INTRAVITREAL INJECTION FOR

ENDOPHTHALMITIS:
• Ideal Intravitreal Injection
• Choice of antibiotic
• Intravitreal corticosteroids
• Dosage
• Dilution
• Administration
• Clinical response and repeat intravitreal
• Drug toxicity
• Drug resistant endophthalmitis
• Newer antibiotics
INTRAVITREAL DRUG
ADMINISTRATION
• Von Sallman and colleagues – 1944
• Intraocular injection of penicillin to eradicate Staph. aureus
endophthalmitis
• Hell to achieve the active concentration of antibiotics in vitreous
cavity rapidly.

When injected early, prior to irreversible destruction of the retina, is

most useful.
IDEAL ANTIBIOTIC FOR
INTRAVITREAL INJECTION
a) Effective against offending organisms

b) Nontoxic to retina and other ocular structures in bactericidal doses

c) Have optimum half life within the vitreous to be effective and non-
toxic

d) Easily available and cost effective.

CHOICE OF ANTIBIOTIC
For gram positive organisms:
• Vancomycin - First choice
• Cefazolin- Second choice

Coverage of gram negative organism:

• Aminoglycosides- Gentamicin or Amikacin(Potential retinal toxicity)
• Ceftazidime
Choice of Antibiotic:
• Modification Based on –
a) Culture report (Organisms isolated)

b) Sensitivity pattern

c) Clinical response
INTRAVITREAL CORTICOSTEROIDS:
• As an adjunct to intravitreal antibiotics
↓Inflammation
1. To control or limit the ocular damage
↓ Cicatrization

2. To reduce the exudation Half-life dexamethasone (vitreous):3.5HRS

INTRAVITREAL CORTICOSTEROIDS:
• • Disadvantages
- Steroid induced toxicity
- Blunting of the immune response
- Acceleration of the infective processes when the antimicrobial agent is
ineffective
AVOID IN FUNGAL ETIOLOGY
• Until now no definitive randomized study has been done to study the role of
intravitreal steroids in endophthalmitis.
• Practice-based Medicine: STEROIDS DEFINITELY HELPFUL IN BACTERIAL
ENDOPTHALMITIS
COCKTAIL:DOSAGE
Vancomycin (1mg)

Ceftazidime (2.25mgs)

+ Dexamethasone (400µgs)
DILUTION TECHNIQUE:
• Guidelines:

1. Prepare immediately prior to use containing the dose in 0.1 ml final

volume
2. Tuberculin syringe (Dead space 0.04 -0.05 ml)
3. BSS or NS or water for injection should be used for dilution
4. Draw upto 0.1 ml of final dilution plus an overfill of 0.1 ml in each
syringe to allow the placement of the needle without loss of dose.
DILUTION TECHNIQUE…
5. 0.1 ml volume of each (total:0.2ml) is injected
• 0.1 ml of vanco(1mg)
• b. 0.1 ml of cefta(2.25mg) + dexa(0.4mg)

6. Paracentesis

7. Injections prepared should be used within 24 hours/preferably

immediately
ADMINISTRATION TECHNIQUE:
• Topical anaesthesia/Lid speculum
• Can be combined with AC/Vit tap
• Limbal / parsplana route
• OPD procedure (or intraoperative)
• 30g needle for injection
ADMINISTRATION TECHNIQUE:
• Mid vitreous cavity

• Bevel of the needle pointing away from the macula

• Inject drop by drop

• Combined therapy: the drugs should be preferably injected separately

CLINICAL RESPONSE
• Improvement within 48 hours
• Decreased corneal edema, AC reaction
• Decreased/resolved hypopyon
• Decreased vitreous exudates facilitating view of the fundus

IMPROVEMENT IN VISION
REPEAT INTRAVITREAL
• 48 hours
• If no clinical response
• Microbiology warrants specific targeting
• Previous antibiotic resistant (Micro report)

No response with 2 I.V. Inj. - VITRECTOMY

DRUG TOXICITY
- D'Amico and Colleagues:
• Compared the toxic doses of various aminoglycosides
• Better understanding of toxic effects

a. Sequence/extent of damage depends on the dose of the specific

aminoglycoside.
b. Toxicity is related with peak drug concentration rather than duration
of exposure.
GENTAMICIN TOXICITY
• First recognizable effect: Accumulation of lysosomal inclusions within
RPE cells.
• Higher Doses: Outer retinal toxicity, disorganisation and
disappearance
• Still higher doses: Full thickness retinal necrosis
• Conway and Campochiaro - Macular infarction
• Amikacin - Aminoglycoside of the choice
DRUG TOXICITY:
• -Dexamethasone:
Upto 400 ug: Non toxic
>400 ug Increased staining of Muller cells
(appears within 6 hours and normalises within 2 days)
: No structuralabnormality.
FUNGAL ENDOPHTHALMITIS:
• Antifungals agents-

• Should not be administered unless fungus is documented

• Highly toxic and needs appropriate care.

• Overall prognosis: poor

FUNGAL ENDOPHTHALMITIS
• Intravitreal injection:

1. Amphotericin B 0.005mg/0.1cc (or) Miconazole 0.025mg/0.1cc (or)

Fluconazole 1.0 mg
2. Cefazolin 2.25 mg/0.1cc
STEROIDS TO BE WITHELD

Newer anti-fungal: VORICONAZOLE 50µgm

CLEAR AND PRESENT DANGER
• In our fight against endophthalmitis

• MULTI-DRUG RESISTANT MICROBES

CASE SCENARIO
• 8 patients: same OT, sameday

• Acute-onset endoph.: 2 day

• Aqueous and vitreous samples for Micro.
• 5 patients underwent vitrectomy, IOL explant in 3
• Intravit.: V+C+D
CASE SCENARIO
• Vitreous sample from all grew pseudomonas aeruginosa

• The initial response to V+C+D was not satisfactory

• 3 patients: re-vitrectomy, SOI in 2

ANTIBIOTIC SENSITIVITY:
CASE SCENARIO
• Post-Micro. Report Colistin was started intravitreal and I.V.

• Intravitreal dose was- 0.1 mg/0.1 ml(1000IU/0.1ml

• Intravenous injection of colistin was given in 5 patients 1million IU 12

hourly for 5 days.
RESULTS:
• 4 eyes: Vision >/= 6/60

• 2 eyes: Vision < 6/60

• 2 eyes: PL, Pre-phthisical

COLISTIN – Brahma-astra!
• Colistin acts by increasing the permeability of the cell membrane and
thus could act synergistically with other antimicrobial agents by
facilitating their entrance into the bacterial wall.
• Most gram-negative microorganisms are susceptible to colistin,
including multidrug- resistant Acinetobacter baumannii and
Pseudomonas aeruginosa strains.
• Because colistimethate sodium is largely excreted in the urine, dose
reduction is required in renal impairment to prevent accumulation.
In conclusion:
• Endophthalmitis: warrants early recognition and early treatment

• Intravitreal injection a must/know-how a must: delay more costly

than over- treatment

• Early referral and management very important