, Nidhi Relhan Batra1, Stephen G. Schwartz2 and Andrzej Grzybowski3, 4
(1)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
(2)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Naples, Florida, USA
(3)
Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland
(4)
Institute for Research in Ophthalmology, Poznan, Poland
Clinical Presentations
The diagnosis of endophthalmitis can be made based on clinical examination findings. The patient may present with gradual or sudden onset of symptoms including lid swelling, pain, redness, discharge, and decrease in the vision. Slit-lamp examination may show lid swelling, conjunctival congestion, chemosis, glaucoma implant exposure, corneal edema, epithelial defect, corneal infiltrate, hypopyon, infiltrates/fibrin membrane in the anterior chamber, plaque inside the capsular bag, loss of fundus red reflex, or infiltrates in the vitreous cavity (Figs. 3.1, 3.2, and 3.3).
Figure 3.1
Acute-onset endophthalmitis. Signs of acute-onset postoperative endophthalmitis following cataract surgery. (a) Conjunctival congestion, mild corneal edema, hypopyon, and hand motions (HM) vision on the day of presentation. (b) Fibrinous membrane in the anterior chamber and pupillary area. (c) Vitritis and hazy view of the posterior segment. (d) Ultrasound demonstrates presence of echogenic shadows in the vitreous cavity
Figure 3.2
Acute-onset endophthalmitis . A 73-year-old female patient with acute-onset postoperative endophthalmitis following cataract surgery presented with conjunctival congestion, mild corneal edema, hypopyon, fibrinous membrane in the pupillary area, and hazy view of the posterior segment
Figure 3.3
Acute-onset endophthalmitis . A 69-year-old male patient with acute-onset postoperative endophthalmitis following cataract surgery presented with conjunctival congestion, mild corneal edema, hypopyon, fibrinous reaction in the anterior chamber, and hazy view of the posterior segment
Microbiology
How to Perform TAP and Inject
Treatment of endophthalmitis includes obtaining a vitreous sample for cultures and injection of intravitreal antimicrobials. By obtaining vitreous sample and using it to identify the causative microorganisms, further management of the patient can be planned after the initial empiric treatment.
Traditional approach for vitreous aspiration (TAP) as per Endophthalmitis Vitrectomy Study (EVS): The Endophthalmitis Vitrectomy Study (EVS ) provided guidelines for the vitreous tap as well as pars plana vitrectomy (PPV) . As per the EVS, 0.2–0.5 mL of vitreous sample was collected by way of the pars plana either by needle aspiration or by vitreous biopsy through a single sclerotomy using a vitrectomy cutter. After the TAP, injections of intravitreal antibiotics were given in separate syringes. If an adequate sample could not be safely obtained, a vitreous biopsy using a vitrectomy instrument was performed. The EVS reported that in a subgroup of patients with presenting visual acuity of hand motions or better, there was no difference in the visual outcome (immediate PPV or TAP). However, in the subgroup of patients with presenting visual acuity of light perception only, visual outcomes were better with immediate PPV compared to TAP.
Current day TAP and inject options (Fig. 3.4): The procedure can be performed in the outpatient clinic under local anesthesia (retro-/peribulbar block). The lids and conjunctiva are prepared with 5% povidone–iodine followed by placement of the speculum. A 23-gauge butterfly needle mounted on 10 cc syringe is inserted through pars plana, and approximately 0.2–0.5 mL of vitreous is aspirated once the needle tip is at the center of the globe. Once the vitreous sample is removed, antimicrobials are injected in to the vitreous cavity. The vitreous sample obtained is sent for the microbiology evaluation including smear and culture. In case of growth on the culture media, antimicrobial susceptibility tests are further performed. A 25G or 27G needle can also be used for vitreous aspiration.
Figure 3.4
Vitreous TAP . (a) Standard preoperative preparation with povidone–iodine. (b) Local anesthesia (retrobulbar or peribulbar block) with lidocaine solution. (c) Speculum placement. (d) Use 23-gauge butterfly needle on 10 cc syringe for tap. (e) Insert 23-gauge butterfly needle on 10 cc syringe through pars plana. (f) Tap 0.2-0.5 ml of vitreous by slow suction followed by antibiotic injection through pars plana
Other modifications: A modification of the vitreous TAP procedure has been recently published. In this modified technique under subconjunctival anesthesia, a valved 25-gauge trocar cannula is inserted through pars plana, and subsequent aspiration of exudates/vitreous and antimicrobial injections are performed through the single port. In a prospective, randomized, single-center trial, Vahedi et al. compared comfort and procedural facility using 25-gauge trocar cannula as a port to aspirate vitreous and inject intravitreal antibiotics to treat acute-onset endophthalmitis. Since there were no significant differences in the patient comfort, physician ease-of-use scores, vitreous sample volume, successful vitreous taps, and microbiological yield between the two groups, the study concluded that 25-gauge trocar technique is a viable option (Fig. 3.5). Comparison of traditional versus 25-gauge trocar cannula-based vitreous TAP is shown in Table 3.1.
Figure 3.5
25-gauge trocar cannula based TAP and inject
Table 3.1
A comparison of the traditional versus 25-gauge trocar cannula-based vitreous TAP
Standard 23-gauge needle-based TAP and inject | 25-gauge trocar cannula-based TAP and inject | |
|---|---|---|
Instrument cost | Low | Higher |
Anesthesia commonly utilized | Retro-/peribulbar | Subconjunctival |
Number of needle entries in the eye
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