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Treatment of Acute Bacterial Endophthalmitis After Cataract Surgery Without Vitrectomy

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Treatment of Acute Bacterial Endophthalmitis After Cataract Surgery Without Vitrectomy Chapter 6 Treatment of Acute Bacterial Endophthalmitis 6 After Cataract Surgery Without Vitrectomy Thomas Theelen, Maurits A.D. Tilanus Core Messages ■ Exogenous endophthalmitis due to ■ A pretreatment vitreous tap for microbi- cataract surgery is rare and occurs in al analysis is always required and should approximately 0.05% of all cases with a begainedbyavitreouscutter. growing incidence since the routine use ■ Inject 1 mg (0.1 cc) of vancomycin, of no-stitch cataract surgery began. 2.5 mg (0.1 cc) of ceftazidime, and 25 mg ■ Most of the patients with acute endo- (0.1 cc) of prednisolone into the vitreous phthalmitis after cataract surgery be- cavity with a 23-gauge needle. come symptomatic between 1 day and ■ If there is no significant improvement 2 weeks after surgery. in the clinical aspect of the eye a second ■ When the diagnosis endophthalmitis has intravitreal injection is administered on been made a medical emergency is pres- thethirdday. ent and the next diagnostic and thera- ■ The causal bacteria seem to be the most peutic steps do not permit any delays. important prognostic factor in endo- We strongly advise carrying out a vitre- phthalmitis after cataract surgery. ous tap and injecting antibiotics into the ■ The production of bacterial exotoxins vitreous cavity within less than an hour and increased microbial motility may after the clinical diagnosis. lead to very early and severe functional ■ Vitreoretinal specialists all over the world damageeveninthepresenceofonly are divided into two camps: those who mild inflammation with a relatively avoid early vitrectomy and those who small amount of bacteria. In such cases, claim the obligation of immediate com- any therapeutical intervention may be pleteparsplanavitrectomy.Eventhough unsatisfactory and the visual outcome recent peer-reviewed literature includes maycommonlybepoor. numerous publications about the treat- ment of postoperative endophthalmitis, noneofthepapersoffersaprospective, randomized study of modern, complete parsplanavitrectomyversusvitreoustap and intravitreal antibiotics only. 70 Treatment of Acute Bacterial Endophthalmitis After Cataract Surgery Without Vitrectomy 6.1 Introduction used, the intraocular lens used seems to add to the specific risk of endophthalmitis [3, 16]. 6.1.1 Basics After cataract surgery, intraocular bacteria can 6.1.2 Pathophysiology be observed in as many as 29–43% of all patients without any pathologic response [7, 29]. A mi- In most cases of intraoperative microbial con- nority of these patients, however, develop an tamination, protective mechanisms known as inflammatory reaction as a result of the coloni- the anterior or posterior chamber-associated im- zation of bacteria or fungi, which gives the clini- mune deviation (ACAID/POCAID) prevent eyes cal impression of endophthalmitis. Exogenous from disastrous inflammatory mechanisms [33]. 6 endophthalmitis due to cataract surgery is rare Compromise of this “immune privilege” by in- and occurs in approximately 0.05% of all cases, traoperative complications like capsular damage with a growing incidence since the routine use or vitreous loss can cause a 14-fold increased risk of no-stitch cataract surgery began [20, 23, 34]. of endophthalmitis [19]. The risk of endophthalmitis is mainly dependent on the surgical technique used [24, 27, 32]; how- ever, there is no evidence that the duration and 6.1.2.1 Phases of Infection complications of surgery as well as diabetes mel- litus and immunosuppression will additionally In infectious endophthalmitis, specific clinical increasethedangerofdevelopingendophthal- phases can be distinguished [15], as illustrated in mitis [30, 36]. As the extent of bacterial adhesion Fig. 6.1. These are dependent on the route of- in appears to depend on the specific lens material fectionaswellasonthetypeandvirulenceofthe Fig. 6.1 Phases of bacterial growth and concurrent endophthalmitis development. The curves show an example of time-dependent intraocular bacterial growth and concurrent endophthalmitis development after cataract -sur gery. Red line ocular integrity/retinal function (dotted in the case of exotoxins); green line bacterial growth; blue line exotoxin release (if appropriate). In the late phase of acute endophthalmitis there is no functional recovery because of retinal damage despite bacterial cell death. The presence of exotoxins may add to severe ocular impair- ment. IP incubation phase, AP acceleration phase, DP destructive phase, Lag bacterial lag phase without increase in cell number, Log phase of exponential bacterial growth, stat stationary bacterial phase, death exponential bacte- rial death phase 6.1 Introduction 71 inoculated microbes and the patients’ immune the virulence of the pathogen the earlier and the state. Under unfortunate clinical conditions more serious the inflammatory response. those phases will develop faster and the destruc- tive power of the inflammation will be stronger. 6.1.2.1.3 Destructive Phase 6.1.2.1.1 Incubation Phase Destruction of retinal tissue is the catastrophic injury eventually leading to the bad functional The first step of exogenous endophthalmitis af- outcome of endophthalmitis. The cytotoxic prop- ter cataract surgery is clinically unapparent and erties of some microbes, as well as the inflamma- develops in the earliest postoperative period. It tion itself, may lead to substantial disorganiza- lasts at least 16–18 h even in patients with highly tion and necrosis of the retina [14, 18, 26]. If this virulent pathogens. The generation time of the phaseofendophthalmitisisreached,thechance microbes is the main determinant for the dura- of successful treatment will diminish rapidly. tion of this phase. 6.1.3 Clinical Diagnosis 6.1.2.1.2 Acceleration Phase Most of the patients with acute endophthalmitis Dependent on the inoculated number and viru- after cataract surgery become symptomatic be- lence of the microbes, endophthalmitis becomes tween 1 day and 2 weeks after surgery. Reduced symptomaticbybreakdownoftheblood–aqueous vision after initially good visual acuity is present barrier. Increasing inflammatory reactions cause in virtually all of these cases [10, 35]. Table 6.1 fibrin exudation and leukocyte migration into lists the most important clinical signs arranged the anterior chamber and vitreous. These signs by their incidence. Figure 6.2 gives a represen- are predominantly accompanied by individual tative illustration of acute postoperative endo- symptoms like visual loss and pain. The higher phthalmitis. Table 6.1 Clinical symptoms of acute endophthalmitis after cataract surgery [10, 35] Indicator Remarks Visual loss Blurred vision down to no perception of light within several hours and up to 1 day (>90%) Uveitis anterior Cloudy anterior chamber: cells, Tyndall sign and fibrin coagulate (>90%) Hypopyon Concavetohorizontalandsmoothinbacterialinfection; (75–86%) sometimesconvexandspikyinfungalendophthalmitis Pain Moderate to heavy ocular pain, sometimes nausea (74–85%) Ocular redness Pericorneal injection, later diffuse redness (>80%) Conjunctival chemosis Eyelid chemosis Vitritis Sometimes with vitreous abscess and retinal edema or signs of retinitis Absent red reflex In the case of severe anterior or total vitritis Corneal edema Sometimes with infiltrates or ring abscess 72 Treatment of Acute Bacterial Endophthalmitis After Cataract Surgery Without Vitrectomy Fig. 6.2 Slit-lamp appearance of acute endophthalmitis 6 6.1.3.1 Role of Ultrasonography Gram-positive bacteria cause by far the most cases of acute endophthalmitis after cataract In the case of opaque media, ophthalmic ul- surgery. The number of Gram-negative cases is trasound may give valuable information about decreasing and current data suggest an incidence the clinical situation of the posterior segment of considerably less than 10% [11]. A survey of in acute endophthalmitis. A recent ultrasono- studies investigating the microbiologic aspects of graphic study of 137 eyes suggested that some postoperative endophthalmitis reveals that co- echographic parameters might help to assess the agulase-negative staphylococci represent about functional outcome of infectious endophthalmi- half of all culture-positive acute endophthalmitis tis [5]. There was a positive correlation between cases, followed by Staphylococcus aureus and β- poor visual outcome and the presence of dense hemolytic streptococci [1, 9, 11]. Figures 6.5–6.7 vitreous opacities and choroidal detachment. give an idea of the microbiologic view of endo- Furthermore,theauthorsfoundanassociation phthalmitis. between the grade of vitreous opacity, choroidal The frequent use of antibiotics in medicine has detachment, and the causative group of bacteria. led to growing resistance of pathogens [17]. In Longitudinal examination by ultrasound may endophthalmitis, bacteria have become increas- also be useful to follow treatment effects and to ingly resistant to ciprofloxacin and cefazolin, a decide whether additional therapy is needed in tendencythatmaybecausedbythegrowingpre- due course. The different echographic appear- operative use of fluoroquinolones [22]. ance of diverse microbes is illustrated in Figs. 6.3 and 6.4. Summary for the Clinician 6.1.4 Microbial Spectrum ■ After cataract surgery the presence of bacteria in the anterior chamber is com- If a vitreous tap is taken, up to two-thirds of all mon. culturesareexpectedtobepositiveandonlyin ■ Postoperative endophthalmitis is rare those cases is exact antibiotic therapy possible and is maintained by surgical technique [12]. Hence,
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