ENDOPHTHALMITIS

Endophthalmitis

Intraocular inflammation predominantly

involving the vitreous cavity and A/C, as a
result of intraocular colonization by
microrganisms.
Pathophysiology
Ocular infection with infectious bacterial load /with
impairment of immune privilege of the eye ,leads to
intense destructive inflammatory reaction .

( Bact. Toxins ,proteases + intense host inflammatory

response ---------- injury.

Intense inflammatory response ----- negative

microbiological studies .
Classification
1) Endogenous : bacterial / fungal / parasite.

2) Exogenous :
a) postoperative.
b) post traumatic .
c) Bleb associated .
d) miscellaneous ; e.g. microbial keratitis ,scleritis
(infectious)
Incidence
*Post cataract 0.07 – 0.5 %.
*post PKP 0.11%.
*post PPV 0.05 %.
*Bleb related 0.2 – 9.6 %.
*traumatic 2.4 – 8.0 % , up to 40% in rural areas with
IOFB.
Signs and symptoms
*Decrease VA.
*pain.
*A/C reaction +/- hypopyon.
*Vitritis .
*others: lid swelling , discharge ,
C.edema, chemosis.
D.Dx
*TASS.
*Complicated , prolong surgery .
*Preexisting uveitis .
*Retained lens material.
*Associated ocular injury .

NB : presence of significant vitritis =

infectious Endoph. Till proven otherwise .
Microbial
Post cataract :
spectrum
CNS 33-77%
S. aureus 10-21%
Streptococci 9-19%
Gram negatif, fungi 6-22%
Delayed onset (chronic) post cataract:
Prop. acne ,corynebacteria,fungi.
Post glaucoma Sx:
CNS 67% early
Streptococci, H. influenzae.
Cont.
Post traumatik :
CNS 16 – 44 %
Bacillus 17 – 32%
Gram negatif 10 -18%
Streptococci 8 – 21%
Fungi 4 – 14 %
Source of infection
*Mainly eye lids and conjunctiva.

*Other sources : e.g.

- Lacrimal drainage system
- Blephritis
- Infected socket in contralateral
posthetic eye
Risk factors for Endoph. Post cataract
surgery
*Disruption of the integrity of the barrier
between A/S and P/S ( post. Caps.tear,zonular
dialysis,vitreous loss).

*clear corneal incision > scleral tunnel.

*wound leakage in the first day post op.

*Silicon IOL > PMMA.

Prophylaxis
*Antiseptics:
5% povidone – iodine for at least 3 minutes is the most
important prophylaxis in many studies;
decreasing conjunctiva +periorbital skin flora .

*Single use instruments is always preferable esp. tubes.

Antibiotics
Topical antibiotics
4th generation fluoroquinolones appears to be very
effective in reducing conj. flora load , achieving high
concentrations in the in the A/C.

But no controlled clinical trial prove their effect in

reducing incidence of Endoph.
Antibiotics
Systemic antibiotics
preopertive or post op has not proven to be of benefit
against post op Endoph.

In penetrating ocular trauma systemic +/- intravitreal

Abx shown to have some protective effects ; two recent
studies.
Antibiotics
 Adding antibiotics to irrigation solution
there was a debate about there use but there is no
study based evidence showing reduction of Endoph.

Also , risk of endoth. Toxicity not studied .

Antibiotics
Injection of intracameral 1mg/0.1ml of
cefuroxime (3000ug/ml @ a/c ) at the
end of surgery:
It has bee shown the risk of Endoph. with this regimen
reduced by almost 5 folds (ESCRS ) study

NB: cefuroxime resist.

MRSA,MRSE,Ent.faecalis,pseud.aur.
Antibiotics
Subconjunctival antibiotics:

It is very common practice to inject Abx subconj. at

conclusion of surgery.

*Gentamycin is not effective against Strept.

Species ,prop.acne.
*Subconj.cefuroxime --- 20ug/ml in A/C much lower
than intracameral.
*till now no proven evidence of it’s help.
Antibiotics
*post op. antibiotics use :
Recommended to use post op Abx of same type
used preop esp. quinolones for 1 - 2 weeks until
the wound is secured ; but this also not proven
to be effective but it is not harmful.

NB they recommendation to start them in the

first day very frequent (Q2hrs) for one day then
QID to decrease A/C contamination load.
Diagnosis
*It is mainly clinical.
*Delay in diagnosis is not uncommon (steroids
,complications ,expected post op inflam.).
*B-scan is an aid , but some times it is misleading .
*if doubt, be safe and consider it as Endoph.,
no body is blaming of over protection but missing
serious irreversibly damaging pathology is this the
situation.
Management of acute post op
Endophthalmitis
*It is a real ophthalmic emergency.
*controversies in management :

Vitreous tap + A/C sampling + intravitreal

Abx&steroids---- in cases VA >=HM (EVS)
VS
Primary Vitrectomy +intravitreal Abx&steroids in all
cases (ESCRS).
Management
ESCRS recommend Primary Vitrectomy +intravitreal
Abx&steroids as a gold standard of care :

To: decrease bacterial load, pus, remove most of the

inflammatory destructing cells and mediators ,
removing the scaffold (vitreous)
Mx
EVS recommends :
a) Vitreous tap + A/C sampling + intravitreal
Abx&steroids---- in cases VA >=HM.

b) Vitrectomy +intravitreal antibiotics &steroids in

cases VA < HM.
* Inravitreal antibiotics can be
repeated every 48 hours
according to the response
Adjunctive measures
According to EVS systemic Abx do not appear to have
any effect on the course and the outcome of
endophthaalmitis.

But : they use ( amikacin + ceftazidime )

systemically ; and ( vancomycin +ceftazidime )
intravitrealy.
They don’t use same Abx , they don’t take in
consideration of G +ve to be the most common to
be covered.
Cont. Adjunctive measures
*As mentioned earlier , the destructive agent in Endoph.
Is the intense inflammatory response + the bacterial
toxins .

*Systemic (oral) steroids is recommended, studies does

not shown any negative effect on the infection course
in cases of bacterial endophthalmitis .
*also , topical steroids has same principle.
Chronic (delayed onset) post operative
endophhalmitis
It is very commonly misdiagnosed as uveitis or
post op. inflammation .

Problems:
a)High rate of recurrence.

b)Difficulty in culturing the organism(mostly prop.

Acne) because it is enclosed in the synechised
capsular bag.
Dx &Mx
*If clinical diagnosis suspected :
1st step:
start systemic Clarithromycin 250mg po BD for 2/52
( it is concentrated 200 X more in macrophages,PMN
containing intracellular bacteria as prop.acne )

If improvement is successful keep close F/U

2nd step :
If no improvement in step one, consider PPV +
intravitreal Abx ( vancomycin +cefazoline ) + posterior
capsulotomy .

3rd step:
If no mprovements in step 2 remove IOL +surrounding
bag .
Outcomes of treatment
*in general more virulent organisms as : staph
aureus,strept, bacillus sp,pseud. Carry the worst
visual outcomes.

*low virulent organisms as ( CNS, P acne ) carry better

visual outcomes .
Cont.

Chronic endoph. Carries a favorable

visual prognosis , one study showed
final VA >=20/40 in 80% of cases .
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