Endophthalmitis

Department of Ophthalmology, MNUMS
MD Bulganchimeg.B

1. Endophthalmitis 3 rd year resident, MNUMS B.Bulganchimeg MD

2. Endophthalmitis Endophthalmitis is defined as an intra-ocular inflammation which predominantly affects the inner spaces of the eye ( vitreous and/or the anterior chamber)

3. Types of endophthalmitis Exogenous (>85%) Acute Postoperative Chronic Postoperative Traumatic Filtering Bleb-Associated After Intravitreal Injections Endogenous (<15%) Originates from sources within the body 2-8% of endophthalmitis cases R ecent intravenous infusion, DM, HIV, IV drug abuse, renal failure on dialysis, cardiac disease, malignancy, immunosuppressive therapy, or indwelling catheters Liver abscess

4. Postoperative endophtalmitis

5. Common organism causing endophthalmitis A. Exogenous Acute onset Postsurgical Gram positive : S. epidermidis, S. aureus , Streptococcus spp. Gram negative : Pseudomonas, Proteus, H. influenzae , Klebsiella , E. coli, Enterobacter Delayed onset Postsurgical Fungi : aspergillus, fusarium , candid, penicillum Bacteria : P. acnes S. epidermidis Post-traumatic Bacillus spp. S. epidermidis Streptococcus spp. fungi ( fusarium ) B. Endogenous Bacteria : B. cereus ( IV abusers), Streptococcus spp., S. aureus, Meningococci , H. influenzae Fungi : mucor , candida

6. Bacterial entry into eye Cascade of inflammatory products Inflammatory cell recruitment Tissue destruction Release of digestive enzymes by the cells & toxins by bacteria PATHOGENESIS

7. Post operative endophthalmitis Cataract surgery 0.08-0.7 % I ntravitreal injections P enetrating keratoplasty 0.11-0.18% Trabeculectomy and glaucoma drainage device implantation 0.2%–9.6% Pars Plana Vitrectomy 0.03-0.05%

8. Postoperative endophthalmitis

9. Acute Postoperative Endophthalmitis S hortly after ocular surgery /within 1-2wk , usually 3-5 days / Epidemiology : APE most common form of endophthalmitis Following cataract surgery 0.08% - 0.68% Rates increasing since clear corneal incisions Highest risk after 2ndary IOL (0.2-0.367%), Lowest risk after PPV (0.03-0.046%).

10. Acute endophthalmitis with hypopyon

11. Source of infection

12. Risk factors

13. Endophthalmitis Vitrectomy Study (EVS)

14. Symptoms

15. Clinical signs Decreased visual acuity Lids- edema Conjunctiva- congestion and chemosis Cornea edema, ring abscess( Pseudomonas and Bacillus ) Anterior chambercells and flare Hypopyon (in 86%patients in EVS)

16. Iris muddy and boggy Pupil-fibrinous exudate IOL-may be covered by fibrin Fundus- vitreous exudates, scattered retinal haemorrhages Periphlebitis loss of red reflex

17. Presenting Visual Acuity HM vs LP - Important Pars plana vitrectomy recommended in patients with visual acuity of light perception (LP). Hand motion (HM) or better, tap and inject intravitreal antibiotics  When measuring VA, the technique of differentiating LP vs. HM vision is most important

18. Differential Diagnosis of Acute Endophthalmitis Occult retention of lens cortex or nucleus Hypopyon uveitis ( Behcet’s or rifabutin ) Inflammatory reaction to intravitreal drug Blebitis Keratitis Toxic anterior segment syndrome (TASS )

19. Toxic anterior segment syndrome (TASS ) Sterile postoperative endophthalmitis Rapid onset ( 12-24 hours, limbus to limbus corneal edema) Noninfectious substance the enters AS Increased intraocular pressure Absent vitreous inflammation Iris damage Response to steroid

20. Diagnosis Clicinal signs, symptoms ,evaluation Ultrasound Microbiological testing Aqueous and Vitreous Specimen PCR

21. Ultrasound Should be performed if significant media opacification prevents adequate view of the fundus Findings c/w endophthalmitis : Dispersed vitreous opacities with vitritis Chorioretinal thickening Rule out: RD or choroidals , dislocated lens material, retained foreign bodies Retinal or choroidal detachment are poor prognostic factors

22. Aqueous tap (40% Gr +) An anterior chamber paracentesis is performed using a 25 or 27 gauge needle and 0.1 ml of aqeous material is aspirated .

23. Vitreous tap (60 % Gr +) A trans pars plana aspiration with a 23 gauge needle 3mm posterior to limbus in pseudophakic and aphakic eyes. 4mm posterior to limbus in phakic eyes 0.2 ml of vitreous aspirated .

24. Microbiological Characteristics (EVS)

25. Treatment goals Retention of useful vision Minimize the infection with antimicrobial agents. Limit the inflammation . Symptomatic relief.

26. Treatment PPV Intravitreal AB Systemic antibiotics Cotricosteroids Supportive treatment

27. Endophthalmitis Is there good reflex ? Yes No Initiate medical therapy and observe patient closely for the 1 st 24 hours Vitrectomy Is there improvement? Yes No Continue the medical therapy and close observation Treatment algorithm of CEVE for acute postoperative endohthalmitis

28. TREATMENT For VA that is "hand motions" or better: Tap and inject. First tap the eye for samples: Anterior chamber aqueous tap with 30g needle on a tuberculin syringe sent for cultures Vitreous sample obtained through the pars plana with a 25 gauge, 1 inch needle directed toward the mid-vitreous cavity and then sent for cultures Inject the vitreous cavity with antibiotics ( ie . Vancomycin and amikacin were used in the EVS. Ceftazidine is often used in clinical practice in the place of amikacin, primarily due to the risk of aminoglycoside toxicity with amikacin) For VA that is worse than "hand motions": Pars plana vitrectomy. Send aqueous and vitrectomy cultures taken during surgery. Inject intravitreal antibiotics at the time of surgery Follow cultures and adjust antibiotics accordingly, if necessary

29. The EVS Conducted between 1990 and January 1994, the EVS was a prospective, randomized, multicenter trial on 420 eyes to determine whether it is necessary in acute postoperative endophthalmitis to use systemic antibiotics or perform routine immediate vitrectomy

30. Materials and method 24 centers across the US 1990.02-1994.01 Patient selection Patients had clinical signs and symptoms of bacterial endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation.

31. Inclusion criteria ETDRS- VA=LP↑ or 20/50↓ Cornea, AC-clear Cornea clear to perform VIT Hypopyon or sufficient clouding of the AC or vitreous to obscure a view of second-order retinal arterioles. Exclusion criteria VA<0.2 before cataract Intraocular surgery Penetrating trauma Injection of IV AB Prior PPV RD, CD strong suspicion of fungal endophthalmitis 18 age ↓

32. Screened 1283 patients 855 patients /6wk-endoph diagnosed/ 510 met eligibilty criteria 420 agreed to participate

33. Study groups

34. Initial procedure ( Eyelid culture, 0.1ml AC sample ) VIT group 3 port pars plana VIT When necessary vizualization , AC was cleared TAP group Vitreous spicemen collected either PP vitreous needle aspiration or vitreous biopsy Vitreous sample 0.1-0.3mL

35. Study medication After initial VIT or TAP procedure all patients: intravitreal inj of amikacin 0.4mg/0.1ml, vancomycin 1.0mg/0.1ml Vanco 25mg/0.5ml+ ceftazidime 100mg/0.5ml+ dexa 6mg/0.25ml→subconj Topical AB 1d/4h Topical cycloplegics , corticosteroids Systemic CS ( prednisoloni 30mg*2→5-10days)

36. Results • Systemic antibiotics do not improve the outcome • Vitrectomy is indicated only in eyes with light perception vision . There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. HM ↑ - immediate VIT not influenced LP – VIT increase VA. a. Three times more likely to achieve ≥20/40 (33% vs 11%) b. Two times more likely to achieve ≥20/100 (56% vs 30%) c. Less likely to incur <5/200 (20% vs 47%)

37. Prevention Pre-operative Povidone iodine drops Topical AB Meticulous draping 2. Intra-operative Irrigation of A/C with vancomycin 3. P ost-operative Intra cameral cefuroxime Post op subconj AB injection Post op AB drops

38. Chronic Postoperative Endophthalmitis (> 6 weeks) Usually manifest several weeks or months after surgery Less common than acute variety Organisms isolated are less virulent bacteria and fungal

39. Chronic saccular endophthalmitis (Note whitish plaque)

40. SYMPTOMS- Photophobia Blurred vision Mild pain SIGNS- KPs in AC Vitreous flare and cells Capsular plaque(in Propionibacterium acnes endophthalmitis after Nd:Yagcapsulotomy ) Granuloma formation in the pupillaryarea or near the section(in fungalendophthalmitis )

41. DDx of postoperative endophthalmitis Noninfectious uveitis Retained lens material Triamcinolone acetonide particles Longstanding ( dehemoglobinized ) vitreous hemorrhage

42. Diagnosis Clinical diagnosis B scan (RD, SCH, retained lens fragment) Cultures (VS>AS) Commonly used cuture media 5% blood agar Chocolate agar Sabouraud agar Anaerobic blood agar

43. Treatment for Chronic Cases Obtain A/C and vitreous samples Identification of infectious organism is key in management of these infections Intravitreal antibiotics However, Vanco is often inadequate for P acnes Often need PPV and removal of capsule with IOL

44. Bleb related endophthalmitis Occurs as a result of pathogenic organisms gaining entry to intraocular tissue through the conjunctival filtering bleb Mean time b/w surgery and endophthalmitis is 19.1 months (range 3-9 years) 0.2 – 9.6% of glaucoma filtering procedures Increased incidence with use of antifibrotic agents Early PPV Thin , cystic, avascular conjunctiva Clinical signs infected W hite bleb Vitritis Hypopyon

45. Endophthalmitis after Intravitreal Injection Increasing use of these agents, therefore concern for risk of endophthalmitis Like acute postop endophthalmitis , CNS is the most common cause No infectious agent is identified in many cases Triamcinolone acetonide crystals can migrate into A/C and mimic hypopyon 1.4%/injection for IVK 0.2%/injection for ranibizumab Intravitreal triamcinolone may play a role in endophthalmitis potentiation

46. Non-infectious Endophthalmitis after Triamcinolone Injection or intravitreal anti-VEGF ( aflibercept ) Crystals in A/C or vitreous cavity can be difficult to distinguish from inflammatory reaction Use gravity-induced shifting of layered material and absence of A/C flare or fibrin as a sign of a non-inflammatory cause Triamcinolone crystals may shift from the inferior anterior chamber angle when the pt is placed on his or her side, a phenomenon that does not occur with sticky, fibrin-laden material in a true inflammatory hypopyon Management options Close observation, topical steroids alone, oral levofloxacin alone

47. Post traumatic endophthalmitis Approximately 25% of endophthalmitis cases After open globe injury, chance of developing endophthalmitis is approx 7% Injuries including IOFB have higher rates

48. Risk factors D irty wound L ens capsule rupture older age(>50) Initial presentation with a delay of more than 24 hours T he presence of intraocular foreign bodies. The incidence of endophthalmitis in cases of penetrating ocular trauma: 3.3% to 30% and after intraocular foreign body: 1.3% to 61%.

49. Managemant Primary repair and removal of IOFB as soon as possible Exclude the possibility of occult, retained IOFB CT scan with thin 1mm cuts Obtain cultures Intravitreal Vanco and Ceftaz Some advocate Gent + Clinda for synergistic effect against Bacillus and Staph Post-traumatic endophthalmitis has worst visual prognosis than other categories

50. Endogenous endophthalmitis (2-8%) Hematogenous spread of organism from distant source It occurs when microorganisms in the bloodstream get into the eye , cross the blood–retinal barrier, and infect the ocular tissue . Retina and choroid primarily involved due to high vascularity. Predisposing factors Diabetes - immunosuppresion ( AIDS,malignancies medications) recent major abdominal surgery – prolong indwelling catheter ( intravenous , TPN) intravenous drug abuser distant infection ( endocarditis, meningitis, septicemia etc ) no structural defect in globe

51. Management of Endogenous Endophthalmitis Cultures are essential and may be lifesaving Vitreous sample should be obtained in all cases ID of causatic organism is made by systemic culture of blood, urine or CSF in 75-80% of cases In contrast to postoperative endophthalmitis , systemic antibiotics are central to the treatment of endogenous endophthalmitis Focal chorioretinitis and associated mild vitritis can respond to systemic therapy alone

52. Symptoms Decreased or blurred vision ( sudden / severe – acute) ( slowly / mild—chronic) Pain Photophobia Redness of eyes Swollen eyelids Discharge White lesion in black part of the eye Floaters Fever

53. Fungal endophthalmitis Chronic infection (Rarely acute) Late onset (Redness + floaters) Fixed cheesy hypopyon Fibrinous mesh like exudation Snowball and fluffy opacities in the vitreous

54. Candidal endophthalmitis The two most characteristic 1. creamy white, well circumscribed chorioretinal lesions , most common in the posterior pole 2. yellow or white fluffy vitreous opacities. “ string of pearls”

55. Aspergillus endophthalmitis Most patients with endogenous Aspergillus Acute or subacute ocular symptoms. AS inflammatory signs: AC cells , KPs, hypopyon In most cases the organism initially affects the posterior segment , forming a yellowish macular infiltrate . It frequently involves the macula, and this probably accounts for the rapid onset of visual loss in many cases.

56. A frequent clinical feature is the pseudohypopyon in either the preretinal ( subhyaloid ) or subretinalspace . V itritis Other features include occlusive vasculitis and retinal hemorrhages. After treatment the area of chorioretinitis progresses to formation of a subretinal scar. T he visual outcome is generally poor