Download Incidence of traumatic endophthalmitis

post-traumatic
endophthalmitis
Elmira hassanpour
MS‫؛‬medical surgical nursing- education
Infection control supervisor at Tabriz Alavi eye
center
1
Disease Entity
Intraocular infection involving the anterior
and posterior segment of the eye after a
traumatic open globe injury.
2
Etiology
Introduction of infectious agent into
the eye during trauma can result in
post-traumatic endophthalmitis. The
incidence of endophthalmitis is
reported in up to 12% of eyes with
history of penetrating injury without
IOFBs. Higher infection rates are
noted in eyes with open globe injury
contaminated with organic matter.
3
4
Incidence of traumatic
endophthalmitis
traumatic 2.4 – 8.0 % , up to 40% in rural
areas with IOFB
5
Most of the cases of post-traumatic
endophthalmitis are bacterial, usually grampositive organisms - Staphylococcus,.
6
Streptococcus, Enterococcus and Bacillus
species. 10% –15% are due to gramnegative organisms mainly Pseudomonas
aeruginosa and some species of
Enterobacteriaceae
7
Polymicrobial post-traumatic
endophthalmitis account for 10-30% of
cases, caused by Gram-positive bacteria,
Gram-negative bacteria or mixed
organisms.
8
Candida species, Aspergillus and Fusarium
are fungal entities that have been
identified in chronic indolent cases.
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Risk Factors
Delayed primary repair of open globe injury
by greater than 24 hours
 Intraocular Foreign Body (IOFB)
 Contaminated injury with soil, rural or organic
matter
 Lens rupture
 Large wound size
 Vitreous prolapse through the open globe
wound

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General Pathology
Infection of the vitreous, retina, and the
anterior segment of the eye
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Pathophysiology
Infectious agents are introduced at the time
of primary open globe injury. The trauma
usually occurs in a non-sterile
environment which increases the risk of
infection.
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Prophylactic antibiotics are used during the
repair of the primary injury but the best
route and duration of the antibiotics to
decrease the risk of endophthalmitis in
non-IOFB penetrating injuries is not
clear.
13
Primary prevention
Expedited closure of the open globe
wound
 Expedited removal of IOFB
 Use of intravitreal antibiotics in cases of
IOFB

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15
Laboratory test
Cultures from the wound, vitreous and
possibly anterior chamber for
identification of aerobic, anaerobic
bacteria and fungus. Gram stain and KOH
preparation of vitreous should also be
ordered. Only 70% of vitreous cultures
usually yield positive results. PCR assays
of vitreous for identification of bacterial
and fungal strains should be considered.
Blood cultures if septicemia suspected
16
For mild suspicious cases of traumatic
endophthalmitis, intravitreal antibiotics
(without vitrectomy) with vitreous
cultures can be considered
17
Management
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General treatment
 Medical
therapy
 Surgery
Emergent admission to the hospital for
emergent localized ocular treatment and
systemic antibiotic treatment.
19
Medical therapy
Start systemic antibiotics immediately;
vancomycin 1 g q12h and ceftazidime 1g
q8h is initiated. Addition of clindamycin
(300 mg every 8 hours), amikacin (240 mg
q8hr) or gentamycin 80 mg q8hr should
be considered in severe cases suspicious
for Bacillus (history of IOFB) or anaerobic
bacteria. Systemic fluconazole (200 mg
BID) or more recently, voriconazole
(200mg BID) is recommended
intravenously for fungal infections
20
Medical therapy
Perform expeditede vitreous biopsy with
empiric intravitreal vancomycin 1mg/0.1ml
and ceftazidime 2.25 mg/0.1ml injections
in cases where emergent pars plana
vitrectomy cannot be performed.
21
Avoid aminoglycosides for gram negative
coverage due to high risk of retinal toxicity.
If history of IOFB is elicited, suspect
Bacillus. B. Cereus is resistant to
cephalosporins
and
has
a
rapid
deterioration of infection
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Medical therapy
Initiate fortified topical vancomycin (50
mg/ml) with ceftazidime (100 mg/ml)
every hour
23
Medical therapy
Initiate fortified topical vancomycin (50
mg/ml) with ceftazidime (100 mg/ml)
every hour
24
Medical follow up
25
Inhospital stay of 3-5 days for intravenous
antibiotic treatment with daily follow-up
for clinical examination and B-scan of the
vitreous cavity is recommended.
26
Once hypopyon resolves and vitritis
improves, the antibiotics are switched to
the oral route and the patient is
discharged from the hospital. Oral
fluoroquinolones (e.g. Ciprofloxacin 750
mg q 12 hr) are widely used for bacterial
infections and oral voriconazole (200 mg
BID) for fungal infections.
27
Semiweekly to weekly follow-ups with Bscans are performed until the infection
fully resolves.
28
Immediate pars plana vitrectomy (PPV) with
intravitreal antibiotics is the mainstay of
treatment for post-traumatic
endophthalmitis.
29
In severe cases where Bacillus is suspected,
a meticulously prepared low dose
gentamycin 40g intravitreal injection
may be considered in eyes with average
volume vitreous cavity with no choroidal
detachment
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Prognosis
Visual prognosis is poor and depends on
the virulence of the infecting organism,
presence of retinal detachment, timing of
treatment, and the extent of initial injury.
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References
Original article contributed by: Neelakshi Bhagat, MD, MPH, FACS,
Marco Attilio Zarbin, MD, PhD, FACS All Post-Traumatic
Endophthalmitis. At http://eyewiki.aao.org/PostTraumatic_Endophthalmitis
Additional Resources
 Bhagat N, Nagori S, Zarbin MA. Traumatic endophthalmitis. Survey of
Ophthalmology. Forthcoming.
 Essex RW, Yi Q, Charles PG, Allen PJ. Post-traumatic endophthalmitis.
Ophthalmology. 2004 Nov;111(11):2015-22.Meredith TA. Posttraumatic
endophthalmitis. Archives of ophthalmology. 1999 Apr;117(4):520-1.
 Peyman GA, Lee PJ, Seal DV. Endophthalmitis: Diagnosis and
Management. London, England: Taylor & Francis; 2004: pp 90-91.
 Soheilian M, Rafati N, Mohebbi MR, Yazdani S, Habibabadi HF, Feghhi M,
et al. Prophylaxis of acute posttraumatic bacterial endophthalmitis: a
multicenter, randomized clinical trial of intraocular antibiotic injection,
report 2. Archives of ophthalmology. 2007 Apr;125(4):460-5.
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