[Endophthalmitis--clinical picture, therapy and prevention]

Abstract

Background: Infectious endophthalmitis is a dreaded situation in ophthalmology, since it often induces a substantial reduction of visual acuity, and in some cases the loss of the eye despite modern medication and surgical treatment methods.

Objective of the study: Compilation of the most important characteristics of postoperative endophthalmitis with acute, delayed and chronic course, posttraumatic endophthalmitis and endogenous endophthalmitis. Comprising the results of the endophthalmitis vitrectomy study, a review of the pharmacotherapy and surgery required is presented.

Therapy: Acute postoperative endophthalmitis is treated by a combination of broad-spectrum antibiotics (vancomycin and ceftazidime or amikacin), which are administered intravitreally, subconjunctivally and topically, if appropriate in combination by systemic antibiotics (vancomycin and ceftazidime or amikacin). If vision diminshes to mere light perception, performance of pars plana vitrectomy is indicated. Treatment of acute postoperative endphthalmitis with delayed occurrence requires that the underlying complications (e.g. suture dehiscences) are eliminated, and is carried out in accordance with the therapeutic principles for acute postoperative endophthalmitis. In chronic postoperative endophthalmitis, which is caused by bacteria, antibiotics (aminoglycosides or vancomycin) are administered topically and intravitreally. If antibiotic treatment is unsuccessful, a pars plana vitrectomy must be performed including posterior capsulotomy, appropriate with total removal of the capsular sac including the posterior chamber lens. In postoperative mycotic endophthalmitis, antimycotics (amphotericin B) are administered intravitreally. If findings are severe, a pars plana vitrectomy must also be carried out with excision of capsule, if necessary with removal of the posterior chamber lens. Antimycotics are applied topically to support treatment. Acute posttraumatic endophthalmitis is treated by intravitreal antibiotic administration (vancomycin and ceftazidime or amikacin) in combination with pars plana vitrectomy and removal of foreign body. Treatment is supplemented by systemic, subconjunctival and topical antibiotic administration. To reduce ocular destruction due to inflammation, systemic and intravitreal administration of steroids is recommended in all postoperative and posttraumatic endophthalmitis conditions. Treatment of endogenous endophthalmitis requires collaboration with an internist. Systemic therapy with antibiotics or mycotics is obligatory. In addition, broad-spectrum antibiotics (vancomycin or aminiglycosides) or antimycotics (amphotericin B) are administered topically and intravitreally in these conditions. In severe ocular infections, pars plana vitrectomy is indicated.

Prevention: To reduce the risk of infection, patients with infectious eye diseases should be excluded from elective operations. Special attention must be paid to risk patients with defects of the immune system. Observation of hygienic regulations is obligatory. Prophylactic perioperative administration of antibiotics has proved to be effective. Patients suffered from penetrating or perforating injuries get systemic antibiotics prophylactically. Qualified follow-up care of the patient is necessary.

Conclusions: The therapeutic principles for treatment of acute postoperative endophthalmitis are determined by the endophthalmitis-vitrectomy-study. Further investigations are required with respect to corticosteroid use.