Take home messages from ARC meet

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1 Take home messages from ARC meet Prophylaxis for endophthalmitis 1) Biometry should not be done on the same day of surgery. 2) Povidone Iodine use before surgery is mandatory (preferably three minutes prior to surgery). 3) Frequent hand sanitizing should be done. 4) Syringing is not required in all cases. It should be done in ROP + (Regurgitation on pressure) cases. 5) Pre op antibiotics not mandatory. 6) Intra cameral antibiotics not mandatory. 7) Re autoclaving of irrigation fluids and viscoelastics not mandatory. Endophthalmitis management 1) Maintain a chart for intra vitreal injections in the OT. 2) Choice of antibiotics Vancomycin ( 1 mg/0.1 ml) and Ceftazidime (2.25mg/0.1 ml) 3) Radical vitrectomy with base dissection (maximum debulking) should be done. Acknowledgement : Dr Kruto Kalita, MS TAKE HOME MESSAGE Preseptal and Orbital cellulitis- Preseptal cellulitis occurs anterior to orbital septum. On examination eyelid edema, erythema, and inflammation is there. Globe is not involved and there is no proptosis. So, ocular motility, vision, pupillary reaction are normal. Pain on eye movement and chemosis absent. Source of infection may be penetrating cutaneous trauma, dacryoadenitis or underlying sinusitis. Orbital cellulitis is more serious condition. Orbital cellulitis involve structures posterior to orbital septum. 90% cases secondary to extension of sinusitis. Fever, leucocytosis, proptosis, chemosis, ptosis, restriction of and pain on ocular movement. Decreases visual acuity, color vision, restricted visual fields and pupillary abnormalities are suggestive of compressive optic neuropathy in orbital cellulitis. Clinical classification of orbital cellulitis : It has 5 groups from Group 1-group5. Group 5 is sight and Life threatening characterised by : cavernous sinus thrombosis and by CNS deficits.

2 Indications for drainage of subperiosteal abscess: 1.Patient 9 years and older 2.Frontal sinusitis 3.Nonmedial location of subperiosteal abscess (SPA) 4.large SPA 5.Suspicion of anaerobic infection (presence of gas in abscess on CT) 6.Recurrence of SPA after prior drainage 7.evidence of chronic sinusitis 8.acute optic nerve or retinal compromise 9.infection of dental origin (as it is anaerobic most probably) Management Hospital admission and otolaryngological opinion. Paediatrician and neurologist opinion may be required. Investigations- TLC, DLC, blood culture, CT scan of orbit, sinuses and brain. This exclude subperiosteal abscess. Lumbar puncture if meningeal signs develop. Antibiotic therapy should cover both aerobes and anaerobes. Intravenous ceftazidime and metronidazole provides good coverage. Vancomycin can be used in case of penicillin allergy. Antibiotic therapy is to be continued until patient is afebrile for 4 days. Methicillin-resistant S aureus in orbital cellulitis is increasing, and empiric antimicrobial therapy should be directed accordingly if it is prevalent in the community. Infection due to methicillin-resistant S aureus is best treated with vancomycin and clindamycin. Fungal orbital cellulitis due to Mucor and Aspergillus species requires antifungals, such as amphotericin B. Nasal decongestants like phenylephrine, oxymetazoline help to drain sinuses

3 Corticosteroids may be helpful, but they should not be started until after any surgery is performed and until the patient has been on appropriate antibiotics for 2-3 days. If glaucoma develops secondary to orbital cellulitis, ocular antihypertensives should be given. In cases of posttraumatic orbital cellulitis, tetanus prophylaxis should be given according to standard protocol. Monitor optic nerve function every 4 hours by testing pupillary reaction, visual acuity and color vision. Antibiotics to change if needed, depending on the results of cultures and the patient's clinical course. Repeat CT scans if the patient's condition worsens or does not respond to appropriate antibiotics. Once patient is improving and has been afebrile for at least 48 hours, shift from IV antibiotics to oral antibiotics (eg, amoxicillin clavulanate, ampicillin, cefpodoxime, cefuroxime, cefprozil) for aerobic infections and metronidazole for anaerobic infections. Indications for surgical intervention no response to antibiotics in 48 to 72 hours (worsening vision, afferent pupillary defect, increasing proptosis), subperiosteal abscess as described above. Canthotomy and cantholysis should be performed on an emergency basis if an orbital compartment syndrome is diagnosed at any point in the course of the disease. Complications: ocular complication- exposure keratopathy, raised intraocular pressure, occlusion of central retinal artery or vein, endophthalmitis, optic neuropathy and subperiosteal abscess. Intracranial complications include cavernous sinus thrombois, meningitis, brain abscess Management of orbital abscess with optic nerve compression- if orbital absess is large enough to compress optic nerve, urgent optic nerve decompression by abscess drainage is required.

4 Hordeonum externum is an acute staphylococcal infection of a lash follicle and gland of zeis. It more commonly occur in children and young adults. On examination, a tender swelling in lid margin pointing anteriorly through skin, usually at lash apex. Treatment include topical antibiotics, hot compress and epilation of associated lash. Hordeonum internum is acute staphylococcal infection of Meibomian gland. Pus point may be seen on inner aspect of eyelid. Warm compress, topical antibiotic and oral anti-inflammatory medication may be used. If a hordeonum is large enough to cause superficial cellulitis than systemic antibiotic is needed. Protocols Conjunctiva: A. Treatment of Adenovial Keratitis: -Lubrications, preferably preservative free, if refrigerated then causes much comfort -Steroids to be avoided as it prolongs viral replication -Cyclosporin drops or Tacroment to be used in case of presence of sub-epithelial infiltration & continued till the disappearance of scars -No role of topical Acyclovir/Gancyclovir eye ointments -No splashing of cold water B. Conjunctival swab before initiating treatment -mandatory if thick purulent discharge suspecting a bacterial pathology -all membranes/pseudomembranes removed to be plated too

5 Cornea: A. Treatment for HSV keratitis- -Dual staining with Flourescence & Rose Bengal for Epithelial disease -Acyclovir eye ointment 5t/day for 21 days or Gancyclovir e/o 3t/day for 21 days -No role of tapering topical antivirals - Steroids to be avoided in treatment of epithelial disease - Dose of oral Acyclovir (a) HSV- 400mg 5t/day for 7-10 days: Prophylactic dose-400mg BD for 1year or beyond (b) HZO- 800mg 5t/day for 7-10days - Testing for corneal sensations in suspected viral keratitis holds true even today. Done in clear cornea & not directly over lesion where it is bound to be decreased. B. Bacterial Keratitis 1. At least 1 smear with 10% KOH staining to be done before initiating treatment -This helps rule in fungal, acanthamoeba & microsporiadia infection (Specificity 96%) - Can be done by doctor by keeping few slides/cover slips/10% KOH solution & a light microscope

6 Severity Grading DB Jones 1988 Features Non-severe Severe Progress Slow Rapid Infiltrate area <6 mm >6 mm depth Sup. 2/3 Inner 1/3 Perforation Unlikely Imminent or present Scleral Involvement Absent Present Initiation of treatment based on (a) microbiology & (b) severity of ulcer Treatment strategies Combination therapy Fortified Cefazolin 5% or 10%+Tobramycin 1.3% Fortified Cefazolin 5% +Fluroquinolone moxi or gati Cephalosporin:Gm +ve cocci AG : Gm ve bacilli Moderate ulcers > 3mm in size Involving visual axis Monotherapy Ofloxacin 0.3 % Ciprofloxacin 0.3 % Gatifloxacin 0.3% Gatifloxacin 0.5% Moxifloxacin 0.5 % Mild ulcers < 3mm in size Not involving visual axis

7 -Initiation of therapy in loading dose to achieve MBC i.e every ½ hourly for first 48 hrs the gradually taper based on clinical response & patient symptoms till the MIC 90 maintained -The most preferred combination of Cephalosporins with Flouroquinolone is Cefazolin & Ciprofloxacin Specific antibiotics Organism Topical Systemic Methicillin resistant Staphylococcus Severe Pseudomonas keratitis Mycobacterium fortuitumchelonae Nocardia Vancomycin 50 mg/ml Ceftazidime (50mg/ml) Amikacin mg/ml Amikacin mg/ml Or Trimethoprim (16mg/ml) sulfamethoxazole (80mg/ml) injectable VM 2gm/day Ceftazidime (1g-2gm/day I/V or I/M) Clarithromycin 500mg bd Trimethoprim/ sulfamethoxazole (10-20mg/kg/day) I/V -Antibiotics must be continued at least in QID dose till the epithelial defect is healed -To evaluate epithelial defect Flourescence staining can be used when in doubt - Abstain from using commercially available combinations like Moxifloxacin+Tobramycin - If no response to treatment for 2 weeks- Non-responsive Ulcer

8 Non healing microbial keratitis Microbiology + Microbiology - Compliance Resistance Mixed/polymicrobial Stop antibiotics for12-24 hrs Re-scrape Special stains/culture Twice negative smears Corneal biopsy C. Fungal Keratitis Epidemiology of local geographical region is important Current Trends Developing countries 1396 isolates 99.3% filamentous fungi 0.7% yeast Gopinathan U et al. Cornea 2002 Developed countries 50% filamentous fungi 50% yeast Tanure M et al. Cornea 2000

9 Initiation of treatment for Filamentous vs Yeast Spectrum of Activity Filamentous Fungi Fusarium Ampho B 0.15% Aspergillus Ampho B 0.15% Yeasts Candida Ampho B 0.15% Natamycin 5% Fluconazole 2% Iatraconazole Voriconazole Caspofungin 0.5% Natamycin 5% Fluconazole 2% Iatraconazole Voriconazole Caspofungin 0.5% Natamycin 5% Fluconazole 2% Iatraconazole Voriconazole Caspofungin 0.5% Medical Therapy Topical Anti-fungals 5% Natamycin hourly:daytime,2 hourly :bed time Taper 4 to 7 days interval If worsening add 0.15% Amphotericin B drops or1% voriconazole Therapy:3-4 weeks

10 Systemic Antifungals Indications Large ulcers >6mm Severe deep keratitis >2/3 inv Scleritis Post-PK Endophthalmitis Drugs Ketoconazole(200mgbd) Fluconazole(200mg bd) Itraconazole(100mg bd) Voriconazole(200mg bd) Liver function tests every 2 weeks Intracameral antifungals Indications Non-responsive to medical therapy Thick Hypopyon Endothelial exudates Deep anterior chamber exudates Amphotericin B µgm /0.1ml/ 5 % dextrose Voriconazole µgm/0.1ml

11 Intrastromal/intracorneal Injections Indications Deep mycotic keratitis Non-perforated corneal ulcers Non-responsive to conventional topical and systemic anti-fungal therapy for 4 weeks Fungal keratitis <2/3 rd stroma <6mm Topical NM 5% 2 hrly 7-10 days >2/3 rd stroma >6mm Topical NM 5 % LFT : Systemic AF ( KC/ VZ) No Response 2 weeks Response + Response - Add Ampho B 0.13% or Topical VZ 1% 2 weeks Topical VZ 1 % 2 weeks Hypopyon Intracameral AF Intrastromal AF Topical VZ1% 2 weeks No Hypopyon Intrastromal VZ 50 μg/0.1ml

12 Algorithm to be followed for management of Corneal Ulcer