Management of endophthalmitis requires aggressive action

Valhalla, NY-The management of endophthalmitis has progressed in leaps and bounds over the past 4 decades. Immediate treatment, however, is vision-saving, with many patients achieving 20/40 vision.

Robert G. Josephberg, MD, described the optimal approach for these patients.

Timing of surgery is key

The Endophthalmitis Vitrectomy Study (EVS), which included 420 patients with endophthalmitis, studied the role of immediate vitrectomy and intravenous antibiotics in the management after cataract surgery or secondary IOLs within 6 weeks after cataract surgery.

The important point was that the surgeries had to be performed within 6 hours of patient presentation. The view of the anterior segment also had to be sufficiently clear to perform a vitrectomy or needle tap. Patients with a poorly visualized anterior segment, cases secondary to trauma, and endogenous, bleb-related, and delayed onset were excluded.

Vancomycin (1 mg) and amikacin (400 μg) were administered, along with topical antibiotics, subconjunctival injections, oral prednisone, intravenous amikacin, and ceftazidime, Dr. Josephberg explained.

Dr. Josephberg recounted that the average onset of symptoms was 6 days postoperatively; 25% of patients had no pain and 14% had no hypopyon. Cultures were positive in only 69% of cases, most of which identified gram-positive organisms. Six percent of patients had cultures positive for gram-negative organisms.

"It is noteworthy that most patients with gram-positive organisms achieved 20/100 visual acuity or better," Dr. Josephberg said. "Patients with the most virulent organisms had worse outcomes, with less than 30% of patients (virulent organisms Staphylococcus aureus, streptococci, and gram-negative organisms) having 20/100 or better visual acuity and 5% having no light perception visual acuity.

"The patients who presented with light perception vision had a better outcome with vitrectomy and three times the chances of achieving 20/40 or better and a 50% less incidence of no light perception vision," Dr. Josephberg reported. "It was noteworthy that 7% of the 420 patients needed re-injection of antibiotics because of worsening of their condition at 36 to 60 hours. It is particularly noteworthy, that one injection of vancomycin and amikacin on the re-taps and re-cultures failed to eradicate many of the organisms."

In addition, there were infections in 40% of the patients treated with documented povidone-iodine preoperatively and in 11% of patients who had documented intracameral antibiotics in the infusion bottle preoperatively at the cataract surgery.

The intravenous antibiotics used at the time of the EVS provided no additional benefit for these patients. An immediate vitrectomy performed up to 6 hours after presentation is of significant benefit for those patients with light perception vision, Dr. Josephberg emphasized. In patients with hand motion or better vision, a vitreous tap or an automatic vitrector biopsy were as effective and were recommended.

Current practice