Endophtalmitis: Anamnesis

Endophtalmitis
Anamnesis
 Nyeri,
 Penurunan tajam penglihatan,
 Mata merah.
 Sejak kapan?
 Satu atau dua mata  endogenous maybe bilateral
 Riwayat trauma
 Riwayat operasi mata
 Endogenous endophtalmitis :
o Riwayat faktor risiko penurunan daya tahan tubuh : diabetes mellitus, systemic
malignancy, sickle cell anemia, systemic lupus erythematosus, and human
immunodeficiency virus (HIV) infection, intravenous drug user
o Sumber infeksi : Extensive gastrointestinal surgery, endoscopy, and dental
procedures, pneumonia, urinary tract infection, bacterial meningitis, or liver
abscess.
Pemeriksaan Oftalmologis
A. Acute onset endoftalmitis. Patient with marked epibulbar hyperemia, iritis, hypopyon, and
endophthalmitis 5 days after cataract surgery B. Chronic onset endoftalmitis. Endophthalmitis in a
patient with progressive intraocular inflammation 3 months after cataract surgery C. Bleb Associated
Endoftalmitis. Patient with endophthalmitis who had sudden onset of decreased vision, redness, and pain
2 years after glaucoma filtering surgery. (AAO buku 12)
 Visus : sangat turun di bawah ekspektasi yang seharusnya

 TIO : klo severe bisa hypotoni
 GBM : full ke segala arah
 PS/PI : edema
 CB : vascular congestion, chemosis, exposed suture, wound/bleb leak
 C : edema, Keratic Precipitate, opacification (trauma)
 COA : hypopyon, fibrinous exudate, flare and cells (+)
 P/I : RAPD (+) (Kanski chapter 9)
 L : Vitreous cells (+)
 F : media keruh, Fundus reflex (-)
Specific physical examination findings are as follows:

 Delayed onset or chronic cases– Occasionally, a white plaque within the equator of the
remaining lens capsule, chronic granulomatous inflammation  gambar B
 Filtering bleb associated– A purulent bleb is seen occasionally with areas of necrosis in
the sclera from the use of antimetabolites seperti pada gambar C
 Posttraumatic– Evidence of penetrating trauma, intraocular foreign body
 Endogenous– Patients may appear systemically ill  demam
Pemeriksaan Penunjang
 B-Scan USG
o choroidal thickening and ultrasound echoes in the anterior and posterior vitreous
support the diagnosis
o Another source of inflammation other than or in addition to bacteria, such as
retained lens material, may be seen
o The ultrasound also provides a baseline prior to intraocular intervention and
allows assessment of the posterior vitreous face and areas of possible traction
o Rarely, a retinal detachment is seen concurrently with endophthalmitis
The vitreous cavity was filled with mild to moderate amplitude point echoes. There was
round mound of choroidal detachment. The patient had a painful red hypotonous eye with
hypopyon, suggesting endophthalmitis.
http://eyewiki.aao.org/Echography_(ultrasound)#Endophthalmitis
 Intraocular culture
o Anterior chamber specimen : Spuit tuberculin + needle 30G
o Vitreous specimen : spuit 3cc + needle 25 G introduced through the pars plana
and directed toward the midvitreous cavity. Vitreous specimens are more likely to
yield a positive culture result than aqueous specimens.
o Pada spesimen dilakukan pemeriksaan : Cultures (blood, chocolate, Sabouraud,
thioglycolate) and smears (Gram and Giemsa stains)
o Trauma : 25 % Bacilus cereus terutama jika berhubungan dengan tanah dan
foreign body  rapid and severe onset; bakteri gram negative lainnya
o Postoperative endophtalmitis
 acute-onset endophthalmitis (within 6 weeks of intraocular surgery):
coagulase-negative Staphylococcus species including S aureus,
Streptococcus species, gram-negative organisms
 chronic (delayed-onset) endophthalmitis (more than 6 weeks after
surgery): Propionibacterium acnes, coagulase-negative Staphylococcus
species, fungi
 bleb-associated endophthalmitis (months or years after surgery):
Streptococcus species, Haemophilus species, gram-positive organisms
o Endogenous endophtalmitis
 The most common gram-positive organisms are Streptococcus species
(endocarditis), Staphylococcus aureus (cutaneous infections), and Bacillus
species (from intravenous drug use).
 The most common gram-negative organisms are Neisseria meningitidis,
Haemophilus influenzae, and enteric organisms such as Escherichia coli
and Klebsiella species.
 In Asia, infection from Klebsiella species in liver abscesses is the most
common cause of endogenous endophthalmitis.
 It is important to also consider endogenous endophthalmitis in newborns
and infants, especially those younger than 6 month
 Traumatic endophtalmitis : CT Scan
 If endogenous bacterial endophthalmitis is suspected, a systemic workup for the source is
required :
o Blood culture
o Sputum culture
o Urine culture
o Chest X-Ray
o Echocardiography
Tatalaksana
 Standard prevention : preparation of eyelids and conjunctiva with 5% povidone-iodine

prior to surgery
 Rawat inap
Acute postoperative :
 Intravitreal antibiotic
o Intravitreal dan subconjunctival broad spectrum antibiotic (vancomycin dan
amikacin). Ceftazidime sekarang menggantikan amikacin karena sifat toksisitas
dari golongan aminoglycoside
 Intravitreal dexamethasone may reduce posttreatment inflammation, but its role in
endophthalmitis management remains controversial. Consider intravitreal steroids (e.g.,
triamcinolone acetate 4 mg/0.1 mL) in select cases with severe vitreous inflammation.
 PPV dilakukan jika Visus < LP, jika Visus > LP tidak terlalu bermakna.
 Intensive topical steroids (e.g., prednisolone acetate 1% /jam)
 Intensive topical fortified antibiotics (e.g., vancomycin and tobramycin, q1h around the
clock for 24 to 48 hours). Intensive topical antibiotics are more important in the setting of
filtering blebs, wound leaks, or exposed sutures.
 Atropine 1% t.i.d. to q.i.d.
 Intravenous antibiotics are not routinely used. Consider i.v. fluoroquinolones (e.g.,moxifl
oxacin) in special circumstances (e.g., bleb-related endophthalmitis or trauma). Third-
and fourth-generation fluoroquinolones may penetrate the vitreous enough to reach
therapeutic levels, especially in inflamed eyes. Some oral antibiotics (e.g., moxifloxacin
400 mg p.o. q.d.) may reach therapeutic vitreous levels and could be considered as
alternatives to intravenous antibiotics.
 Nyeri berkurang  respon terhadap terapi
 Prednisone oral 60mg + ranitidine
 Dalam waktu 48 jam pasien biasanya menunjukkan perbaikan  topikal fortified
antibiotic diturunkan jadi antibiotic fluoroquinolone
Chronic postoperative endophtalmitis

 Terapi initial seperti acute postoperative tapi jangan dikasi steroid dulu karena
kemungkinan penyebabnya bisa jamur
 Vitrectomy
 If a fungal infection is suspected or vitreous smear is consistent with fungus :
o intravitreal amphotericin B, 5 to 10 μg or intravitreal voriconazole (50 to 100
μg/0.1mL) at the time of vitrectomy.
o topical antifungals (e.g., natamycin 5% or voriconazole 1% q1h), and/or systemic
antifungal medications
Traumatic endoftalmitis :
 klo Bacilus cereus : vancomycin dan clindamycyin, klo bakteri gram negative :
ceftazidime
 ATS – TT
Komplikasi dan Prognosis
 The complications of endogenous endophthalmitis can be serious. If the diagnosis of

systemic infection is missed, the patient may develop sepsis and even die.
 In severe cases, recurrent or persistent intraocular infection may require numerous
surgeries and repeat injections of intravitreal antibiotics.
 In addition, complications such as cataract development, retinal detachment,
suprachoroidal hemorrhage, vitreous hemorrhage, hypotony, and phthisis bulbi can occur
in the most severe cases.
 The prognosis is directly related to the offending organism and the systemic status of the
patient.
Dikutip dari Kanski chapter 9

Endophtalmitis: Anamnesis

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Endophtalmitis

 Visus : sangat turun di bawah ekspektasi yang seharusnya

Specific physical examination findings are as follows:

 Standard prevention : preparation of eyelids and conjunctiva with 5% povidone-iodine

Chronic postoperative endophtalmitis

Komplikasi dan Prognosis

 The complications of endogenous endophthalmitis can be serious. If the diagnosis of

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