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 traumaticPost 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%

S.No.

Procedure

Incidence of culture positive endophthalmitis

1 Extracapsular Cataract extraction 0.072 %

2 Intracapsular cataract extraction 0.093 %

3 Secondary IOL implantation 0.30 %

4 Penetrating keratoplasty 0.11 %

5 Filtering surgery for glaucoma 0.061 %

6 Pars plana viterectomy 0.051 %

Comparison of incidence of post surgical endophthalmitis

Sources of infection Airborne contaminants

• Respiratory origin• Surface origin (skin,

clothing etc)• Air conditioning system

Solutions and medications

• Saline for irrigation and other purposes

• Instruments• Skin antiseptics

Tissues• Skin of hands and

operating field• Lid margins and

eyelashes• Conjunctival sac• Lacrimal sac• Nasal mucosa• Corneal grafts• Vitreous implants• Fellow eyes

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

Systemic conditions• Active infection (URTI,

skin, soft tissue)• Diabetes• Immune compromise

Surgical factors IOLs with

polypropylene hapticsVitreous

communicationWound abnormalitiesUse of silk suture for

wound closureContaminated

irrigating solutions

Microbiology Bacteria

Gram positive• Staphylococcus aureus• Staphylococcus epidermidis• Streptococcus pneumoniae• Streptococcus haemolyticus• Streptococcus viridians• Bacillus subtilis• Bacillus megaterium• Clostridium perfringes

Fungi• Actionmyces species• Sprotrichum schenkii• Candida species• Fusarium species

Gram negative• Pseudomonas

aeruginosa• Proteus species• Kiebsiella • E.coli• Enterobacter

aerogenes• Other coliforms• N.catarrahalis

Insulting agent / specific organism

Vascular changes•Vasodilatation

•Increased capillary permeability

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

•Increased fluid exudation•Cellular infiltration

•Adequate inoculums of organism•Virulent organism

•Poor host immunity

Limits further organism reproduction

Progressive infection with secondary manifestation

Release of digestive enzymes and toxins

Types Surgical endophthalmitis

Fulminant ( within 4 days )Fulminant ( within 4 days )•Gram negative bacteriaGram negative bacteria

•StreptococciStreptococci•Staph aureusStaph aureus

Acute ( 5 – 7 days ) Acute ( 5 – 7 days ) •Staph epidermidesStaph epidermides

•Coagulase negative cocciCoagulase negative cocci

Chronic (more than 4wks )Chronic (more than 4wks )

Delayed entery •Viterous wick syndrome

•Bleb related

Delayed onset •Fungi

•P.acne•Staph epidermidis

Infective Noninfective

Endogenous Exogenous

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 :

• Prominent visual loss

• Painful red eye• Photophobia• Purulent

discharge• Frequent

headaches

Signs:• Exaggeration of usual inflammatory signs • Marked lid edema • Increased ciliary congestion and chemosis• Corneal edema• Limbal ring abscess, suture abscess,wound

dehiscence• Anterior chamber reaction

o Presence of cells and flareo Turbid o Hypopyon

• Iris o Muddy and boggyo Tendency to form posterior synechiae

• Pupillary response either absent of sluggish• Reterolenticular flare• Viterous reaction

o Viterous exudateo 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

http://www.djo.harvard.edu/files/2610_316.jpg

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

Organism grow slowly

Sequester in capsular bag

Out of reach of host defences

Stimulate immunologic reaction

Persistent inflammation

Organism may get

entery to eye after Nd YAG capsulotomy

Propionibacterium acne

• Viterous wick syndromeo 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 associatedo Type of bleb

Thin walled Cystic Positive Siedel’s test

Differential diagnosis• Sterile inflammation

Parameter Enophthalmitis Sterile inflammation

Focal infiltrate Commonly present

rare

Fundus glow Poor/absent Ok/mildly poor

Viterous cavity Haze ++ Clear/mild haze

Colour of exudates

Yellowish White

IOP Low normal

• Corneal edema due to raised IOP Corneal edema due to raised IOP postoperativelypostoperatively

Diagnosis

Proper history Clinical picture B scan: helps to rule out other condition that

mimic endophthalmitiso Retinal detachmento Choroidal detachmento Dislocated lens / nucleuso Parasite infestationo RIOFB

Microbiologic investigations:For identification of organismsTo 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

Culture: 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

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 OTClean laundried clothes should be wearedEffective scrubbing of hands by surgeonSterile disposable cap, mask, and glovesSterile /disposable OT gowns

Patient Painting of periocular skin with 10% povidone iodineCover with sterile eye towel drapping to exclude eyelids from

operative fieldAntibiotics use in infusion fluidIrrigate IOL before insertion to remove adherent bacteriaMinimize duration of exposure of IOL to operating room

environmentCareful wound closureMinimizing duration of surgerySubconjunctival antibiotics at the end of surgery

Postoperative :Postoperative antibiotics eye drps and

ointmentPatient with prolonged surgery, viterous loss,

diabetes, immunocompromised individuals consider close follow up

Careful suture removal

Treatmentof endophthalmitis

Medical therapy Surgical therapy

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

Corticosteroids

VitrectomyEnucleation

Definitive Supportive

CycloplegicIOP 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

First choice Second choice Third choiceInj. Vancomycin 1000 microgram in 0.1mlInj. Ceftazidime 2.25 mg in 0.1ml

Inj. Vancomycin 1000 microgram in 0.1mlInj. Amikacin 400 microgram in 0.1ml

Inj. Vancomycin 1000 microgram in 0.1mlInj. Gentamycin 200 microgram in 0.1ml

Bacterial endophthalmitis

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• Catarct in phakic eyes

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 1gm IV/ 12 hr

Ceftazidime 2gm IV/ 8hr

Ceftriaxone 2gm IV/ 8 hr

Cefazolin 1.5gm IV/ 6hr

Amikacin 240mg IV/12 hr

Tobramycin 1gm IV/ 12 hr

Gentamycin 1gm IV/ 12 hr

Amphotericin B 0.7-0.1mg / kg / day IV

Fluconazole 200mg/day

Topical antibiotics

Combination of two drugs covering gram positive and negative organism is given

EVS prefer:

Vancomycin 50mg/ml + Amikacin 20mg/ml

Vancomycin 25mg /0.5ml

Gentamycin 25mg /0.5ml

Cephaloridine 25mg /0.5ml

Methicillin 25mg /0.5ml

Tobramycin 25mg /0.5ml

Gentamycin 25mg /0.5ml

Subconjuncival antibiotics:

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 necrosiso Corneal opacification

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 dropsIntravitreal dexa 0.4mg in 0.1ml

Subconj dexa 1mg in 0.25 ml

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 responseAdequate undiluted viterous specimen Increase antibiotic concentration within eyeRemoving 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

Thank you