intravitreal inj and ppv are the treatment for endophthalmitis .

1. ENDOPHTHALMITIS
2016
INTRAVITREAL INJ & PPV
Indoredrishti.wordpress.com

2. DR DINESH MITTAL DR SONALEE MITTAL
DRISHTI EYE HOSP VIJAYNAGAR INDORE

8. OUTLINE

9. LAYOUT OF A OPERATION THEATER

10. LAYOUT OF A OPERATION THEATER

11. WALLS FLOORS AND DOORS

12. OPERATING ROOM

13. VENTILATION CONTROL

14. DISADVANTAGES OF FORMALIN

17. ENVIRONMENTAL DECONTAMINATION

18. ENVIRONMENTAL DECONTAMINATION

19. CHOICE OF DISINFECTANT

20. DISCIPLINE IN OPERATION THEATER

21. GLOVING

22. OPERATION THEATER ENVIRONMENT

23. OPERATION THEATER ENVIRONMENT

24. CLEANING INSTRUMENTS

25. STERILIZATION

26. EFFICACY OF STERILIZATION

27. STERILE PRODUCTS

29. SAMPLES TO BE COLLECTED

30. MICROBIOLOGICAL TESTING OF OT AIR ( SETTLE PLATE )

32. WHAT TO DO AT CLUSTER INFECTION

33. WHAT TO DO AT CLUSTER INFECTION

34. WHAT TO DO AT CLUSTER INFECTION

35. WHAT TO DO AT CLUSTER INFECTION

36. WHAT TO DO AT CLUSTER INFECTION

37. RISK FACTORS FOR ENDOPHTHALMITIS

38. RISK FACTORS FOR ENDOPHTHALMITIS

40. RISK FACTORS FOR ENDOPHTHALMITIS

41. RISK FACTORS FOR ENDOPHTHALMITIS

42. RISK FACTORS FOR ENDOPHTHALMITIS

43. RISK FACTORS FOR ENDOPHTHALMITIS

46. INTRODUCTION
•Infectious endophthalmitis is a potentially
devastating condition involving the internal
structures of the eye. It is one of the most
feared complications of cataract extraction
and other intraocular surgeries. Rarely, it can
occur endogenously from a systemic nidus of
infection.

47. INTRODUCTION
•Endophthalmitis is classified on the
basis of the source of the infection, as
exogenous, which is the most common
subtype, or endogenous. The avascular
densely packed collagenous matrix of
the cornea and sclera serves as a potent
barrier against infectious infiltration in
normal eyes.

48. INTRODUCTION
•Violation of these structures, typically by
surgery or trauma, makes eye susceptible to
entry of pathogenic organisms, and may lead
to exogenous endophthalmitis. Bacteria are
often causative agents in these cases.
There are typically no associated systemic
findings such as fever and minimal, if any,
peripheral leukocytosis.

49. Endogenous endophthalmitis
• Endogenous endophthalmitis occurs in otherwise
healthy eyes in association with transient or
persistent bacteremia or fungemia. It is observed
most frequently in immunosuppressed patients
and intravenous drug users, and less commonly in
patients with cardiac valvular disease, persistent
sites of infection elsewhere in the body, and in
those undergoing dental work. Fungal infections
are most common, but a third of patients will
present with bacterial endophthalmitis, often
caused by gram-negative species .

50. Exogenous
Endophthalmitis

51. Classification of Endophthalmitis
• Infectious endophthalmitis is classified
by the events leading to the infection and
by the timing of the clinical diagnosis.
The broad categories include
postoperative endophthalmitis (acute-
onset, chronic or delayed-onset,
conjunctival filtering-bleb associated),
posttraumatic endophthalmitis, and
endogenous endophthalmitis.

52. Classification of Endophthalmitis
• Miscellaneous categories include cases
associated with microbial keratitis,
intravitreal injections,or suture removal.
These categories are important in
predicting the most frequent causative
organisms and in guiding therapeutic
decisions before microbiologic
confirmation of the clinical diagnosis .

54. TRAUMA
• The risk of endophthalmitis following open
globe injuries ranges from 4.2 to 7%. In
contrast, following closed globe injuries,
endophthalmitis is exceedingly rare.
Staphylococcal species are most common
causative agents in trauma-related
endophthalmitis, and some species such as
Bacillus cereus are seen only in trauma.
The source of the infection is typically the
penetrating material .

55. TRAUMA
• The rate of infection rises dramatically to 10–15%
when an IOFB is present and if the repair is delayed
beyond 24 hours of the injury. Even without overt
infection, prophylactic intravitreal antibiotics
should be considered at the time of the IOFB
removal, since in nearly a quarter of patients
cultures of the IOFB will be positive for bacteria,
and risk of intravitreal antibiotics is generally low.
In rural settings, where organic material
contamination is common, endophthalmitis
following penetrating ocular trauma achieves rates
as high as 30%, with Bacillus species isolated in
46% of cases and polymicrobial isolates in 42%.

56. Cataract surgery
•Post-cataract endophthalmitis is categorized
on the basis of the time to onset following
surgery, as acute (within 6 weeks) or
delayed. The incidence of endophthalmitis
after cataract extraction is reported to be
0.04–0.15%. Some authors suggest an
increase in the incidence of endophthalmitis
beginning in the late 1990s/2000, in parallel
with the increased use of clear cornea
cataract wound placement .

57. Cataract surgery
• Post-cataract endoph is typically associated
with defects in surgical wound and violation
of lens capsule, which can provide a route of
entry for infectious agents. The patient’s
own periocular flora is source of infection in
majority of cases of endophthalmitis. In 68–
82% of post-cataract endophthalmitis cases,
an identical genetic or molecular signature
was present in vitreous isolates and
commensal bacteria occupying the patient’s
conjunctiva, eyelids or nose .

58. CATARACT SURGERY
•The Endophthalmitis Vitrectomy Study
(EVS) was a major prospective
randomized clinical trial analyzing the
treatment of acute post-op endoph, and
it identified
in 70% of cases; less
common were in
nearly 10%, species in
9%, in 2%, and
organisms in 6%.

59. Cataract surgery
•In pediatric patients undergoing
intraocular surgery, the risk of
endophthalmitis is estimated to be 0.07–
0.16%, with 82% of cases presenting by
the third post-operative day. Pediatric
endophthalmitis is typically caused by
gram-positive bacteria; 47% of cases are
associated with nasolacrimal duct
obstruction or upper airway infection .

60. Cataract surgery
•Among various antiseptics studied, 5%
povidone iodine solution was able to
reduce incidence of endoph . In delayed
onset endoph , Propionibacterium acnes
is the most commonly implicated
pathogen, accounting for nearly 40% of
isolates . It has a subtle presentation
and indolent course .

61. Glaucoma filtration procedures
• Glaucoma surgery is associated with endophthalmitis in
2.1–2.6% of cases. Endophthalmitis following glaucoma
surgery, unlike postcataract infections, tends to be
delayed and is often associated with prior episodes of
blebitis . Diabetes, use of anti-metabolites as well as
inferior bleb location increases risk and hastens onset of
endophthalmitis. Delayed onset bleb-related
endophthalmitis is associated with Streptococcus
species (25%) and gram-negative organisms, particularly
Haemophilus influenzae (18%).

62. Intravitreal injections
• Intravitreal injections of triamcinolone have
a 0.87% incidence of infectious
endophthalmitis, possibly due to inhibition
of immune function against inadvertently
introduced pathogenic agents. Accordingly,
the intravitreal injections of ANTI VEGF
drugs , including ranibizumab, are
associated with significantly lower endoph
rates of 0.02–0.08%.

63. Intravitreal injections
•Diabetics may be at higher risk, however.
The majority of the cases are caused by
Streptococcus or Staph species
representing commensal flora of ocular
adnexa and oropharynx. The risk of infection
may be lessened by decreasing
oropharyngeal droplet transmission at time
of the injection .

64. Intravitreal injections
• The use of compounding pharmacies, which
involves the parceling of a single medication such
as bevacizumab into multiple intravitreal
injections, may increase incidence of infection
and has been associated with local outbreaks of
endoph. Avastin vial may be adulterated also .The
use of postinjection antibiotics does not appear to
decrease the frequency of endoph, but, in fact,
may lead to selection of drug resistant bacteria in
the nasopharynx and on the ocular surface .

65. AVASTIN INDUCED ENDOPHTHALMITIS
• Vial itself may be adulterated and hence containing
toxins . So even if the vial is opened on the table and pt
given intravit injection pt. will develop symptoms like
TASS . In case of avastin symptoms will be localized in
posterior segment so this should be called TOXIN
POSTERIOR SEGMENT SYNDROME and not TOXIN
ANTERIOR SEGMENT SYNDROME ( TASS ) . These
symptoms will develop in few hours and are a type of
sterile reaction to toxins . And if the avastin gets
infected during compounding then infective endoph will
develop after some days .

66. ORGANISMS THAT CAUSE ENDOPHTHALMITIS
•Bacteria, fungi, protozoa, and parasites are
all capable of producing endophthalmitis .
Bacteria are the most common group of
organisms causing endophthalmitis. Gram-
positive organisms are responsible for 60–
80% of acute infections in all large series.
These organisms vary widely in their
virulence and, therefore, in their effect on
the eye.

67. INFECTIVE
AGENTS
CAUSING
ENDOPHT
HALMITIS

68. POST-OPERATIVE ENDOPHTHALMITIS
•Worldwide, the reported incidence of
post-operative endophthalmitis is 0.04-
4%. Post cataract surgery incidence is
0.265% (more with clear corneal
incision), post keratoplasty 0.382% and
post vitrectomy 0.05%. The incidence of
bleb associated infection is 0.2%-9.6%.

69. POST-OPERATIVE ENDOPHTHALMITIS
•Though rare, it is potentially the most feared
and devastating complication of intraocular
procedures and can lead to a permanent,
complete loss of vision. Endophthalmitis has
been associated with severe visual loss in
20% of patients. A series of endophthalmitis
cases may force a temporary shutdown of
the operation theatre.

70. Patient symptoms
•Patient symptoms indicative of endoph
include ocular pain, diminished vision and
headache. Although pain is an important
symptom, it is not universal. It is important
to differentiate infective endoph from sterile
post-op inflammation. Toxic Anterior Segment
Syndrome (TASS) is an acute postop inflammatory
reaction in which a noninfectious substance
enters the anterior segment and induces toxic
damage to the intraocular tissues. Almost all
cases occurred after uneventful cataract surgery.

71. TASS
•In TASS, most develop symptoms
within 12-24 hrs , there is decrease in
visual acuity, corneal edema is from
limbus to limbus, there is moderate to
severe AC reaction with cells, flare,
hypopyon and fibrin, pupil may be
dilated and non-reactive and IOP may
be normal or raised.

72. TASS
•Post operative endophthalmitis may be early
or delayed. Most common causative agents
are gram positive coagulase negative
organisms. However in India, gram negative
organisms and fungi are also important in
aetiopathogenesis. Differentiation is
important as the management and prognosis
of TASS is significantly different . Delay in
diagnosis leads to delay in initiating
appropriate treatment.

74. Patient symptoms
•Endophthalmitis should be suspected
when there is pain and increased in AC
reaction on slit lamp examination on first
post operative day or later . However pain
may be absent in 25% cases. Decreased
glow on distant direct ophthalmoscopy
has high sensitivity but low specificity on
first post operative day.

75. Patient symptoms
• On subsequent post operative days, decrease in vision
following initial improvement along with pain should
immediately raise the index of suspicion. Presence of
exudates in vitreous on indirect ophthalmoscopy is 100%
specific.
• Presence of hypopyon and vitreous exudates is usually
diagnostic of endophthalmitis.
• If there is NO HYPOPYON, role of distant direct
ophthalmoscopy, slit lamp examination, indirect
ophthalmoscopy and ultrasound B scan very important in
deciding surgical intervention, rule out other causes like
masquerade.

76. Patient symptoms
•Slit lamp examination helps to see
dilatability of pupil, wound margin (many
cases related to suture removal).
•In cases with poorly dilating pupils and
significant AC reaction (+++) and best
corrected visual acuity better than 6/60,
sterile reaction should be considered and
treatment started with intravenous bolus
steroids and topical steroids and
antibiotics.

77. Patient symptoms
•However if BCVA <6/60, endophthalmitis
should be considered and patient should be
administered intravitreal antibiotics. An
USG B scan may aid in the diagnosis with
non dilating pupils and severe AC reaction
by demonstrating vitreous echoes.
•Presence of vitreous exudates clinches the
diagnosis of endophthalmitis.

78. Antimicrobial therapy
• The target area for microbial therapy in endoph is
vitreous cavity. Intravitreal therapy is the
cornerstone of antimicrobial administration,
whereas role of subconj and systemic antibiotics
is more controversial. Because most cases of
endoph manifest as acute fulminant infections, the
initial antibiotic administration is usually made
without culture results to identify the organism
definitively. The choice of agent administered
initially is therefore empirical . Broad-spectrum
coverage is important, and choice depends in part
on microbes expected in a given clinical setting.

79. Antimicrobial therapy
• Gram-positive bacteria predominate in all types of acute
endoph, but specific organisms and their frequency vary.
Microbes causing acute postoperative endoph are most
often the pt. own bacterial flora. Staphylococcal species
account for more than two-thirds of all cases, but Gram-
negative organisms are also encountered. In acute
traumatic endophthalmitis, Gram-positive organisms are
the most commonly identified, but this includes a high
incidence of Bacillus species. In traumatic endoph, the
microbes reflect not only patient’s flora but also
contaminants from the scene of the trauma. Gram-
negative infections and mixed infections are encountered
more often than in acute postoperative cases.

80. Antimicrobial therapy
• In delayed postoperative endoph,
Propionibacterium acnes, nonvirulent
staphylococci, and fungi are most
often the causative agents. When
infection is associated with a filtering
bleb, Streptococcus species are
identified in a high percentage of
cases.

81. Antimicrobial therapy
• Characteristics for ideal drugs for the treatment of
bacterial endophthalmitis include the following:
• 1. Bactericidal properties. Because the eye is an immune-
privileged site, like the central nervous system, a
bactericidal drug rather than bacteriostatic agent is
preferred.
• 2. Broad spectrum of coverage. Coverage must include
Gram-positive organisms, especially methicillin-resistant
staphylococci and Bacillus species in trauma cases, and
Gram-negative organisms.
• 3. Excellent therapeutic ratio (activity/toxicity) after
intravitreal injection.

82. Antimicrobial therapy
• 4. Good therapeutic ratio after IV injections. Most
antimicrobials penetrate the vitreous cavity poorly after
IV injection because of the blood–eye barrier. Intravitreal
antimicrobial levels are only rarely reported to reach
levels above the MIC for organisms usually seen in
endophthalmitis after IV or oral administration. Hydrophilic
antibiotics (including aminoglycosides and β-lactam
antibiotics) have less potential for penetration into the eye
than lipid-soluble compounds. On the other hand, there is
significant systemic toxicity to the antimicrobials
commonly used in treating endophthalmitis, particularly
the aminoglycosides and amphotericin. Furthermore, some
combinations of antibiotics have a favorable spectrum of
coverage (e.g., vancomycin and aminoglycosides), but
their toxicities are additive when used simultaneously.

83. Antimicrobial therapy
• 5. Favorable pharmacokinetic properties. Intraocular
inflammation enhances penetration of certain antibiotics.
Vitrectomy has been shown to enhance the penetration of
cefazolin, vancomycin, and ceftazidime into the eye.
Repeated IV dosing may contribute to increased
penetration into the vitreous cavity after IV
administration, particularly in inflamed and previously
operated eyes. After intravitreal administration antibiotics
are eliminated through either an anterior or posterior
route. Aminoglycosides are eliminated anteriorly, and the
β-lactam antibiotics are removed posteriorly. Vitreous
removal shortens the half-life of all antimicrobial agents
studied in animal models. Lens removal decreases the
half-life of antibiotics eliminated anteriorly.

84. Antimicrobial therapy
• Inflammation may increase the half-life of antimicrobials
excreted posteriorly, such as cefazolin; blocking agents
such as probenecid may also increase the half-life of
these drugs. The half-life for anteriorly excreted drugs
such as gentamicin and amikacin is decreased by
inflammation. A higher initial dose is preferred whenever
possible to allow the drug to remain at levels greater
than the MICs of common pathogens for a longer period.
Known activity of the drug is also an important
• consideration in the choice of the antibiotics. If drugs are
given in equivalent concentrations, the one with higher
activity against suspected organisms should be chosen.

85. Antimicrobial agents
•Four groups of antimicrobials are
commonly prescribed in endoph:
•(1) cephalosporins;
•(2) aminoglycosides;
•(3) fluoroquinolones; and
• (4) antifungal agents.

86. Cephalosporins
• The cephalosporins are synthetic penicillins active against
the bacterial cell wall. They are well tolerated systemically,
and cefazolin has been established to be a relatively safe
drug when 2.25 mg is injected intravitreally. All the
cephalosporins have good broad-spectrum coverage for Gram-
positive and some Gram-negative organisms, but the first-
generation drugs are weak against enterococcus and
meticillin-resistant staphylococcal organisms. Injection of
cefazolin (2.25 mg) into the aphakic eye produces levels
greater than the MICs for approximately 48 hours. Ceftazidime
is a promising antibiotic for Gram-negative coverage in
endophthalmitis therapy because it has good cerebrospinal
fluid penetration and excellent Pseudomonas coverage. In a
study of 37 Gram-negative isolates from cases of endoph,
80% were susceptible to ceftazidime.

87. Vancomycin
• Vancomycin has been recommended as the antibiotic of
choice for Gram-positive coverage. Its coverage is purely
Gram-positive, but its spectrum includes all of the
staphylococcal species, Bacillus, and P. acnes. The
mechanism of vancomycin is inhibition of cell wall
assembly, in addition to damaging protoplasts and
inhibiting RNA synthesis. The intraocular therapeutic ratio
for vancomycin is good, although the half-life suggests that
therapeutic concentrations will be maintained for only
about 48 hours after intravitreal injections. Vitreous
sampling after intraocular injection in human infection has
suggested that potentially therapeutic levels may persist
for 3–4 days after initial injection depending on the initial
dose.

88. Aminoglycosides
• Aminoglycosides have a spectrum that includes both
Gram-positive and Gram-negative organisms. They are
chosen particularly for their Gram-negative coverage in
endoph . The mechanism of action for aminoglycosides is
to inhibit protein synthesis. Unfortunately, the intraocular
therapeutic ratio after intraocular injection is a source of
problems. Retinal vascular infarction has been frequently
reported after gentamicin, and it has also been noted
after amikacin administration. Tolerated dosages may be
higher for amikacin than for gentamicin, but all of the
aminoglycosides cause retinal changes after higher
intravitreal dosages. The half-life of amikacin is
approximately 8 hours in inflamed, vitrectomized eyes.

89. Aminoglycosides
• Because of the limitations in the amount given for the
initial dosage, the concentration of these antibiotics
remains above the MIC for only 24–36 hours after
administration. The therapeutic ratio for treatment of
ocular disease after IV administration is also unfavorable
because of systemic toxicity. Penetration of gentamicin
into the eye after IV administration has been studied in
both rabbits and humans. It does not reach therapeutic
levels in traumatized rabbit eyes, normal rabbit eyes, or
human eyes with various ocular diseases after single
doses.

90. FLUOROQUINOLONES
• The quinolones are broad-spectrum antibiotics with both
Gram-positive and Gram-negative coverage. Their
mechanism of action is thought to be inhibition of DNA
synthesis. The second-generation drugs are ciprofloxacin
and ofloxacin, while levo-floxacin is a third-generation
agent. The fourth-generation drugs, gatifloxacin and
moxifloxacin, have significant potential in the prophylaxis
and treatment of endophthalmitis. Initial reports of the
therapeutic ratio of ciprofloxacin after intraocular
injection suggest that intraocular toxicity occurs at low
dosage levels. Fluoroquinolones penetrate the blood–
ocular barrier more readily than do several of the other
classes of antimicrobials. Ciprofloxacin has reasonable
penetration after oral administration, but many ocular
pathogens have developed resistance to it.

91. FLUOROQUINOLONES
• After two doses of oral administration levofloxacin achieves
concentrations in the aqueous and vitreous above the MIC (90)
for many Gram-positive and Gram-negative pathogens but not
for Pseudomonas aeruginosa. Studies of penetration of
gatifloxacin and moxifloxacin into noninflamed eyes
undergoing vitreous surgery after oral administration of two
doses demonstrated that the percentages of serum
concentrations achieved in the vitreous and aqueous were
26.17% and 21.01%, respectively. These levels are above the
MIC (90) for most of the pathogens producing human disease.
These include: Staphylococcus epidermidis, S. aureus,
Streptococcus pneumoniae, S. pyogenes, Enterococcus
faecalis, Proteus mirabilis, Escherichia coli, and
Propionibacterium acnes, among others. Notably, however,
neither agent achieved vitreous MIC (90) for Pseudomonas
aeruginosa and moxifloxacin did not reach the MIC (90) for
Bacteroides fragilis.

92. ANTIFUNGAL AGENTS
• Amphotericin has been considered the gold standard in
antifungal therapy. Its mechanism of action is the
alteration of membrane permeability by combination with
sterols and fungal cytoplasmic membranes. The
intraocular therapeutic ratio has not been well studied,
but the usual recommended dosage is 5 μg/mL. After IV
there are significant systemic complications, including
renal toxicity. Penetration into the eye is also relatively
poor. After intraocular injection, the half-life has been
reported to be 9.1 days. The half-life is further decreased
by inflammation and vitreous removal. Vitrectomy and
oral fluconazole have been reported to treat Candida
endophthalmitis successfully, with fewer side-effects.

93. ANTIFUNGAL AGENTS
• Fluconazole has significant penetration into
noninflamed eye after oral administration.
Voriconazole is a triazole antifungal agent which is
a second-generation synthetic derivative of
fluconazole It demonstrates a broad spectrum of
action, including Aspergillus species, Candida
species , and has a low MIC (90) for many
organisms. After oral administration, therapeutic
levels are achieved in aqueous and vitreous in non-
inflamed eyes. Uses of intravitreal voriconazole
for fungal endoph have been reported.

94. Pars plana vitrectomy
• PPV plays a role in many phases of endoph
therapy. As initial therapy it is validated by the
EVS results only for acute postcataract extraction
infections in eyes presenting with vision of hand
motions or less. In addition to use as initial
therapy in many of these clinical settings, PPV
should also be considered for eyes not responding
to an original tap-and-inject strategy, and may be
necessary to clear vitreous opacities in eyes
cured of infection when spontaneous clearing
does not occur.

95. Preoperative evaluation
• A careful and extensive history should be taken.
Clinical details such as systemic infectious
disease, type of eye injury, or previous surgery
may hold important clues to the identity of the
infecting organism. Particular attention should be
paid to the length of time from the surgical insult
or trauma to the onset of symptoms and to the
time that has passed since symptoms began.
Previous antibiotic or corticosteroid therapy
should be noted. A thorough ocular examination
should include a careful search for any possible
route of entry for the infecting organism.

96. Preoperative evaluation
• The effects of the inflammation should also be
noted: corneal clarity and thickness, condition of
any surgical wound, degree of anterior-chamber
reaction, hypopyon, clarity of the vitreous,
visibility of the retina, and presence or absence of
a red reflex. USG can define the degree of
condensation of the vitreous, determine whether
the retina is attached, and identify choroidal
swelling. Preoperative ERG findings may have a
predictive value for postoperative visual result, but
this has not yet been well defined.

97. MANAGEMENT
• At present, best choice of intravitreal antibiotics is
Vancomycin (1 mg in 0.1 ml) combined with
Ceftazidime (2.25 mg in 0.1 ml) in separate syringes.
• Alternatively, Vancomycin may be combined with
Amikacin (400 μg in 0.1 ml).
• Topical treatment comprises Moxifloxacin 1 hourly or
Fortified Cefazoline + Tobramycin 1 hourly along with
cycloplegics in the form of Atropine every six hourly.
Intravenous Ciprofloxacin 200 mg twice daily is
required in very severe cases.

101. Intravitreal antibiotics
• Intravitreal antibiotics are the key to management
because levels above the minimum inhibitory
concentration of most pathogens are achieved, and
are maintained for days. They should be
administered immediately after culture specimens
have been obtained. Antibiotics commonly used in
combination are ceftazidime, which will kill most
Gram-negative organisms (including Pseudomonas
aeruginosa) and vancomycin to address Gram-
positive cocci (including methicillin-resistant
Staphylococcus aureus).

102. Intravitreal antibiotics
• ○ The antibiotics are injected slowly into the mid-
vitreous cavity using a 25-gauge needle.
• ○ After the first injection has been given, the
syringe may be disconnected but the needle left
inside the vitreous cavity so that the second
injection can be given through the same needle;
alternatively a second needle can be used.

105. Medications
•Various antibiotics may be considered for
intravitreal injection . The most commonly
used medications in suspected bacterial
endophthalmitis include vancomycin and
ceftazadime. Intravitreal vancomycin
provides broad coverage for over 99% of
gram-positive organisms and ceftazadime is
effective against 100% of gram-negative
bacteria observed in post-operative
endophthalmitis .

106. Surgical Intervention
• The results of EVS study are still applicable to
post-cataract endophthalmitis cases today, with
some modifications. In post-cataract patients
presenting with intraocular inflammation and a
visual acuity at the level of light perception, PPV
with injection of intravitreal antibiotics appeared
to improve the visual outcomes compared with
intravitreal antibiotics alone. For patients with
visual acuity of hand motion or better, PPV with
intravitreal antibiotics appeared to provide no
additional visual benefit compared with intravitreal
antibiotics alone .

107. Surgical Intervention
• The main goals of PPV in endophthalmitis are to
obtain sufficient tissue for diagnosis and to debulk
the pro-inflammatory debris. In practice, a culture
result of the removed material alters clinical
management in less than 5% of cases. While the
EVS included limited vitrectomy, more extensive
debridement may provide better outcomes.
Removal of the IOL is typically not required, except
in cases of chronic low-grade endophthalmitis
associated with P. acnes resistant to medical
therapy .

108. WHEN TO DO PPV
• Oral Steroids administered as 1-1.5 mg / kg single dose
along with oral antibiotics. Ciprofloxacin 750 mg twice
daily for 7-10 days usually preferred although currently
many clinicians prefer oral Gatifloxacin or Moxifloxacin.
After intravitreal antibiotics, patient is monitored for
24-36 hours. If there is worsening, patient has to be
taken up for surgical intervention in the form of PPV . If
there is no worsening, medical treatment can be
continued for 48 hours following which decision
regarding additional intravitreal antibiotics or surgical
intervention is to be taken. Improvement in fundus glow
with decrease in hypopyon is indicative of clinical
improvement. Medical treatment should be continued.

109. WHEN TO DO PPV
• in situations where there is a partial response to
intravitreal antibiotics with resolution of hypopyon
but persisting AC reaction (3-4+), further
intravitreal antibiotics are not preferred,
conservative medical management is continued
and patient is readied for surgical intervention.
• In situations where there is no response to
intravitreal antibiotics or in very severe infection,
RADICAL pars plana vitrectomy with peeling of
hyaloid and base dissection is required. There is no
role for core vitrectomy in this situation.

110. PPV
• IOL removal during vitrectomy for endophthalmitis may
be indicated in severe endoph, P acne endoph, fungal
endoph and recurrent endoph.
• The eye is usually quite where signs are more
prominent than symptoms. Vitreous Balls, fungal
granuloma may be seen. Smears, cultures may help if
on initial treatment, there is no/ partial response or
worsening, Vitrectomy is the only hope. Treatment
includes oral and intravitreal voriconazole (50-100 ug) or
intravitreal amphotericin (5-10 ug). Steroids should be
stopped. Oral/ intravenous antibiotics, cycloplegics and
topical antibiotics are usually continued

111. SURGICAL TECHNIQUES
• GA is preferred because of the difficulty of
obtaining adequate LA for an inflamed,
painful eye. LA may be adequate for shorter
procedures or if the patient’s medical
condition warrants this approach. The first
technical problem that confronts the surgeon
is placement of the infusion cannula.
Because the media is almost always too
cloudy for the surgeon to be able to visualize
a pars plana port, this infusion cannot be
used for the initial stages of the operation.

112. SURGICAL TECHNIQUES
• Because the incision and placement of the infusion
port are easier in a firm eye, it is often worthwhile
placing an inferotemporal port with sutures,
reserving its use for later in the procedure, once
the location of the tip in the vitreous cavity can be
verified. The clarity of the cornea and anterior
chamber and the presence of the crystalline lens
or a pseudophakos will determine the first incision
into the eye after cannula placement. If the
anterior vitreous can be easily seen, a pars plana
incision 3.5 mm from the limbus can be the first
incision.

113. SURGICAL TECHNIQUES
• If light is not needed during the initial portion of
the procedure, a bent needle or other blunt
infusion port can be positioned in the center of the
pupillary space, where its position can be
monitored. This infusion can be turned on at this
stage so that the incision through the pars plana
for the cutting instrument may be made in a firm
eye. That incision is also made 3.5 mm posterior to
the limbus. The initial instrument placed in the eye
may combine both light and infusion. Alternatively,
a full-function instrument combining infusion, light,
cutting, and suction is a good option for these
cases.

114. SURGICAL TECHNIQUES
• The anterior chamber often contains significant amounts
of fibrin and hypopyon. Because the cornea invariably has
some combination of epithelial edema, folds, and cells
deposited on the posterior surface, the iris and central
anterior vitreous are often impossible to visualize
adequately. Initial incisions may be made in the limbus at
9.30 and 2.30 clock positions, modifying the location as
necessary depending on condition of the previous
surgical wound and on the presence of a filtering bleb.
Fluid is infused into the anterior chamber as inflammatory
debris is removed with the suction and cutting instrument
. This may also be accomplished with a single incision
and a small-gauge instrument combining infusion, cutting,
and suction .

116. SURGICAL TECHNIQUES
• . The use of a single incision reduces the flexibility of the
surgical approach, however. When two incisions are used and
when it is necessary to switch the cutting instrument from one
site to the other, it is useful to remove the cutting instrument
from its site and then replace it with a second infusion on a
blunt needle the same size as the cutting instrument. Only
then is the initial infusion removed and the cutting instrument
replaced in its site. This allows the pressure to be maintained
at a constant level, minimizing chances of hemorrhage and
making passage of instruments through limbal incisions
easier. An inflammatory membrane usually extends
continuously over lens or pseudophakos and on to surface of
iris. When a pseudophakos is present, the lens need not be
removed; attempting to do so may increase the risk of
bleeding.

117. SURGICAL TECHNIQUES
• The inflammatory membrane, however, should be removed
from its surface for better visualization of posterior segment.
It may be initially incised with a myringotomy blade or other
sharp needle and then elevated for removal with a cutting
instrument . It may also be engaged with a hooked needle and
rolled on to the needle. Removal of an inflammatory membrane
from the crystalline lens should begin over the iris, close to the
pupillary border, if it is believed that the lens can be spared.
Often, because of poor dilation of the pupil and poor
visualization of the internal structures, the lens in phakic eyes
must be removed. The fastest way to accomplish this is with
fragmentation through pars plana incisions, although young,
soft lenses can often be removed with cutting instruments. In
severe cases the cornea and anterior chamber may be totally
opaque. In theses eyes, a temporary keratoprosthesis can be
used, followed by a penetrating keratoplasty .

118. SURGICAL TECHNIQUES
• Material for culture and stain should be removed
from the eye early in the case. Because anterior-
chamber samples frequently do not render positive
culture results, attention should be directed to
obtaining an adequate vitreous sample. In most
surgical setups, the tubing that comes from the
suction–cutting portion of the instrument can be
opened. Alternatively, a very short piece of tubing
is attached to the egress port of the vitrectomy
probe . A sterile syringe is connected, and the
vitreous is withdrawn with manual suction.

119. SURGICAL TECHNIQUES
• 0.2 mL is removed before starting infusion into the
eye to obtain an undiluted sample. The material is
then immediately sent to the laboratory for Gram-
and Giemsa-stain as well as cultures on blood
agar, chocolate agar, brain–heart infusion, and
Sabouraud’s media or broth and in thioglycolate
broth. It is important to obtain specimens for
culture before any antibiotics are injected into the
eye. The vitrectomy is now progressively carried
posteriorly. The vitreous removal is performed
initially in the center of the vitreous cavity.
Pockets of more heavily infiltrated vitreous are
sometimes located; in the aphakic eye, peripheral
depression may be used to bring these into view.

120. SURGICAL TECHNIQUES
• Aggressive removal of all infiltrated vitreous in the
basal area should not be attempted because this
often results in retinal tears. The presence of a
posterior vitreous detachment, on the other hand,
allows more complete vitreous removal. If the
vitreous is still attached, a judgment must be
made about the amount of vitreous to be removed.
The cutting of vitreous adjacent to inflamed or
necrotic retina will often cause retinal breaks;
these are difficult to seal and may result in failure
of the case.

121. SURGICAL TECHNIQUES
• In eyes with posterior vitreous detachment, a
white mound of inflammatory debris may be
visible over the posterior pole. This should be
approached with care and may be gently
aspirated into the cutting port. If the mound
proves to be solid and adherent, small amounts
can usually be removed, but in most cases it is
unwise to attempt to remove large portions. In
some instances material is flocculent and
equivalent to an unorganized hypopyon; this can
be gently sucked up with vacuum techniques .

122. SURGICAL TECHNIQUES
• If visibility is so poor that vitreous posterior to the
central area cannot be adequately defined, repeated
attempts should be made to clear the anterior chamber.
Membranes can also be present on the posterior surface
of the lens, and these should be removed. If good
visibility cannot be obtained, it is better to discontinue
the procedure than to risk retinal damage by cutting
posteriorly with inadequate visualization. The procedure
is completed by closing all incisions in a water-tight
manner and injecting intraocular antibiotics. After
closure of the conjunctival incisions, subconjunctival
antibiotics are often injected. The major intraoperative
complications to be feared are hemorrhage and retinal
detachment.

123. Elevation of fibrin membrane from
lens and iris to mobilize for cutting.

124. A short piece of tubing connects a syringe to
vitrectomy probe to obtain a vitreous sample.

125. Vacuuming
removal of
“hypopyon”
from
macular
area.

126. SURGICAL TECHNIQUES
Retinal breaks are a major problem. A choroidal
hemorrhage may be devastating and can destroy the eye.
The best way to avoid this complication is to keep
intraocular pressure at a constant level during the entire
procedure, thereby preventing hypotony. If choroidal
hemorrhage does develop, intraocular pressure should be
immediately raised to high levels in an attempt to close
bleeding vessel. Breakdown of the original surgical wound
is also occasionally encountered. Resuturing the wound
with broader bites may be necessary. Since the
introduction of small gauge vitrectomy, the use of 23G and
25G instruments has become more popular in the
treatment of infectious endophthalmitis. However, many
surgeons choose to routinely suture all sclerotomies at the
end of these cases.

127. Postoperative management
• If treatment is proceeding well, patients usually
have a dramatic improvement in ocular pain by the
first postoperative day. Nonetheless, some form of
analgesic, including narcotics, is often required.
Resolution of disease can be monitored in part by
progressive reduction in pain. Antibiotics given
intravitreally at time of surgery maintain high
therapeutic levels for 24–48 hours. In bacterial
disease, necessity for repeat intravitreal injection
is not known with certainty; levels exceeding
minimal bactericidal levels are present for at least
24–36 hours after most intravitreal injections .

128. Postoperative management
• . Drops may also be prepared by the hospital pharmacy in
highly concentrated doses; administered from 5 to 20
times daily, they may have a booster effect but probably
do not significantly increase intraocular concentrations.
Not all infections are cured by a single dose of injected
antimicrobial. If the inflammation appears to worsen the
physician should suspect that the infectious process
remains active. A repeat tap and injection of antibiotics,
chosen on the basis of the culture results, should be
considered; if the media appears significantly opaque, or
if the initial therapy was only injection of antibiotics, a
vitrectomy may be considered. If the initial culture
sensitivities show that the organism is resistant to the
antibiotic originally injected, injection of an appropriate
antibiotic is recommended .

129. Postoperative management
• Vancomycin, ceftazidime,cefazolin, or a fluoroquinolone
may be useful when a longer duration of antimicrobial
effect is desired than the 24–48 hours provided by
intravitreal injection. Second operations are frequent in
patients with endophthalmitis. In the EVS , 35% of all
eyes needed some secondary procedure. Opacities in the
vitreous cavity may continue to interfere with vision, even
if the eye responds well in terms of inflammatory signs.
The retina should be monitored at regular intervals with
ultrasound if the surgeon cannot be sure by indirect
ophthalmoscopy that it remains attached. Removal of
these opacities may be undertaken with a repeat
vitrectomy as an elective procedure once the eye
becomes quiet.

130. Complications
• The cornea is often edematous in the early postoperative
period. Epithelial edema usually clears within the first week if
the endothelium has not undergone major damage; stromal
edema will also slowly clear. Persistent epithelial defects may
occasionally be seen, and their healing can be compromised
by the frequent use of topical medications. Pigmented cells
may remain on the posterior surface of the cornea for months.
If epithelial edema does not clear and the eye seems
otherwise salvageable, a corneal graft may be considered.
Elevated pressure usually responds to medical management
and improves as the inflammatory process resolves.
Persistent hypotony, which not only contributes to poor
corneal clearing but is also usually associated with persistent
inflammation and a progressive downhill course, even in the
presence of a sterile vitreous cavity should raise the
suspicion of a leaking wound site.

131. Complications
• Ultrasonography may reveal choroidal detachment; the
only management currently available is a vigorous
attempt to control the inflammatory process medically.
Inflammatory signs (usually more flare than cells) can
persist for many weeks after surgery, especially if the
initial disease was severe. Bacterial products such as
endotoxins in Gram-negative infections and exotoxins in
Gram-positive infections may persist, even after
successful vitrectomy, resulting in a recurrence of
vitreous cavity fibrin and cells 24 hours after an adequate
vitrectomy. If there is no sign of slow but steady
improvement, the ultimate outcome is almost uniformly
poor, and phthisis is the usual result.

132. Complications
• Cataract may also develop in the postoperative period if
the crystalline lens has been left in place. Cataract
removal can also be performed electively when the eye
becomes quiet. If the ultrasound or clinical examination
indicates the presence of significant vitreous opacities
associated with the lens change, a pars plana approach
may be used for fragmentation of the lens and removal of
the vitreous opacities during the same procedure. Retinal
detachment is a feared complication of vitrectomy for
endophthalmitis. Retinal detachment occurred in 8.3% of
eyes in the EVS. Tears that occur at the time of surgery
are managed as outlined earlier. Unrecognized
intraoperative tears, such as entry-site tears, can result
in a detachment soon after surgery. Necrotic retina may
also break down, creating an atrophic retinal break.

133. Complications
• Standard buckling procedures may help in many cases,
but these may be difficult to perform because of the
inability to see the fundus clearly on account of corneal
opacity, poor dilation of the pupil, persistent opacity of
the media, haze on the surface of an IOL, or opacification
of the vitreous base. These retinal detachments can
sometimes be repaired successfully, but they are
reportedly the major cause of failure in most series.
Anatomic success was achieved in 78% of the cases in
the Endophthalmitis Vitrectomy Study, but the
occurrence of detachment was correlated with a poor
visual outcome .

134. Complications
• Proliferative vitreoretinopathy is a major risk in eyes with
detachment; sympathetic ophthalmia has also been
reported.Despite anatomic success, some eyes see
poorly. Postoperatively a small percentage of eyes
injected with aminoglycosides at surgery develop
whitening of the macular area with intraretinal
hemorrhages in the posterior pole. Fluorescein
angiography demonstrates shutdown of the capillaries
and arterioles supplying the macula and vision is
frequently poor. Histologic examination of similar
appearing lesions produced experimentally in primates by
injection of gentamicin shows extensive destruction of
the nerve fiber layer.

135. PRACTICAL EXAMPLES

136. DURING
CATARACT
SURGERY
THERE WAS
UNFORESEEN
SOME
COMPLICATIONS

137. REACTION
DISAPPEARED
AFTER
INTENSIVE
STEROIDS

138. ENDOPHTHALMITIS DEVELOPED ON 3RD POST OP DAY .
TREATED WITH INTRAVITREAL VANCOMYCIN 1MG AND
CEFTAZIDIME 2.25 MG
POST INTRAVITREAL INJ PT IMPROVED .

139. PPV WITH IOL REMOVAL DONE IN THIS CASE
AS THIS CASE DOES NOT RESPOND TO
INTRAVITREAL INJ OF VANCOMYCIN AND
CEFTAZIDIME .

140. CONCLUSION
•Endophthalmitis remains a devastating
complication of intraocular surgery and
penetrating ocular trauma despite recent
advances in diagnosis and treatment. Two-
thirds of cases are postoperative, and 20–
25% occur after penetrating trauma. Gram-
positive organisms predominate in incidence
and usually fare better than Gram-negative
infections, with Staph epidermidis having a
better prognosis than S. aureus. Fungal
endoph accounts for 5–10% of all cases.

141. CONCLUSION
• Intraocular antibiotics are well established
as the mainstay of treatment for endoph
because of the poor penetration of
antibiotics into the vitreous cavity when
administered by other routes because of
the blood–retina barrier. Antibiotics are
sometimes injected into the vitreous cavity
as the only intravitreal therapy, whereas on
other occasions they are combined with
pars plana vitrectomy .

142. CONCLUSION
• Pars plana vitrectomy has the advantage of
removing bacteria and their toxins and clearing
the ocular media, allowing a more rapid visual
recovery. The eye is sterilized more quickly and
reliably. Most authors recommend vitrectomy as
the initial therapy for fungal infections and for the
secondary structural changes, such as vitreous
opacification, occurring after chronic infections
such as Toxocara canis. Most authors recommend
vitrectomy for Propionibacterium acnes infections
and for traumatic endophthalmitis.

143. CONCLUSION
• In bacterial infections, immediate vitrectomy is
recommended for the most severe infections,
including clinical settings such as filtering blebs,
which are known to have a high incidence of
virulent organisms. Vitrectomy is then followed
by intraocular antibiotic injection. Although
severity of infection is difficult to define
precisely, mild to moderate infections are
managed with immediate vitrectomy by some
authors, but others recommend initial intraocular
antibiotic injection, followed by vitrectomy only
if the disease worsens.

144. CONCLUSION
• The Endophthalmitis Vitrectomy Study
demonstrated that vision with only light
perception was an indication for immediate
vitrectomy based on improved results in these
eyes compared with a strategy of vitreous tap and
injection of antibiotics. Results of therapy for
endoph have improved in the last decade.
Reasonable return of vision is often achieved in
cases with negative culture results and infections
with S. epidermidis and some fungi. Smaller
percentages of eyes infected with S. aureus and
even fewer with Gram-negative organisms survive
with recovery of ambulatory vision.

145. CONCLUSION
•Infections after trauma have a poorer
prognosis than postoperative cases after
cataract extraction; postoperative pars
plana vitrectomy eyes and eyes with
filtering blebs do poorly. The length of time
from onset of infection to initiation of
therapy and differences in virulence from
one strain of bacteria to another are other
important factors in outcome.

147. THANK
YOU
DR DINESH
DR SONALEE