Prachi Dave and Ritesh Narula
Centre for Sight Eye Hospital
The endophthalmitis session at DRM 2023 aptly focused on how the endophthalmitis spectrum is changing in India and how one needs to relook at our conventional management approach to this serious vision-threatening complication.
The session opened with Dr. Tara Prasad Das from LVPEI, Hyderabad, India, discussing the initial reports from Endophthalmitis Management Study (EMS), a prospective study examining the management of endophthalmitis in India. His talk focussed on the importance of including the inflammatory score in addition to vision while managing endophthalmitis. The inflammatory score is graded from mild to severe based on the clinical findings of both anterior and posterior segments and the score is used to decide the first line of management, which can range from only intravitreal antibiotics to a complete vitrectomy with silicone oil. Further, he discussed the changing antibiotic susceptibility trends, wherein the gram-positive cocci were found still susceptible to vancomycin, while the gram-negative bacilli showed a more favourable response to colistin or amikacin rather than ceftazidime. The role of SANGER sequencing in isolating organisms from culture-negative aspirates was also discussed. Dr. Das concluded that the management of endophthalmitis must be algorithmic and since every patient can present differently, it should be customized for every patient.
Dr. Janani Sreenivasan from Sankara Nethralaya, Chennai, India, then discussed an interesting case of acute postoperative endophthalmitis due to Nocardia which subsequently developed an amikacin-induced macular infarction. Nocardia endophthalmitis is an insidious, deep-seated, indolent infection with a guarded visual prognosis. They characteristically present with iris nodules. They respond well to amikacin but a big takeaway from the discussion was that repeated doses of amikacin should be at least 48 hours apart to prevent macular ischemia. Another pearl from the discussion was that ocular nocardiosis is classified as systemic CNS nocardiosis and they need about 9-12 months of oral treatment to prevent recurrence.
The case of endogenous endophthalmitis by Aspergillus flavus after a single dose of intravenous infusion was presented by Dr. Pooja Bansal from Guru Nanak Eye Centre, Delhi. She stressed the possibility of Aspergillus endophthalmitis even after a single IV infusion in immunocompetent individuals and highlighted the fact that the fungus can cause florid neovascularisation to develop even after a complete vitrectomy. Aspergillus can spread rapidly, involves the macula early causing macular infarction, and has a high risk of choroidal invasion. She recommended intravitreal voriconazole with vitrectomy, panretinal photocoagulation, and anti-VEGF agents in such cases.
Next, Dr. Vivek Dave, from LV Prasad Eye Institute, Hyderabad, spoke to us virtually about using endoscopic systems for vitrectomies in endophthalmitis. It is of particular use in eyes with compromised corneas where a thorough and early vitrectomy is not possible due to poor visualization. The advantages are that a simultaneous corneal transplant or keratoprosthesis is not needed and since the corneal edema is usually transient, they are given the opportunity to recover without the need of a transplant. Over 4 video presentations, he highlighted the use of endoscopic vitrectomy for removal of intraocular foreign bodies, post traumatic endophthalmitis and retinal detachment repair, all in eyes with a compromised cornea and poor view for conventional vitrectomy. The disadvantages of the system are a steep learning curve and the nonavailability of stereopsis since these surgeries are performed using a 2D screen.
The session culminated with an interesting debate on use of silicone oil following vitrectomy for endophthalmitis. Dr. Jatinder Singh, Eye Foundation, Coimbatore, favored the use of oil instillation highlighting its role in preventing postoperative hypotony, reducing the risk of postoperative retinal detachment, promoting compartmentalization of antibiotics and thereby increasing the concentration of antibiotics in the retro-silicone oil space. Dr. Abhishek Kothari, Jaipur, argued that there is limited evidence to support silicone oil as an antibacterial agent, while it may cause sequestration of microbes and inflammatory cytokines near vital surfaces and can only limit a detachment if it occurs. Patients also need a second surgery for oil removal. Both sides agreed that a good vitrectomy is key in treating severe endophthalmitis.
Overall the session highlighted that we have come a long way from the Endophthalmitis Vitrectomy Study and need to relook at our conventional protocols in diagnosis and management of endophthalmitis.