1. post-traumatic endophthalmitis Elmira hassanpour medical surgical nursing- education ؛ MS Infection control supervisor at Tabriz Alavi eye center 1

2. Disease Entity Intraocular infection involving the anterior and posterior segment of the eye after a traumatic open globe injury. 2

3. Etiology 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. 4

5. Incidence of traumatic endophthalmitis traumatic 2.4 – 8.0 %, up to 40% in rural areas with IOFB 5

6. Most of the cases of post-traumatic endophthalmitis are bacterial, usually gram- positive organisms - Staphylococcus,. 6

7. Streptococcus, Enterococcus and Bacillus species. 10% –15% are due to gram- negative organisms mainly Pseudomonas aeruginosa and some species of Enterobacteriaceae 7

8. Polymicrobial post-traumatic endophthalmitis account for 10-30% of cases, caused by Gram-positive bacteria, Gram-negative bacteria or mixed organisms. 8

9. Candida species, Aspergillus and Fusarium are fungal entities that have been identified in chronic indolent cases. 9

10. Risk Factors Delayed primary repair of open globe injury by greater than 24 hours Delayed primary repair of open globe injury by greater than 24 hours Intraocular Foreign Body (IOFB) Intraocular Foreign Body (IOFB) Contaminated injury with soil, rural or organic matter Contaminated injury with soil, rural or organic matter Lens rupture Lens rupture Large wound size Large wound size Vitreous prolapse through the open globe wound Vitreous prolapse through the open globe wound 10

11. General Pathology Infection of the vitreous, retina, and the anterior segment of the eye 11

12. 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. 12

13. 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. 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

14. Primary prevention Expedited closure of the open globe wound Expedited closure of the open globe wound Expedited removal of IOFB Expedited removal of IOFB Use of intravitreal antibiotics in cases of IOFB Use of intravitreal antibiotics in cases of IOFB 14

15. 15

16. 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

17. For mild suspicious cases of traumatic endophthalmitis, intravitreal antibiotics (without vitrectomy) with vitreous cultures can be considered 17

18. Management 18

19. General treatment  Medical therapy  Surgery Emergent admission to the hospital for emergent localized ocular treatment and systemic antibiotic treatment. 19

20. 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 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

21. 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. 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. Medical therapy 21

22. 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 22

23. Initiate fortified topical vancomycin (50 mg/ml) with ceftazidime (100 mg/ml) every hour Medical therapy 23

24. Initiate fortified topical vancomycin (50 mg/ml) with ceftazidime (100 mg/ml) every hour Medical therapy 24

25. Medical follow up 25

26. 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

27. 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

28. Semiweekly to weekly follow-ups with B- scans are performed until the infection fully resolves. 28

29. Immediate pars plana vitrectomy (PPV) with intravitreal antibiotics is the mainstay of treatment for post-traumatic endophthalmitis. 29

30. 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 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 30

31. 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. 31

32. 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/Post- Traumatic_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. 32

33. 33