Endophthalmitis für Praktiker¤sentationen...• DD lens-induced uveitis SAoO 2020, Matthias...
Transcript of Endophthalmitis für Praktiker¤sentationen...• DD lens-induced uveitis SAoO 2020, Matthias...
Endophthalmitis für Praktiker
Prof. Dr. Matthias Becker
www.triemli.ch/augenklinik
Augenzentrum
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 2
Learning Objectives: Endophthalmitis
The audience knows…
• …how to make the diagnosis
• …how take the first steps of therapy
• …has knowledge about the most important aspects of the „current state of the art“
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 3
AirVote
a. I only refer to the best cataract surgeons – they never produce
endophthalmitis cases!
b. Topical antibiotics are a critical MUST in postoperative cataract
management
c. „Tap & Inject“ is a great option to safe time and start treatment early
d. Be careful with povidone-iodine: never use it inside the eye!
e. Pain is an unusual symptom for endophthalmitis
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 4
Endophthalmitis (EO) – Take home messages
• Endophthalmitis probably cannot be completely prevented, but its incidence may
be reduced
• Consensus on best postoperative management is still lacking
• Have your emergency network ready – just in case…
• Shoot first – ask questions later…? „Tap & Inject“ revisited
• Use of povidone-iodine in irrigating fluid or as an intravitreal injection is a viable
prophylactic and therapeutic future option
• Pain is an important clinical finding in EO
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 5
Exogenous Endophthalmitis
• Acute postoperative EO• < 30 days postop
• Post-Cataract: 0.07 – 0.32%
• Post-IVOM: 0.0075% per injection (0.03-0.06% office procedure)
• Post-Glaucoma, post-Vitrectomy, trauma, foreign body, corneal ulceration, periocular infection
• Gram-positive (coagulase-negative staphylococci: Staph. epidermidis, Staph. aureus)
• Gram-negative (Pseudomonas aeruginosa)
• Postoperative delayed-onset EO• > 6 weeks postop
• Anaerobic gram-positive (Propionibacterium acnes)
• DD lens-induced uveitis
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 6
Endogenous Endophthalmitis
• Metastatic
• Predesposing systemic risk factors
• Diabetes
• liver/cardiac disease
• in-dwelling catheters
• iv-drug abuse
• Streptococcus, Staphylococcus, Candida,
Klebsiella
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 7
Post Injection endophthalmitis (PIE)
• Risk higher after intravitreal corticosteroids than after intravitreal anti-
VEGF agents
• Prophylactic antibiotics are not a necessary part of intravitreal injection
preparation and management (meta-analysis)
Open J Ophthalmol. 2013;3:46
• Post Injection Cluster-endophthalmitis (PICE): outbreak of five or
more cases on a particular day in a single operating room in same
center
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 8
Ocular examination
• Ocular tenderness
• Swollen lids
• Conjunctival hyperemia
• Discharge from eyes (watery / purulent /
mucopurulent)
• Circumcorneal congestion
• Corneal edema, associated corneal ulcer
• Anterior chamber reaction
• Hypopyon
• Iris swollen with hazy details
• Vitreal infiltration
• Fungal balls or fluffy exudates or string of pearls
may be seen in fungal endophthalmitis
• Poor fundus red-reflex
• Media haze
• No lens or anterior vitreous details
• Intraocular pressure may be raised and affects
prognosis of the condition
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 9
Endophthalmitis Management – Where are we “Now”
• Preoperative 5% povidone-iodine
antisepsis
• Intravitreal antimicrobial injections
• Improved vitrectomy instrumentation
• Newer alternative antimicrobials
• Polymerase chain reaction (PCR)
• Peptide nucleic acid–fluorescence in
situ hybridization (PNA-FISH)
• Big data allows to better evaluate
outcomes and to compare rates of
endophthalmitis (IRIS Registry)
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 10
• So far only prospective randomized partially masked multicenter trial
• 16’603 patients
• Use of intracameral cefuroxime at the end of surgery reduced the occurrence of
postoperative endophthalmitis by factor 4.97x
• High rate of endophthalmitis (0.33%) in cohort not receiving intracameral
cefuroxime. More easily allowed intracameral cefuroxime to significantly improve
the endophthalmitis rate
• Study was stopped prematurely
• Use of multiple surgical techniques
Endophthalmitis Study Group
J Cataract Refract Surg 2007;33:978
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Criticisms of Intracameral Antibiotics (IA)
• Potential risk of dilutional error
• Contamination
• Cost-benefit concerns
• Number needed to treat
• Emerging antimicrobial resistance
• Potential complications
• Infection
• TASS: Toxic anterior segment
syndrome
• HORV: Hemorrhagic occlusive
retinal vasculitis
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 12
Criticisms of Intracameral Cefuroxime
• Complete lack of activity against
Enterococci, Pseudomonas species,
and Enterobacteriaceae species
• Low activity against methicillin-
resistant Staphylococcus aureus
(MRSA) and S. epidermidis (MRSE)
• Increasing resistance of coagulase-
negative staphylococci
• Enterococci and coagulase-
negative Staphylococci are
responsible for majority of EO
• Add Ampicillin to Cefuroxime,
because of its activity against
Enterococci
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 13
Intracameralists vs. Topicalists
• Several studies reporting…
• No benefit of IA when topical
antibiotics (TA) were used
• No benefit of TA use when IA were
used
• Preoperative topical antibiotics
significantly reduce conjuctival flora –
effect on postoperative
endophthalmitis??
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 14
Current recommendation for postoperative therapy in
cataract surgery
Lwowski CM, et al. Klin Monbl Augenheilkd 2019;236:636
Nepafenac, Bromfenac, Ketorolac
• Using antibiotic eye drops in addition to antibiotic injections probably lowers
the incidence of endophthalmitis compared with using either injections or eye
drops alone («moderate-certainty evidence»)Gower EW, et al. Cochrane Database Syst Rev 2017;2:CD006364
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Current Intravitreal Antimicrobials for Endophthalmitis
• Vancomycin
• Ceftazidime
• Amikacin
• Amphotericin-B
• Voriconazole
• Reduction of anterior chamber contamination rate
after cataract surgery by intraoperative irrigation
with 0.25% povidone-iodine
Am J Ophthalmol 2011;151:11
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IRIS registry
• World’s largest specialty clinical data registry
• Aggregated, de-identified data
• 61 million unique patients (USA)
• 253 million patient visits
• 15’000 clinicians in ophthalmology practices
have registered to electronically contribute
their data through their electronic health
record systems
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 17
Pershing S, et al. Ophthalmology 2020;127:151
• United States cataract surgery patients, 2013-2017 (5’401’686 patients)
• Acute-onset endophthalmitis in 0.04%
• Risk factors may include younger age, cataract surgery combined with other
ophthalmic surgeries, and anterior vitrectomy
• Excellent vision after surgery (44% achieving driving-level vision)
• Big data from clinical registries like IRIS has great potential
• Evaluating rare conditions such as endophthalmitis
• Including developing benchmarks
• Longer-term time trend investigation
• Comprehensive analysis of risk factors and prophylaxis
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 18
Shoot first - ask questions later
• Give antibiotic injections earlier than
we currently do
• Referring ophthalmologist the moment
that endophthalmitis is suspected
• Then send patient in for biopsy
• Improved PCR techniques confirm the
diagnosis without relying on live
organisms
• Additional intravitreal dexamethasone
does not improve outcome
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 19
Conclusions
• Trend from earlier vitrectomy for debridement of bacteria, toxins and
inflammatory debris, better diffusion of antibiotics and potentially a more rapid
visual recovery towards
• »Big data» will continue to provide outcome measures and trends for
endophthalmitis prevention and treatment
• Big data is good at detecting associations, but it cannot tell us which associations
are meaningful
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 20
Endophthalmitis (EO) – Take home messages
• Endophthalmitis probably cannot be completely prevented, but its incidence may
be reduced
• Consensus on best postoperative management is still lacking
• Have your emergency network ready – just in case…
• Shoot first – ask questions later…? „Tap & Inject“ revisited
• Use of povidone-iodine in irrigating fluid or as an intravitreal injection is a viable
prophylactic and therapeutic future option
• Pain is an important clinical finding in EO
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 21
AirVote
a. I only refer to the best cataract surgeons – they never produce
endophthalmitis cases
b. Topical antibiotics are a critical MUST in postoperative cataract
management
c. „Tap & Inject“ is a great option to safe time and start treatment early
d. Be careful with povidone-iodine: never use it inside the eye
e. Pain is an unusual symptom for endophthalmitis
SAoO 2020, Matthias Becker, Endophthalmitis, 26.2.2020, Seite 22