and Mitrofanis Pavlidis2
(1)
Department of Ophthalmology, Uppsala University Hospital, Uppsala, Sweden
(2)
Augencentrum Köln, Cologne, Germany
Electronic supplementary material
The online version of this chapter (doi:10.1007/978-3-319-20236-5_12) contains supplementary material, which is available to authorized users.
Electronic supplementary material
for this chapter is accessible online at http://extras.springer.com/ by searching via the ISBN.
12.1 General Introduction
Video 12.1: Candida endophthalmitis
Video 12.3: Endophthalmitis
Video 12.3: Endophthalmitis and subchoroidal haemorrhage
The Endophthalmitis Vitrectomy Study recommends intravitreal antibiotics if the visual acuity is > hand motion and vitrectomy and if visual acuity = light perception. In practice, most vitreoretinal clinics tend to perform a vitrectomy at earlier stages with a better visual acuity. Due to the increasing number of intravitreal injections, the incidence of endophthalmitis is rising. In every tertiary vitreoretinal centre, clear treatment guidelines should be established; all necessary antibiotics and an examination of the microbiological specimens should be available at all times.
In recent years, there is a significant increase of endophthalmitis in patients following intravitreal injections of anti-VEGF agents. In contrast to the previously more common endophthalmitis following cataract surgery, the majority of these patients are still phakic and the lens or opacified vitreous adjacent to the lens might impair the view of the posterior segment for vitrectomy. If you perform a phacoemulsification, then open the posterior capsule and do not insert an IOL in order to improve the outflow of aqueous and reduce bacterial growth in the capsular bag.
If you are contacted from a peripheral institution regarding a patient with presumed endophthalmitis and a delay of several hours before the patient can be seen in your institution is to be expected, it is advisable to ask the referring Ophthalmologist to perform an intravitreal injection of antibiotics before sending the patient. Time is of paramount importance in treating endophthalmitis, and the benefit of earlier antibiotic injection overrides the disadvantages of a short delay in the referral and possibly the failure to obtain a specimen for microbiology.
12.2 Antibiosis (2005 DGII Guidelines for Prophylaxis and Treatment of Endophthalmitis) [1]
1.
1 mg/0.1 cc vancomycin and
2.
2.25 mg/0.1 cc ceftazidime (Fortum)
12.2.1 Preparation of Antibiotic Therapy
12.2.1.1 Vancomycin
You need: 1× vancomycin 500 mg and 2× plastic ampoules 10 ml NaCl 9 mg/ml (9 %)
1.
Dissolve 500 mg of vancomycin in 10 cc NaCl 9 mg/ml (first ampoule).
2.
Aspirate 2 cc of the second NaCl 9 mg/ml ampoule and discard it.
3.
Add 2 cc of the dissolved vancomycin (first ampoule) into 8 cc of NaCl 9 mg/ml (second ampoule). The ampoule contains now 10 cc of vancomycin 10 mg/ml
4.
Inject 0,1 cc (=1 mg) vancomycin into the vitreous cavity.
(Remark: cc = ml)
12.2.1.2 Ceftazidime
You need: 1× Fortum 500 mg and 2× plastic ampoules 10 ml NaCl 9 mg/ml (9 %).
1.
Dissolve 500 mg of Fortum in 10 cc NaCl 9 mg/ml (first ampoule).
2.
Aspirate 8.8 cc of the second NaCl 9 mg/ml ampoule and discard it. The second ampoule contains now 1.2 cc NaCl 9 mg/ml.
3.
Draw 1 cc of the dissolved Fortum and inject it into the second ampoule. The second ampoule contains now 2.2 cc Fortum 22.7 mg/ml.
4.
Inject 0.1 cc (=2.27 mg) Fortum into the vitreous cavity.
12.2.1.3 Instruments
1.
3-port or 4-port trocar system
2.
Insulin syringe for sampling
12.2.1.4 Potential tamponade
Silicone oil
12.2.1.5 Individual Steps
1.
27G three ports with chandelier light
2.
Specimen from the anterior chamber
3a.
Pseudophakic eye: Flushing of the anterior chamber and the capsular bag
3b.
Phakic eye: Phacoemulsification without IOL
4.
Specimen from the vitreous cavity
