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.
Table of Contents
1. Diagnosis and Management Plan For Endophthalmitis
2. Management plan
3. Doses and Preparation of Intravitreal Injections
3.1 Antibacterials
3.2 Antifungals
3.3 Steroids
3.4 Preparation of intravitreal injections
4. Procedure and Technique
4.1 Choice of antimicrobials
4.2 Anesthesia
4.3 Site
4.4 Vitreous aspiration and injection
4.5 Precautions
5. Follow up
6. Role of vitreous lavage
6.1 Procedure
7. Role of Pars Plana Vitrectomy
8. Complications of therapy
8.1 Inadequacies
8.2 Retinal and Macular Toxicity
8.3 Others
9. Outcome
10. Conclusions
Research Objectives and Key Topics
The primary objective of this work is to establish a simplified, standardized management protocol for endophthalmitis, specifically focusing on the effective use of intravitreal antibiotic injections to improve patient visual outcomes and reduce surgeon hesitancy regarding the procedure.
- Clinical diagnosis of early and late symptoms/signs of endophthalmitis.
- Step-by-step management algorithms for post-operative inflammation.
- Evidence-based dosing and preparation guidelines for intravitreal antimicrobial agents.
- Procedural techniques for safe vitreous aspiration and injection.
- Follow-up protocols and prognostic indicators for monitoring treatment success.
Excerpt from the Book
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.
Chapter Summaries
Diagnosis and Management Plan For Endophthalmitis: Outlines the crucial early clinical symptoms and signs required for rapid diagnosis to prevent permanent vision loss.
Management plan: Provides a visual decision-making flowchart to navigate appropriate treatment steps based on patient symptoms like hypopyon or vitreous opacification.
Doses and Preparation of Intravitreal Injections: Lists standard dosages for common antibacterials, antifungals, and steroids, alongside technical instructions for drug preparation.
Procedure and Technique: Details the clinical approach to selecting antimicrobials, administering anesthesia, and performing the actual injection with necessary sterile precautions.
Follow up: Describes the criteria for monitoring post-injection recovery and identifying prognostic signs to decide between continued injections or transitioning to topical treatment.
Role of vitreous lavage: Explores the use of vitreous lavage as a practical alternative to full vitrectomy in specific patient cases.
Role of Pars Plana Vitrectomy: Summarizes the indications and expert referral requirements for performing core vitrectomy when needle aspiration is insufficient.
Complications of therapy: Analyzes potential risks associated with the procedure, including toxicity and iatrogenic damage, and emphasizes proper technique to minimize these occurrences.
Outcome: Reports the success rates of the study in terms of anatomical preservation and visual acuity restoration.
Conclusions: Recaps the necessity of high clinical suspicion and the efficacy of direct intravitreal antimicrobial application.
Keywords
Endophthalmitis, Ocular Surgery, Intravitreal Injections, Vitreous Aspiration, Ophthalmology, Antibiotics, Vitrectomy, Hypopyon, Visual Acuity, Post-operative Inflammation, Retinal Toxicity, Ocular Trauma, Clinical Management, Antimicrobial Therapy, Steroids
Frequently Asked Questions
What is the core focus of this publication?
The booklet focuses on the management of endophthalmitis, specifically advocating for the use of intravitreal antibiotic injections as the primary treatment strategy following ocular surgery or trauma.
What are the primary themes covered in the text?
Key themes include early diagnostic criteria, technical protocols for drug preparation and injection, procedural safety, follow-up monitoring, and the assessment of treatment outcomes.
What is the main objective of the research presented?
The goal is to provide a simplified, standardized guide to help surgeons gain confidence in performing intravitreal injections, thereby improving patient prognosis.
Which scientific methods are primarily discussed?
The text discusses clinical observation, standardized injection protocols, AC tap procedures, and the application of pars plana vitrectomy as a secondary intervention.
What topics are explored in the main body of the work?
The main body covers the diagnosis of symptoms and signs, detailed pharmacological preparation of injections, specific surgical techniques, and clinical follow-up strategies.
Which terms characterize the work?
The work is characterized by terms such as intravitreal therapy, ocular infection management, surgical complications, and vitreous diagnostic signs.
Is it necessary to perform vitrectomy in all cases of endophthalmitis?
No, the authors suggest vitrectomy is reserved for cases where vitreous aspiration is impossible or as recommended by specific study groups for severe cases of reduced visual acuity.
Why is systemic administration of antibiotics discouraged by the authors?
Based on the Endophthalmitis Vitrectomy Study (EVS) conclusions, the authors note that systemic antibiotics lead to increased toxicity, higher costs, and longer hospital stays without sufficient efficacy.
How should a surgeon respond if a patient shows no improvement after an initial injection?
The protocol suggests repeating the vitreous tap and intravitreal injection after 24 hours if the initial response is inadequate, provided the condition is not already improving.
- Citar trabajo
- Zia Mazhry (Autor), 2014, Treatment protocol for post operative endophthalmitis, Múnich, GRIN Verlag, https://www.grin.com/document/283205
