UNIT DR MATHRUBOOTHAM SRIDHAR’S

DR ABHIJEET (DNB TRAINEE)APOLLO CHILDRENS HOSPITAL

Clinical History7 Y / FFever – 10daysLeft leg pain– 8daysUnable to walk– 8days

ON EXAMINATION

FebrileTachycardiaTenderness Lt thigh, Lt groinSystemic exam-normal

DIFFERENTIAL DIAGNOSISPyaemic abscessTropical myositisCellulitisosteomyelitis

D 1 admissionHb-9TC-37,900DC- P92 ,L5,M2,E1ESR-75mm 1 hrMP – negCPK- 74 IU/L

Investigation (cont)

USG abdomen -Lt iliac muscle inflammed,well defined echogenic collection in muscle going to post lateral region,3.7x3x4.5cm suggestive -iliac psoas abscess

D 3 of admission New symptom -redness Rt eyeNo discharge / photophobiaUnderwent I & D of psoas abscessIV ceftriaxone-tazo,amikacin initially.Blood and pus C/S- Staph.aureus

(Methicillin sensitivity not done) Teicoplanin was started and amikacin

was stopped.

D 4 of admissionRedness Rt eye persistedpain Rt eyeRt eye -smallOphthalmic consult – Ant segment-congested,pupillary

membrane, vitreous exudates ++, PL + PR defective disc ,macula –N Dilated tortous blood vessel. Suggestive-endophthalmitis.

Vision-impaired furtherCT Scan Brain – NTreated-IV fluconazole,IV dexa moxifloxacin,prednisolone,

atropine,gentamycin eye drops,Discharged after 9days.

Sankara nethralaya Operative procedure LensectomyVitrectomyIntra vitreal antibiotic

Our Hospital

Further ManagementHb-10.1TC-15,300DC- P58,L38,M2CRP-2.2USG-bulky Lt Psoas muscle,residual

abscess.Echo – NOn IV Ceftriaxone-taz,TeicoplaninPrednisolone,atropine,genta eye drops.

DISCUSSION

ENDOPTHALMITISWhat is it?

Refers to an infection within the eye, particularly infection of the vitreous.

Because the vitreous is in direct contact with the retina, endopthalmitis is vision-threatening and should be managed as an ophthalmologic emergency!!

Clinical outcome dependent on infecting organism, rapidity of diagnosis and therapy

CLASSIFICATION Based on clinical setting,can be classified

according to:1. etiologic agent: bacteria, fungi (Candida,

aspergillus,) viruses (HSV, CMV, VZV, rubeola, rubella,) protozoa (toxo,) parasites (cysticercus)

2. mode of entry3. location in eye

localized vs panophthalmitis (inflammation involving all ocular tissue layers, including the episclera)

According to mode of entry

ExogenousExogenous EndogenousEndogenous

Micro-org directly introduced from Micro-org directly introduced from environmentenvironment

Haematogenous spread of Haematogenous spread of organisms as a metastatic organisms as a metastatic infectioninfection

Usually occurs following surgery:Usually occurs following surgery:

i.e. i.e. post-operative post-operative endophthalmitisendophthalmitis

or trauma i.e. post-traumatic or or trauma i.e. post-traumatic or keratitiskeratitis

Structural defect of eye is not Structural defect of eye is not necessarynecessary

Mainly bacterialMainly bacterial Common predisposing factors are Common predisposing factors are immunocompromised status, immunocompromised status, septicemia or IV drug abusesepticemia or IV drug abuse

Mainly fungalMainly fungal

Ind J Med Micro 1999; 17(3): 108-115

Most common organisms responsible for endophthalmitis

Gram positive bacteria 75%-Gram positive bacteria 75%-85%85%

Gram negative bacteria 10%-Gram negative bacteria 10%-15%15%

Staphylococcus epidemidis Staphylococcus epidemidis 43%43% Pseudomonas Pseudomonas 8%8%

Streptococcus spp Streptococcus spp 20% 20% Proteus Proteus 5%5%

Staphylococcus aureus Staphylococcus aureus 15%15% Haemophilus influenzae Haemophilus influenzae 0-1% 0-1%

Propionibacterium acnes Propionibacterium acnes 30 30 reportsreports

Klebsiella 0-1%Klebsiella 0-1%

Bacillus cereus Bacillus cereus 1%1% Coliform spp 0-1%Coliform spp 0-1%

Fungi (rare)Fungi (rare)

Candida parapsilosisCandida parapsilosis

AspergillusAspergillus

Cephalosporium spp.Cephalosporium spp.

Br J Oph 1997, 81:1006-15

SymptomsVisual loss Eye pain and irritation Headache Photophobia Ocular discharge Intense ocular and periocular

inflammation Injected eye

SignsEyelid swelling and erythema Injected conjunctiva and sclera Hypopyon (layering of inflammatory cells and exu

date [pus] in the anterior chamber) Vitreitis Chemosis Reduced or absent red reflex Proptosis (a late finding in panophthalmitis) Papillitis Cotton-wool spots Corneal edema and infection White lesions in the choroid and retina

Endogenous endophthalmitisRare, occurring in only 2-15% of all cases of

endophthalmitis. Average annual incidence is about 5 per

10,000 hospitalized patients.In unilateral cases, the Right eye is twice as

likely to become infected as the left eye. Since 1980, Candida spp. infections of the eye

have increased, related to increasing number of immunocompromised persons (HIV/AIDS, BMT, etc.)

PAPER EVIDENCE

Endophthalmitis,  a rare metastatic bacterial  complication of haemodialysis  catheter-related sepsis (this  is the name of  the paper)

   Nephrology Dialysis Transplantation 2007 22(3):939-941; doi:10.1093/ndt/gfl683

“Most cases of endogenous endophthalmitis are unilateral with the right eye affected more frequently, probably due to a more direct arterial flow via the right carotid artery”

 

Yan Ke Xue  Bao. 2004 Sep;20(3):144-8. The clinical analysis of endogenous endophthalmitis. Liang L, Lin X, Yu A, Lin A, Yuan Z. Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China. PURPOSE: To study the clinical characteristics, therapeutic efficacy and investigate prognostic factors of endogenous endophthalmitis. METHODS: Twenty-eight cases (28 eyes) of endogenous endophthalmitis were surveyed retrospectively. The clinical characteristics, primary infection foci, predisposing systemic disease, complications, pathogens examination, therapeutic options and efficacy were analysed. RESULTS: The endogenous endophthalmitis occurred more frequently in the right eye than in the left one. The respiratory tract was the most common primary foci. The positive rate of pathogens culture was higher in vitreous sample than that in other tissues. Cataract and retinal detachment were the common complications. The visual improvement and infection control were achieved in 13 eyes (46.43%). These 13 patients received treatment (3.77 +/- 2.49) days after onset of endophthalmitis being much earlier than that of others [(10.13 +/- 4.98) days, P = 0.002]. The prognosis was relevant to the type of the disease. The anterior segment inflammation type (anterior type) had better prognosis than posterior segment inflammation type (posterior type) and that of inflammation in both parts (mix type) (P < 0.05). There were no significant relation between the prognosis and the age, predisposing systemic disease, vitreous antibiotic injection and vitrectomy (P > 0.05). CONCLUSIONS: Endogenous endophthalmitis is a vital ocular emergency. Early diagnosis and effective treatment combination with systemic and local antibiotics are of significant value. The anterior type is prone to have better outcome than the others.

ENDOPHTHALMITISDiagnosis:

Clinical impression confirmed by positive aqueous or vitreous culture

Negative culture does not exclude the diagnosis

Culture can be obtained from aspiration of the aqueous or vitreous, or vitrectomy Vitrectomy: 10% culture (-) Vitreous aspirate: 25% culture (-) Role of PCR unclear

ENDOPHTHALMITIS: THERAPYCurrently no consensus on what constitutes

appropriate aggressive therapyEvolving preference toward early mechanical

vitrectomy and intravitreal administration of broad-spectrum antibiotics

ENDOPHTHALMITIS: EVSEndophthalmitis Vitrectomy Study Group. Results of the enophthalmitis vitrectomy study: A randomized trial of immedicate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmology 1995; 13: 1479-1496.

Endophthalmitis Vitrectomy Study (EVS) NIH-sponsored, prospective study of 420

patients with post-cataract endopthalmitis Designed to answer 2 questions:

1. Combined with injection of antibiotics, is immediate vitrectomy a better approach than vitreous tap/biopsy?

2. Are systemic antibiotics beneficial?

Patients eligible if they had signs and symptoms of endophthalmitis occurring within 6 weeks of cataract surgery or secondary IOL and visual acuity ranging from 20/50 to light perception

Endophthalmitis Vitrectomy StudyPatients randomized to 4 treatment groups392 completed nine months of follow-upFindings:

Patients that received systemic antibiotics did not have improved visual outcome

Visual outcome will be better in vitrectomy/biopsy

No difference in outcome between the immedicate vitrectomy and tap/biopsy groups

ENDOPHTHALMITIS: THERAPYIntravenous antibiotics: EVS used

ceftazidime, and amikacin or ciprofloxacinSeparate studies have demonstrated IV

vancomycin, ceftazidime, cefazolin reach therapeutic levels in the vitreous cavity in the inflamed eye

Periocular and topical antibiotics used, clinical benefit uncertain

ENDOPHTHALMITISIntravitreal antibiotic therapy:Greatest intraocular concentration of

antibiotics after intravitreal injectionIntravitreal vancomycin (1mg/0.1cc,) +

amikacin (0.4mg/0.1cc) or ceftazidime (2.25mg/0.1cc)

AFTER EFFECTIVE AND PROMPT TREATMENT

KEY MESSAGESEndophthalmitis is a serious ocular infection that

can result in blindnessExogenous >endogenousRight eye >left eyeOutcome depends on rapidity of diadnosis and

treatmentVitrectomy and intrvitreal antibiotics is better Systemic antibiotics were not much helpfulHigh index of suspicion and detail systemic

examination is must as childs presents initially with mild redness without pain /photophobia

Thank you