Endophthalmitis. Experts Corner

Transcription

1 Endophthalmitis Seenu M. Hariprasad Endophthalmitis is one of the most devastating complications after cataract surgery. Post traumatic endophthalmitis and endogenous endophthalmitis have more devastating prognosis. The management protocol for post cataract surgery endophthalmitis was given by endophthalmitis vitrectomy study almost a decade back. Although the recommendations are still followed but with the advent of modern vitrectomy machines and newer antibiotics there has been a paradigm shift in the management of endophthalmitis. The management of posttraumatic, chronic endophthalmitis or endogenous endophthalmitis differs from the management of post cataract surgery endophthalmitis. With proper awareness, early diagnosis and treatment of endophthalmitis the prognosis can be improved manifolds. The questions have been prepared by Dr. Sangeeta Roy (SR) Senior Resident Vitreo Retina Service, from R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi Atul Kumar Dr. Seenu M. Hariprasad (SMH): MD, Associate Professor and Director of Clinical Research Chief, Vitreoretinal Service, University of Chicago Department of Surgery, Section of Ophthalmology and Visual Science Dr. Atul Kumar (AK): MD, Professor Retina Services, R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi. Dr. S. Natarajan (SN): DO, MS, FRVS, MABMS, MORCE, FABMS, Chairman and Managing Director, Aditya Jyot Eye Hospital Pvt. Ltd., Major Parmeshwaran Road, Wadala (West), Mumbai, Maharashtra. Dr. Lalit Verma (LV): MD, Consultant, Centre For Sight, Safdarjung Enclave, New Delhi Dr. Cyrus M. Shroff (CMS): MD, Consultant, Shroff Eye Centre, Kailash Colony, New Delhi S. Natarajan SR: What is the incidence of postoperative endophthalmitis in your centre? What is the incidence of endophthalmitis due to other etiologies? SMH: Incredibly low under 2 cases per year from cataract surgery may be another 2 per year from trauma or endogenous cases. AK: The incidence of postoperative endophthalmitis from our Centre is less than 0.5%. The most common cause of endophthalmitis other than post cataract surgery endophthalmitis is of post traumatic etiology. SN: 0.02% to 0.03% LV: It is very rare. We get more referred patients than in-house patients. In last 8 months had 2 cases: one after silicone oil removal and one after corneal surgery. Other etiologies are: Post Traumatic endophthalmitis. Haven t seen Endogenous Endophthalmitis at CFS for over 5 years. CMS: Incidence of endophthalmitis in our institutions has been around 0.05%. Being referral centre, a total of 154 patients of endophthalmitis have been treated at the hospital from Lalit Verma Cyrus M. Shroff www. dosonline.org l 11

2 2008 to date. Of these 132 (86%) were postoperative, 18 (12%) were post traumatic and 4 (2%) were endogenous. SR: What are the common organisms found in microbiological investigation in the cases of endophthalmitis in your centre? SMH: Staph epidermidis is most common. AK: According to our unpublished data, we found Staphylococcus epidermidis as the most common organism isolated followed by Pseudomonas species, Acinetobacter, anaerobic spore forming bacteria and Staphylococcus aureus. Among fungal agents Aspergillus species was most common followed by demetacious fungi. In cases of post traumatic endophthalmitis anaerobic Gram negative organisms, Bacillus sp and fungus have been found more commonly. Post traumatic cases can also have a mixed microbial infection. In cases of metastatic endophthalmitis many times we don t find any organisms because of the systemic treatment that the patients already received before being referred to the Centre. SN: Coagulase negative staphalococcus LV: Despite sending Vitreous biopsies / Frank Pus Culture reports are rarely positive Something to do with quality of microbiological labs? Reported include Klebsiella in 1 case; Staph aures in 1 case. CMS: In a series of 132 patients of post operative endophthalmitis, 48 were culture positive, of which 20 were fungal [Aspergillus (8) Fusarium (1)], 14 were Pseudomonas aeruginosa, 13 were Staph aureus, 5 were Streptococcus pneumoniae, 3 were nocardia, 1 was Streptococcus viridians,1 was bacillus and 1 was Klebsiella. The spectrum in post traumatic endophthalmitis was streptococcus -3, Pseudomonas -2, Staph aureus -2, Fusarium-1 and Fungal-1. SR: What is the role of a microbiological investigation set up in the management of endophthalmitis? How does microbiological investigation alter your management in a case of endophthalmitis? SMH: This is a very interesting question in my career the microbiological investigation has never changed my initial management or choice of injected or oral antibiotics in suspected endophthalmitis. It may, rarely, change the course of management after initial intervention. AK: The most important role of microbiological investigations is to confirm the infective cause and to identify the causative organisms. It has been seen the chances of isolating the organisms from the vitreous samples is around 60% to 70%. Although we use a broad spectrum antibiotic for intravitreal antibiotics but still antibiotic sensitivity testing could play an important role in non responding cases. In the present era of modern vitrectomy surgery we can directly go ahead with pars plana vitrectomy in non responding cases. SN: Initially we start with the broad spectrum antibiotics (FQ s) after sending relevant sample for microbiological stain and culture sensitivity. We modify and titrate treatment according to the microbiological reports. LV: Initial management of Post - Operative Endophthalmitis is standard and is not altered / Infact since it is a matter of emergency we give a combination of Vancomycin + Ceftazidime. However samples for Microbiological testing are sent in all cases They are important a) from Medico-Legal point of view and b) in cases which do not respond Lab tests may reveal different organism with different sensitivity or may sometimes show growth of Fungus (not rare in our country). CMS: Broad spectrum coverage is first line of treatment in all cases of acute endophthalmitis. Microbial investigation has a definite role in further management especially in patients who show a poor response or worsen on treatment. Microbial investigation determines the postoperative topical antibiotics and if intravitreal antibiotics have to be repeated. Microbial investigation has a definitive role in Chronic endophthalmitis. PCR with its ability to detect minute quantities of bacterial DNA is a useful test in Chronic endophthalmitis as infection is often localized and the load of bacteria small. SR: In the modern era of vitreoretinal surgeries do you strictly follow the recommendations of endophthalmitis vitrectomy study? SMH: No not precisely we intervene with vitrectomy sooner to debulk the toxins in the posterior segment of the eye. AK: Endophthalmitis Vitrectomy Study is the largest multi centric trial done for the management of postoperative endophthalmitis the conclusions and recommendations of which are still followed in this era of modern vitrectomy surgery. Although these are not followed in cases of posttraumatic endophthalmitis where we are less conservative and err more towards early pars plana vitrectomy. Yes I do keep in my mind the recommendations given by EVS, however, with improved surgical instrumentation and newer antibiotics my management differs from case to case. SN: We follow the guidelines of EVS, but still we prefer to give systemic antibiotics in our centre. LV: Not Really. All Patients irrespective of presenting Visual Acuity receive Intravitreal Antibiotic Injection. 12 l DOS Times - Vol. 19, No. 9 March, 2014

3 Threshold for doing Vitrectomy is low if cornea is clear enough. Prefer doing a Complete Vitrectomy with Base dissection and peeling of Posterior Hyaloid. Post- Operatively Most patients receive Oral Fluoroquinlones. Oral Steroids are added in tapering doses 24 hours after initial procedure. CMS: EVS guidelines still form a broad outline for management of endophthalmitis cases. Vitrectomy is often done earlier. If cornea is not a limiting factor, patients are taken up for vitrectomy if optic nerve and first order vessels are not visualized. SR: Do you prefer to give intravenous antibiotics in a case of endophthalmitis? SMH: We have published extensively on this topic. We prescribe oral moxifloxacin as the penetration of this antibiotic is essentially the same as intravenous and the spectrum of activity is appropriate for the organisms that we are most concerned about in postoperative endophthalmitis. AK: As per the Endophthalmitis Vitrectomy Study, there is not much role of intravenous antibiotics in cases of post cataract surgery endophthalmitis as the penetration of these antibiotics in the vitreous cavity is less even with a compromised blood retinal barrier. But in the present era we can use the 3rd and 4th generations Cephalosporins which have better penetration in an inflamed eye and MIC can be attained in the vitreous cavity with these antibiotics. Intravenous antibiotics also play a primary role in endogenous endophthalmitis to tackle the systemic nidus of infection. SN: Yes. LV: Generally Not. Do give high doses of Oral Fluoroquinolones which have been shown to penetrate Vitreous Cavity. In a sick patient prefer Intravenous Antibiotics in a hospital set up, under physician care. CMS: Intravenous antibiotics may have an adjunctive role in management of endogenous endophthalmitis. Its role in acute postoperative endophthalmitis is limited to special situations if patient has a focus of infection elsewhere or if a patient is developing panophthalmitis. SR: When do you prefer to start oral and topical steroids in a case of bacterial endophthalmitis? SMH: Not before at least 3 days of antibiotic therapy. Sometimes i don t use steroid. Data is divided regarding the benefit of steroid in the management of endophthalmitis. Clinical judgment critical here. AK: In cases of postoperative bacterial endophthalmitis oral and topical steroids can be started only after taking care of the infection with intravitreal antibiotics. It helps in resolving the inflammatory component. Steroids in any form should never be started if there is any suspicion of fungal endophthalmitis. SN: Soon after surgery and after ruling out fungal element. LV: Tapering doses of Oral Steroids (starting with 1 mg/kg) are added 24 hours after the initial intervention (whether Intravitreal Antibiotics or Vitrectomy). Topical Steriods (every 2 hours) are also added after 24hours of treatment with concentrated topical antibiotics (Cefazoline and Tobramycin given half hourly alternatively, round the clock) + Moxifloxacillin eye drops every 2 hours + Cycloplegics 4 times a day. Aim is to Initially load the patient with Antibiotics from all routes and soon start Anti- inflammatory steroids to minimise damage to Optic Nerve and Macula. CMS: In acute bacterial endophthalmitis we prefer to start oral and topical steroids after first line of treatment has been given which may either be intravitreal antibiotics or vitrectomy. Care is taken to rule out any focus of infection in the cornea before initiating topical steroid drops. SR: How do you manage a case of chronic late onset endopthalmitis? How do you prefer to manage a case of P.acne endophthalmitis? SMH: Vitreous tap and intravitreal injection of vancomycin and ceftazadime would also use oral moxifloxacin. a) Vitreous tap and intravitreal injection of vancomycin and ceftazadime would also use oral moxifloxacin b) Open posterior capsule with YAG capsulotmy c) Perform vitrectomy and open posterior capsule and injection of intravitreal antibiotics. d) IOL explants. AK: Chronic endophthalmitis patients should be examined carefully to pick up the subtle signs of endophthalmitis. The patients are usually asymptomatic and they undergo a relapsing and remitting course along with history of use of steroids. The patients should be asked for any history of YAG capsulotomy. The eye should be examined for any posterior capsular plaque, iris nodules, fungal balls in the posterior chamber.in cases of suspicion vitreous biopsy should be taken and sent for microbiological investigations. Prompt vitrectomy should be done in cases of fungal endophthalmitis. In cases of P. Acnes endophthalmitis, vancomycin wash should be given in the bag along with intravitreal antibiotics in early cases. In advanced cases IOL explant only, or IOL explant with pars plana vitrectomy can be done. www. dosonline.org l 13

4 SN: Adequate clinical judgement, we rule out cause for late onset with fungal or P.acne element. T/T for P.acne- Intra bag Vancomycin. If not controlled PPV +Complete removal of capsular bag with IOL +IOAB. LV: Most of these patients give history of been treated as Uveitis with some giving history of temporary relief with steroids and cycloplegics but again recurs. If patient has not received in-the bag Injection of Antibiotics prefer to give In-the-bag Vancomycin and observe for 1-2 weeks. If response is inadequate do a Vitrectomy with IOL removal. Later when the eye quietens and BCVA is good advise for a Glued IOL for visual rehabilitation. CMS: Chronic endophthalmitis usually presents as a chronic, insidious and recurrent granulomatous iridocyclitis, that initially responds to topical steroids and relapses when steroids are tapered. We prefer to do an AC tap with intravitreal antibiotics/ antifungal in these cases, sample is sent for PCR. If initial clinical presentation is suspicious of P acnes (whitish plaque on the post capsule) we would give intracameral vancomycin with intravitreal vancomycin, ceftazidime and decadron at time of AC tap. If diagnosis is made after microbial investigation patient is taken up for irrigation of capsular bag with vancomycin and intravitreal antibiotics. Often patients do not respond to the injections and patient is then taken up for a complete vitrectomy with IOL removal and intravitreal antibiotics. We find that most of these patients do not really settle down unless IOL is removed. SR: Do you prefer to do a primary vitrectomy in a case of fungal endophthalmitis? SMH: No, not always. Many of these cases can be treated with oral, topical, or intravitreal voriconazole. AK: Yes, in cases of fungal endophthalmitis early primary pars plana vitrectomy should be considered as the infection is more destructive to the ocular structure and its very difficult to contain the infection with the help of available antifungal drugs. SN: No. LV: Yes Severe Fungal Endophthalmitis (Fusarium / Aspergillus) responds best to Primary Vitrectomy. Few patients of Mild Infection have shown good response to Intravitreal Voriconazole + Oral Voriconazole. CMS: Vitrectomy is often first line of treatment in a case of fungal endophthalmitis. But if disc and first order vessels are seen we prefer a trial of intravitreal antifungal agents along with systemic antifungals based on microbial investigation. SR: What is the prognosis of paediatric endophthalmitis? What do you recommend to improve the prognosis in a case of paediatric endophthalmitis? SMH: No comment AK: The prognosis of paediatric endophthalmitis is usually poor as usually the cause of endophthalmitis in children is posttraumatic in origin. The causative organisms in posttraumatic endophtahlmitis is Gram negative anaerobic organisms and fungus, which are more virulent than the organisms responsible for post cataract surgery endophthalmitis. The children are more prone to develop different complications after vitrectomy like band shaped keratopathy or retinal detachment due to membrane formation. Because of the more virulent kind of infection in pediatric age group a prompt pars plana vitretomy should be done rather than conservative management. SN: Prognosis is not good as most of the cases are post trauma. Thorough evaluation and exploration, adequate microbial agents. LV: Early detection is the key. Paediatric Endophthalmitis generally presents late by which time Salvage Vitrectomy is the only answer. Here again complete Vitrectomy with base dissection and peeling of hyaloid is important so as not to leave any nidus of infection. CMS: Paediatric Endophthalmitis is usually post traumatic or endogenous. Primary Vitrectomy usually with lensectomy and silicon oil tamponade is the management of choice. Further intervention may be required as hyaloid separation is often difficult at time of primary vitrectomy. Early intervention is especially important in case of pediatric endophthalmitis. SR: What gauge of surgery do you prefer for pars plana vitrectomy in eyes with endophthalmitis? SMH: 23G. AK: In the present era micro incisional vitreous surgery (23 gauge) is preferred over 20 gauge surgery, the bore of the vitrector is wide enough to aspirate exudates. SN: 23G. LV: Now I do all cases with 23 G. Only if large IOFB has to be removed enlarge one port (HybridVitrectomy). CMS: 23gauge vitrectomy is usually the preferred 14 l DOS Times - Vol. 19, No. 9 March, 2014

5 gauge. We often prefer a straight entry for infusion taking into account the possibility of choroidals. If choroidals are extensive a 20 gauge 6mm infusion cannula is used. Superior sclerotomies could be 23 gauge- (hybrid surgery) or 20 gauge. We prefer to suture the sclerotomies at the end of surgery in endophthalmitis (makes it safer to give subconj antibiotics if reqd in postop period). SR: What do think about induction of posterior vitreous detachment in the present era of new generation vitrectomy machines? What should be the extent of peripheral vitrectomy with a duty cycle controlled system? SMH: No comment. AK: According to the recommendations of EVS, PVD should not be induced in cases of pars plana vitrectomy for endophthalmitis and only core vitrectomy should be done to avoid formation of breaks in a necrotic retina. Even in the present era with the modern vitrectomy system we should not attempt to induce the PVD to avoid break formation in the retina. Though peripheral vitrectomy can be performed with the help of duty cycle controlled systems which causes minimal traction over the retina. SN: Chances of break are more due to inflammation and poor visibility, we prefer core vitrectomy. LV: With New generation Vitrectomy machines which offer better fluidics, IOP control and port optimisation Induction of PVD is not as difficult. As said earlier, Vitrectomy has to be complete in all cases with base dissection and PVD induction. CMS: PVD induction and complete base excision is not aimed for in vitrectomy for acute endophtalmitis as the retina is edematous and friable. Aim is to debulk as much of vitreous as possible safely and to give intravitreal antibiotics. However in chronic endophthalmitis we often try and remove the post hyaloid and do a complete peripheral vitrectomy. SR: Which tamponading agent do you prefer after pars plana vitrectomy in a case of postoperative endophthalmitis? SMH: No comment. AK: It is better to use silicone oil as a tamponading agent. Silicone oil is also supposed to have antibacterial effect as seen in the study done by Azad et al in the centre. (Graefes Arch ClinExp Ophthalmol 2003;241:478-83) SN: We prefer Air/Gas in cases with no retinal detachment cases and Silicone oil in retinal detachment cases. LV: Generally I use Silicone Oil ( Cs). Advantage of using Silicone Oil: Oil is impervious to any microorganism; Anterior Segment Inflammation/ Infection (after a complete Vitrectomy) can be managed with concentrated Antibiotics as used by our Cornea colleagues; Any Inflammation/ Infection between the Silcone oil and Retina can be treated with high doses of Oral / Intravenous Antibiotics. Other advantage of using Silicone Oil is It provides clearer media in early post-op period (may be important in one-eyed) Also, if required laser can be done in early post-op period. Only disadvantage of using Silicone Oil is it requires another surgery. CMS: If tamponade is required, silicon oil would be tamponading agent of choice. SR: How do you prefer to manage a case of endogenous endophthalmitis? SMH: Find systemic cause and treat systemically. May also need intravitreal injection of vancomycin and ceftazidime. Would also use oral moxifloxacin in severe cases AK: Endogenous endophthalmitis cases at our centre are admitted for full work up which includes good history regarding previous illness, any surgical intervention or hospitalisation and comorbidities including diabetes. The immune status of the patient should also be assessed These patients then undergo Routine Haemogram, renal function tests, Blood culture, Chest X ray and USG abdomen as a routine to look for any infective focus. If we can find any organ specific complaint or infective focus, culture from the site is preferred. However, 40-50% patients have no ocular history and systemic work up is negative. Thus intraocular cultures (aqueous, vitreous or both) are performed in all cases before starting empirical treatment. At this time I often inject intravitreal antibiotics, antifungal, however are injected only when there is confirmed smear or culture positivity for fungal infection. I start patients on systemic broad spectrum antibiotics (Ceftriaxone and Vancomycin) after the initial tap and see for response on twice daily monitoring till culture reports are awaited. If culture comes positive treatment is given depending on sensitivity. I go for pars plana vitrectomy if there is no response to systemic therapy or if it continues to worsen. SN: Thorough history, clinical examination and systemic evaluation to find the focus of infection and treat the cause. LV: Admit the patient under overall supervision of Physician. www. dosonline.org l 15

6 Send Blood Cultures. Try to identify the source of Infection in consultation with Physician. Start Intravenous Antibiotics If poor response in 3-5 days discuss with Patient and Family and advise Vitrectomy have to minimise the toxic effects of Infection/ Inflammation on Optic Nerve and Macula. CMS: A thorough history and systemic evaluation is mandatory in a case of endogenous endophthalmitis. Visual prognosis is usually very poor and early diagnosis and prompt management helps in improving the results. Systemic intravenous antibiotics and if indicated antifungal should be started at the earliest. SR: What do you think about the role of primary pars plana vitrectomy in endogenous endophthalmitis? SMH: Consider in case by case basis. No hard and fast rule applies to all cases. AK: PPV is often required in these cases and should be decided early in case of no response to systemic therapy. Prognosis in these cases is however guarded no matter what you do except in stage 1 or 2 of the disease. SN: Yes, vitrectomy is done to decrease the bulk organisms and exudates. LV: Role is increasing with the availability of high end machines. Threshold for Vitreous Surgery has decreased with the safety features of modern small gauge MIVS. CMS: Unlike postoperative endophthalmitis there is no role of AC tap to determine the causative organism. Therapeutic Vitrectomy is required to obtain a sample for microbial investigation. It is advisable to send the sample for PCR besides the routine microbiology testing. We usually prefer doing a complete Vitrectomy with Silicon oil tamponade as first line of treatment. SR: What are your recommendations for the new generation of budding vitreoretinal surgeons in view of management of endophthalmitis? SMH: Early diagnosis and aggressive rapid intervention yields best outcomes. AK: The young ophthalmologists should be well versed with the early signs and symptoms of endophthalmitis so that they can diagnose a case of endophthalmitis early and start the treatment. They should be conversant and more aggressive in starting the treatment like intravitreal antibiotics. All the young vitreoretinal surgeons should learn basic steps of pars plana vitrectomy. They should also learn the art to counsel the patients about the prognosis of such patients and proper consent be taken for any such kind of invasive procedure. SN: As a V-R surgeon, handling cases of endophthalmitis becomes our primary responsibility. I recommend that proper history taking, accurate clinical judgement, use of newer investigation and diagnostic modalities and need of prompt and correct treatment should be given. The importance of counselling should not be forgotten. LV: Have high Index of suspicion in patients who have more than expected reaction. Diagnose Early. First Line of management is Intravitreal Antibiotics. Give them early even on a holiday. Do not keep repeating Intravitreal Antibiotics. Involve your seniors and hospital authorities to save yourself from litigation issues. Have low threshold for Vitreous Surgery. Do complete Vitrectomy. CMS: Face the situation head on. Consider the condition infective unless proved otherwise. Initiate treatment early and do not take half-hearted measures. Use adequate anesthesia. Topical is not a good idea in these inflamed eyes. Give a block or adequate sedation. Don t hesitate to suture cataract incision and your sclerotomies. And finally take another opinion if you have any doubt or even for patient s satisfaction and reassurance. DOS Correspondent Sangeeta Roy MBBS 16 l DOS Times - Vol. 19, No. 9 March, 2014