recommendation – there is no point taking a sample before the surgery; an ample amount of the infected material will be collected during surgery.
5“Surgical” in reality means a combination of vitrectomy and medical treatment.
6See the comment in the box in Chap. 43.
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In my opinion the presence of pus inside the eye represents a surgical indication.7 I also believe that a condition, which can rapidly lead to irreversible loss of vision, deserves all the weapons at the ophthalmologist’s disposal to be utilized against it.8 This includes the use of systemic antibiotics – and, primarily, surgery.
Vitrectomy is my default option, as long as the patient’s systemic condition permits it.9 The only exception is an endophthalmitis so early that retinal details can still be visualized. In such a case I am willing to use medical treatment (the maximum possible; see Table 45.1), but keep the patient under very close observation: hourly self-check10 for pain and visual deterioration (see Fig. 45.1 for the decision-making process).
Table 45.1 Medical treatment in endophthalmitis*
Route of administration; schedule |
Drug |
Dose (in a volume of) |
Intravitreala; the initial injection is given |
Vancomycin |
2 mg (0.1 ml) |
before or at the conclusion of surgery; |
Ceftazidime |
2.25 mg (0.1 ml) |
repeated as needed |
Dexamethasone |
0.4 mg (0.1 ml) |
Intravenous; every 12 h |
Vancomycin |
1 g |
|
Ceftazidime |
1 g |
Subconjunctival; daily or as needed |
Vancomycin |
25 mg (0.5 ml) |
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Ceftazidime |
0.1 g (0.5 ml) |
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Dexamethasone |
12 mg (3 ml) |
Topical; hourly or as needed |
Moxifloxacine |
0.5% |
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Ofloxacin |
0.3% |
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Tobramycin |
0.3% |
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Steroid |
Depends on availability; |
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use the strongest one |
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Pupil dilator |
Atropine, tropicamide |
*The medications need to be changed based on the results of the culture.
aIf antibiotics and steroid need to be added to the infusion fluid during vitrectomy (silicone oil implantation is planned, see the text for more details), the same concentration should be used.
Q&A
QBy going to surgery at such an early stage, will some of the eyes not undergo PPV unnecessarily (i.e., they would have improved on medical therapy alone)?
AYes, some of the eyes could have been cured by medical therapy alone – but it is impossible to predict at an early stage which these eyes would be. The surgeon gives up control (and risks a poorer outcome) by waiting; in addition, the earlier surgery is performed, the easier it is technically, which in turn means that the risk of surgery is very low.
7Ubi pus, ibi evacua.
8Especially since initially it is not known what the organism is and whether a fulminant infection will occur.
9As explained in Chap. 5, it is the patient who must choose this option based on the ophthalmologist’s impartial information.
10The patient is hospitalized, and the nurse also checks on the patient hourly. This schedule is continued throughout the night as well.
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Endophthalmitis
Retinal details visible +
Tap for sample and maximal medical therapy
Hourly check-up
Improvement
Continue with the medical therapy
Retinal details visible -
PPV
No improvement
Fig. 45.1 Decision-making tree to select the treatment in endophthalmitis. Medical treatment is continued even if PPV is performed. See the text for more details.
If surgery needs to be delayed for any reason, full medical treatment is given, even if it will reduce the chance of having a positive yield of the subsequent culture. Surgery does not obviate the need for medical treatment (see above). Heavy topical steroid treatment must be started as soon as the patient has been examined to reduce the corneal edema and the eye’s inflammatory reaction.
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If the cornea is too hazy to allow safe PPV,11 the surgeon still has a few options to choose from (see Table 45.2).12
Table 45.2 Management options if corneal opacitya interferes with visualization during PPV for endophthalmitis
Option |
Endophthalmitis, semi-advancedb |
Endophthalmitis, advanced |
Give up on the |
Acceptable only if rapid progression |
Major damage threatens (loss of |
surgical option |
(to advanced endophthalmitis) |
vision and eyeball) |
altogether |
does not occur |
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Delay the surgery |
Acceptable only if the delay is short. |
Even if the delay lasts only for a |
until the cornea |
The chances of a meaningful |
few hours,d severe intraocular |
clearsc |
reduction in the corneal haziness |
damage threatens |
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are not too high |
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Do limited surgery |
May be acceptable but rapid |
Partial vitrectomy is preferable to |
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progression to advanced |
no vitrectomy. Conversely, poor |
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endophthalmitis remains a |
visualization is not an excuse if |
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possibility |
the surgeon causes significant |
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iatrogenic damage |
TKP |
Better than all the previous options, |
Optimal solution since a PK will |
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but it may be unnecessary |
likely be necessary in the future |
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(“overkill”) because the cornea |
anyway. The survival chance of |
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would eventually clear up |
the graft is over 90% |
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spontaneously |
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EAV |
Optimal solution, but the surgeon |
Optimal solution, although a PK |
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must be very experienced in this |
will likely be necessary in the |
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technique |
future anyway |
aThe corneal opacity is not a bacterial infiltration – if it is, the only acceptable option is TKP-PPV.
bNot early anymore, but not quite an advanced one yet.
cThis will be sped up if topical steroids are used. Full antibacterial (fungal) therapy must be initiated without delay.
dIt is unlikely that in an advanced case of endophthalmitis, the corneal edema sufficiently clears up in a few hours, even if the topical steroid is used every few minutes.
Completeness of the vitrectomy is the key to success. If a PVD is not created or the macular surface not vacuumed, the toxins and enzymes of the organism and the inflammatory debris (as a result of the body’s immune reaction) will continue to damage the retina (see Fig. 45.3).
11Use of the BIOM is an especially great aid in endophthalmitis, allowing complete surgery in many eyes that otherwise would require TKP-PPV or EAV.
12The culprit may also be the material that accumulated in the AC; once the AC is cleaned, visibility dramatically improves (see Fig. 45.2). The problem here is that his may be impossible to determine preoperatively.