EyeWorld Asia-Pacific March 2015 Issue

19 March 2015 EWAP FEATURE Views from Asia-Paci c: Management & Treatment of Endophthalmitis Kenneth FONG, MA, MBBChir (Cambridge), FRCOphth (UK), FRANZCO (Aust), AM (Mal) Consultant Ophthalmologist and Vitreoretinal Surgeon, Sunway Medical Centre 46150 Petaling Jaya, Malaysia Tel: + 603 74916585 Web: eyeretina.my W hile endophthalmitis is rare after uncomplicated phacoemulsi cation cataract surgery (average reported rate 0.1%), it can be devastating to the vision of the patient. It is essential to do everything possible to prevent this from occurring. My approach in prevention is to manage it from a preoperative, intraoperative, and postoperative perspective. Preoperative High risk cases of infection should be identi ed and managed accordingly. These include: 1. Immunocompromised patients (e.g., those with poorly controlled diabetes, patients on immunosuppresants) 2. Autoimmune diseases (e.g., rheumatoid arthritis, severe eczema) 3. Mentally challenged patients (e.g., Down’s syndrome) 4. Severe lid margin disease or active eye infection 5. Patients who are unable to care for themselves (e.g., physically disabled, frail and elderly) Surgery should not be done until their speci c medical conditions are optimized and a clear postoperative regimen has been discussed with the patient’s carers. Intraoperative Cleaning the eyelashes, conjunctiva, and surrounding eye area with povidone iodine remains the most effective way in prevention of endophthalmitis. The eyelashes should be isolated from the surgical eld with an adhesive plastic eye drape and speculum. Creation of the main corneal incision is very important. I use a 2.6-mm keratome and make a square-shaped two-plane incision. The length of the corneal would is approximately the same as the width of the wound and this longer corneal wound allows better sealing after surgery. At the end of an uncomplicated cataract operation, I hydrate the main wound and side ports and inject 0.1 ml of moxi oxacin into the anterior chamber via one of the side ports. The antibiotic is drawn directly from a new bottle in the operating theater. The same bottle is then given to the patient to be used postoperatively. I do not use cefuroxime or vancomycin intracamerally as it requires prior compounding and dilution. 1 I do not want to risk giving the wrong dose of antibiotic into the eye and causing retinal toxicity and corneal damage. I would recommend putting a suture on the main corneal wound in higher risk cases like vitrectomized and highly myopic eyes and for patients who may rub their eyes after surgery (e.g., in cases of eczema, Down’s syndrome). Postoperative My usual postoperative topical eye drops regimen is moxi oxacin and 1% predinoslone acetate every 3 hours to the eye when the patient is awake. No drops are used while sleeping. I do not routinely give systemic antibiotics postoperatively. A clear plastic eye shield is to be worn over the eye when sleeping for 1 week. The patient is discouraged from rubbing the eye and told not to splash water into the operated eye for at least 2 days. Treatment of postoperative endophthalmitis 2 Acute postoperative endophthalmitis usually occurs within 48 hours after surgery and it is very obvious to diagnose with a triad of hypopyon, pain, and blurring of vision. I immediately perform a “tap and inject” for the patient in the clinic regardless of the visual acuity. I take 0.1 ml of vitreous uid and 0.1 ml of aqueous for culture and sensitivity of organisms. This is then followed by intravitreal injection of 0.1 ml vancomycin (1 mg/0.1 ml) and 0.1 ml ceftazidime (2.25 mg/0.1 ml). These antibiotics have to be prepared from powder form and care should be taken to prevent dilution errors. I would also start the patient on oral moxifoxacin 400 mg once a day for 5 days. This 4th generation uoroquinlone has been shown to have superior systemic penetration to the eye. 3 I do not use intravitreal or systemic steroids. The decision to perform pars plana vitrectomy depends very much on the visual acuity of the patient. If the patient has visual acuity better than HM vision, I would normally wait for 48 hours and see if the antibiotic injection has improved the vision and hypopyon. If the patients vision is worse than HM vision at initial presentation or does not improve after 48 hours of intravitreal antibiotics, I would perform sutureless 23-gauge pars plana vitrectomy (PPV), anterior chamber washout, and intravitreal vancomycin and ceftazidime injection. I avoid removing the IOL during the initial surgery. I would consider removing the IOL if the infection recurs after vitrectomy surgery. Performing vitrectomy surgery on such cases is often very dif cult as the eyes are very in ammed and the cornea is often cloudy. I try to induce a posterior vitreous detachment to remove as much vitreous as possible all the way to the pars plana area. There is a high risk of retinal detachment due to the in ammation which can cause vitreous traction and retina tear. Modern vitrectomy techniques using sutureless trocars have reduced the risk of vitreous traction and retinal detachment. The Endophthalmitis Vitrectomy Study has had a signi cant effect on the management of patients with acute-onset endophthalmitis after cataract surgery. Treatment of such patients generally follows EVS guidelines and most are now treated in the clinic with vitreous tap and intravitreal antibiotics rather than in the operating room with PPV, and most are managed as outpatients without the need for hospitalization and without intravenous administration of antibiotics. 4 The visual outcomes after treatment of endophthalmitis is not good with only about 50% of eyes achieving better than 20/40 vision. 5 Hence, prevention of endophthalmitis must be our priority when performing cataract surgery. References 1. O’Brien TP, Arshinoff SA, Mah FS. Perspectives on antibiotics for postoperative endophthalmitis prophylaxis: potential role of moxi oxacin. J Cataract Refract Surg. 2007 Oct;33(10):1790-800. 2. Vaziri K, Schwartz SG, Kishor K, Flynn HW. Endophthalmitis: State of the art. Clin Ophthalmol . 2015;9:95–108. 3. Kampougeris G, Antoniadou A, Kavouklis E, Chryssouli Z, Giamarellou H. Penetration of moxi oxacin into the human aqueous humour after oral administration. Br J Ophthalmol . 2005 May;89(5):628–631. 4. Endophthalmitis Vitrectomy Study Group; Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol . 1995;113;1479-1496. 5. Wong TY, Chee SP. The epidemiology of acute endophthalmitis after cataract surgery in an Asian population. Ophthalmology . 2004;111(4):699-705. Editors’ note: Dr. Fong has no nancial interests related to his comments