Endophthalmitis is a devastating complication of ocular surgery and trauma, which may lead to total loss of vision and sometimes even the eyeball. Management of endophthalmitis presents one of the most challenging problems in ophthalmology. Two third of all cases of endophthalmitis occur after surgery. 90% are caused by bacteria and the remaining 10% by fungi, viruses and parasites. Incidence reported in literature is 0.1% to 0.4%. Though no study is available, incidence in our setup seems to be even higher.
Traditionally endophthalmitis had been treated with topical and systemic antibiotics given both orally as well as parenterally but with poor therapeutic response. Another mode of treatment that has now become the standard treatment for endophthalmitis in developed countries is intravitreal injection of antimicrobials. Studies have proven this to be an effective, probably the only effective treatment available so far. In Pakistan this way treatment has not yet been widely practiced.
The authors have carried out a study on 56 eyes diagnosed as cases of endophthalmitis. The patients were treated with intravitreal injections. Results were encouraging. Anatomical integrity was preserved in 90% of cases and 60% had a visual acuity of 6/60 or better. A gold medal winning paper was presented by one of the authors in Ophthalmo 96 based on the above study. Great enthusiasm was shown about the technique. The Chairman of the conference advised to publish the technique.
The aim of this booklet is to present in a simple way the management of endophthalmitis using the technique of intravitreal injections. Secondly we want to decrease the undue hesitancy and fear about the use of intravitreal injections. By the end of the booklet the reader will feel confident to practice the procedure on his own whenever and wherever needed.
Diagnosis and Management Plan
Slight to no pain.
Decrease in visual acuity, which may be the only symptom.
Patient should be clearly told that vision is going to improve day by day and any deterioration after initial improvement must be taken seriously and immediately reported to the surgeon.
Marked visual loss.
Patient may present with minimal signs. Anterior chamber may be clear. Cells in vitreous may be the only finding on examination. This finding alone is sufficient to diagnose endophthalmitis in appropriate setting. One must have a routine look into the vitreous during postoperative examination since as already mentioned the patient may be absolutely symptom free.
Cells in the vitreous.
Absent red reflex.
The recognition of early symptoms and signs is the most important in the treatment of endophthalmitis. Late symptoms and signs do not mean that we should wait till the condition is established. Neither it means that the condition has become untreatable.
Abbildung in dieser Leseprobe nicht enthalten.
- Injections should be prepared just before use. Left over quantity can be used to make fortified eye drops.
- Distilled water is required for the constitution of vials. BSS/Ringer’s Lactate/Saline is used for dilutions
- Expiry for the constituted vial is one week or as specified by the manufacturer if distilled water is used.
- Discard the dilutions after single use.
Procedure and Technique.
Choice of antimicrobials
Time of onset gives some clue to the type of organism.
- Staph aureus and gram-negative organisms usually present between first and third postoperative days with severe signs.
- Staph. Epidermidis usually presents with mild signs between fourth and tenth postoperative days.
- Fungus generally presents around third post op. week with mild signs.
When no stain or culture or gram stain report is available an antibiotic combination which covers both gram positive and gram negative organisms along with a steroid is used.
Steroid is used in a routine cover but must not to be used if a fungal infection is suspected.
All the antifungal drugs are very toxic and should not be used until there is a very strong suspicion or positive staining or culture report for the fungus.
- Choice of anesthesia depends on the surgeon and the patient. Intravitreal injection can be given under topical anesthesia. Another method is to give the anesthetic agent subconjunctivally at the site of injection.
- If the patient is apprehensive or feels excessive pain surgeon should not hesitate to give retrobulbar or peribulbar anesthesia.
Injection site is 3.5mm posterior to the limbus in aphakic and 4.0mm posterior to the limbus in phakic eyes.
Vitreous aspiration and injection
To give the injection we use a 1cc syringe with detachable needle of size between 24G to 27G.The bigger gauge needle is required in younger patients and in cases where the vitreous abscess is thicker and difficult to aspirate. Tip of the needle is directed towards the centre of the vitreous cavity. First the vitreous is aspirated. If vitreous cannot be aspirated AC tap should be performed. Never try to inject without aspiration. After aspiration the syringe is removed holding the needle in place with an artery forceps. Now the syringe containing the antibiotic is attached to the same needle and injected. All the steps are performed under sterile conditions using sterile ingredients and aseptic technique. Volume of each injection is 0.05 to 0.1cc.with total injectable volume in the range of 0.1 to 0.3cc.
In cases where vitreous aspiration is not possible and we have to resort to AC tap, the final injectable volume should be kept as little as possible. This can be done by making each injection in a volume of 0.05cc instead of 0.1cc. To achieve this, the same guidelines should be followed as already given in the table.
- Great care should be taken while preparing the injections. Low dose will result in inadequate response whereas higher doses are toxic for the retina.
- Sterility should be maintained throughout.
- Injection site should be accurately determined using a caliper. Too anterior injection may result in hemorrhage. Too posterior injection may lead to retinal detachment.
- Tip of the needle should be pointed towards the centre of the vitreous cavity.
- Tip of the needle should not be more than 1 to 1.25cm in the vitreous cavity.
- Do not inject if you are unable to aspirate the vitreous. Instead go for an AC tap and inject into the vitreous.
- Inject slowly and steadily. Injection jet may damage the retina.
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- Institution / Hochschule
- HFHS - Höhere Fachschule für anthroposophische Heilpädagogik, Sozialpädagogik und Sozialtherapie – CPMC
- treatment intravitreal injections