Contents of the Endophthalmitis Kit or Pack

Equipment for preparation of patient

• Tetracaine (anaesthetic) drops
• Povidone iodine
• Drape
• Speculum
• Equipment for sub-Tenon’s anaesthetic injection – 10 ml 2% lidocaine – 10 ml syringe – Sub-Tenon’s cannula – Westcott scissors

Equipment for vitreous biopsy/tap

• 23 G or 25 G needle
• 5 ml syringe
• Calipers

Equipment for preparation of antibiotic injections

• 1 vial of 500 mg vancomycin or 1 vial of 500 mg (250 mg/ml) amikacin
• 1 vial of 500 mg ceftazidime
• 3 x 10 ml sodium chloride 0.9% injection (saline)
• 4 x 10 ml syringe
• 2 x 5 ml ^syringe
• 2 x 1 ml syringe
• 1 x sterile galley pot (for amikacin)
• 6 x 21 G needles for preparation of antibiotics
• 2 x 30 G needles for intravitreal injection

Written instructions for preparation of antibiotic injections (to be prepared prior to vitreous tap and biopsy)

• Vancomycin 1 mg/0.1 ml
  – Reconstitute 500 mg vial with 10 ml saline
  – Withdraw all 10 ml into 10 ml syringe
  – Inject 2 ml of this solution back into vial
  – Add 8 ml saline into vial to make up to 10 ml (10 mg/ml)
  – Use 1 ml syringe to draw 0.1 ml of this solution (1 mg/0.1 ml)
• Amikacin 400 μg/0.1 ml
  – Use 10 ml syringe to withdraw 1.6 ml of amikacin (250 mg/ml)
  – Make up to 10 ml in the syringe with saline
  – Discard 9 ml from syringe and make the remaining 1 ml up to 10 ml (in the syringe) with more saline
  – Transfer the solution into a sterile galley pot and use 1 ml syringe to draw 0.1 ml of this solution (400 μg/0.1 ml )
• Ceftazidime 2 mg/0.1 ml
  – Reconstitute 500 mg vial with 10 ml saline
  – Withdraw all 10 ml into 10 ml syringe
  – Inject 2 ml of this solution back into vial
  – Add 3 ml saline into vial to make up to 5 ml (20 mg/ml)
  – Use 1 ml syringe to draw 0.1 ml of this solution (2 mg/0.1 ml)

Acute endophthalmitis: prophylaxis, clinical diagnosis and treatment

How to PREVENT endophthalmitis

Risk factors

• Avoid surgery on patients with any known eye infections, e.g. blepharitis or conjunctivitis, or who have a lacrimal duct obstruction.
• Note that patients with an ocular prosthesis in the fellow orbit, or who wear contact lenses, are at risk of infection.

Prophylaxis

• Povidone iodine 5%: cornea and conjunctival sac.
• Povidone iodine 10%: periorbital area; wait a minimum of 3 minutes before incision.
• Surgeon scrubs, puts on sterile gown and gloves.
• Drape eye, tape eyelids and lashes (do not cut lashes).

In particular reference to cataract surgery:

• Perform safe surgery (watertight incisions, manage complications effectively).
• Avoid silicone intra-ocular lenses (IOLs).
• Give intracameral injection of 1 mg cefuroxime in 0.1 ml saline (0.9%) at end of surgery.

How to RECOGNISE endophthalmitis

1 Suspect endophthalmitis if any of the following symptoms or clinical signs are present, particularly if there is a previous history of surgery, intravitreal injection or penetrating trauma.

• Blurred vision
• Pain
• Red eye
• Hypopyon
• Vitreous opacities
• Swollen eyelids
• Poor red reflex

2 Perform B-scan ultrasonography (if available) to check for vitritis or retinal detachment.

3 Do not delay diagnosis by first giving a trial of corticosteroid drops!

How to RESPOND to endophthalmitis

DO NOT DELAY! TREAT AS A MEDICAL EMERGENCY

Within 1 hour

Perform an intravitreal tap/vitrectomy through the pars plana. Collect samples of vitreous for Gram stain and culture. A vitrectomy may be indicated if the patient has perception of light only.⁶

TECHNIQUE: How to do an intravitreal tap

• Use aseptic technique with drape
• Instil topical antibiotics and povidone iodine 5%.
• Administer subconjunctival or sub-Tenon’s anaesthetic.
• Insert the needle (23 or 25 G) 4 mm (phakic eyes) or 3.5 mm (pseudophakic/aphakic eyes) behind the limbus into the middle of the vitreous cavity, pointing at the optic disc (approx 7–8 mm deep) and aim to aspirate 0.3–0.5 ml of vitreous fluid.

Immediately following the intravitreal tap, inject antibiotics into the vitreous.

1st choice:

• vancomycin 1 mg in 0.1 ml and
• ceftazidime 2 mg in 0.1 ml

OR 2nd choice:

• amikacin 400 μg in 0.1 ml and
• ceftazidime 2 mg in 0.1 ml

Note: Use a new syringe and a new 30 G needle for each drug. Do not mix drugs together in the same syringe.

Following the injections of intravitreal antibiotics, inject dexamethasone (preservative free) 400 μg in 0.1 ml into the vitreous using a different syringe and 30 G needle. (The use of steroids remains controversial but is recommended by the European Society of Cataract and Refractive Surgeons.)

Consider adjunctive systemic therapy with the same antibiotics as those used intravitreally for 48 hours to maintain higher levels within the posterior segment of the eye.