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Current Concepts in Postoperative Endophthalmitis

Silvia Bopp

Bremen, Germany

Acute postoperative endophthalmitis is the most important emergency situation in Ophthalmology. Inflammatory cells, lytic enzymes and bacterial toxins can destroy the retina irreversibly within hours. Despite of efficient treatment modalities, risk of blindness is still 15%.
Immediate therapy is indicated, but treatment modalities are still under debate. The EVS-study has given evidence-based guidelines for early acute endophthalmitis after cataract surgery and secondary IOL-implantation. However, different clinical manifestations may be present, such as late-onset, acute or chronic and recurrent endophthalmitis. Appropriate therapy for these subtypes is still controversially discussed. There is general agreement, that the EVS-recommendations might not be applicable for clinical manifestations other than early, classic endophthalmitis.
Basic rules in endophthalmitis treatment are to perfrom an anterior chamber and vitreous TAP and to apply broad-spectrum antibiotics intravitreally. The significance of antibiotics injected subconjunctivally and given systemically (oral/intravenous) has yet to be established; as is administration of intravitreal and systemic steroids. Surgical treatment options besides of vitrectomy, such as excision of the lens capsule and removal of the IOL need to be evaluated also.
Based on clinical studies, our won experience over 20 years in the field, experim-ental data and pathogenic considerations, we suggest 4 management strategies for various clinical manifestations of endophthalmitis (Eo): 1. acute, early-onset Eo (classic), 2. chronic, late-onset Eo, 3. mild Eo with capsule-sequestration of infectious plaques and 4. recurrent Eo. Characteristic cases are demonstrated by videotapes. Treatment recommendations (medications, dosage) are available by internet (www.retina.to/) and by a handout.
Modern treatment modalities presupposed, postoperative infectious endophthal-mitis can be controlled in approximately 95% and useful vision regained in 85% of cases (50% *0.5). According to the traditional surgical postulate: "local infections must be treated locally!", application of intravitreal antibiotics has proven most efficient, but vitrectomy is recommended for most cases. Treatment regime for acute, early-onset endophthalmitis is largely standardized, but other clinical manifestations may require modifications. We suggest appropriate therapeutic concepts based on the individual clinical course of endophthalmitis.