Purulent endophthalmitis

CLINICAL PROTOCOL FOR DIAGNOSIS AND TREATMENT

correlational studies and clinical case studies

V

Evidence based on clinical cases and examples

Grade A B C D

Gradation

Level I evidence or consistent multiple Level II, III, or IV evidence Level II, III, or IV evidence, generally considered consistent data Level II, III, IV evidence, but data generally inconsistent Weak or unsystematic empirical evidence.

Diagnostic criteria for diagnosis: 12.1 Complaints and medical history (LE - A)[3]: decreased visual acuity (sometimes to light perception, floating opacities in the visual field); eye pain without/with irradiation to surrounding tissues; limitation of eyeball mobility; redness of the eyeball, mucosal edema, may be accompanied by purulent discharge, lacrimation; eyelid edema, sometimes pastosity of eyelid tissues; general malaise, possible fever, nausea, weakness.

Clinical sign cornea

vitreous body

lacrimation inflammatory changes of eyelid skin Endophthalmitis

edema, descemetitis, precipitates exudate, detritus

mild moderate Corneal ulcer

ulcer, infiltrate with de-epithelialization

vitritis

marked pronounced Iridocyclitis

edema, precipitates

vitritis

absent absent or mildly

pronounced

Recommended by the Expert Council of the RSE on REM "Republican Center for Health Development" of the Ministry of Health and Social Development dated October 15, 2015, Protocol No. 12

PURULENT ENDOPHTHALMITIS

I. INTRODUCTORY PART 1. Protocol name: Purulent endophthalmitis.

Protocol code:

ICD-10 code(s): H 44.0 Purulent endophthalmitis; H 44.1 Other endophthalmitis;

Abbreviations used in the protocol: VB – vitreous body VA – visual acuity US – ultrasound examination CT – computed tomography MRI – magnetic resonance imaging 5. Protocol development/revision date: 2015.

Patient category: adults and children.

Protocol users: therapists, pediatricians, general practitioners, ophthalmologists, ophthalmic surgeons.

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

Assessment of the level of evidence for the recommendations provided [3].

Evidence level scale: Level Type of Evidence of Evidence Evidence obtained from meta-analysis of a large number of 1 I well-designed randomized studies.

Randomized studies with low levels of false-positive and false-negative errors.

Evidence based on results of at least one well-designed II randomized study.

Randomized studies with high levels of false-positive and false-negative errors Evidence based on results of well-designed III non-randomized studies.

Controlled studies with one patient group, studies with historical control group, etc.

Evidence obtained from non-randomized studies.

IV Indirect comparative, descriptive

List of main and additional diagnostic measures: 11.1 Main (mandatory) diagnostic examinations conducted at the outpatient level [3,4,5]: visometry (without/with correction) (LE – C)[5]; tonometry (non-contact) (LE – C)[5]; biomicroscopy (LE – C)[5]; ophthalmoscopy (LE – C)[5]; US of the eyeball (LE – A)[5].

Additional diagnostic examinations conducted at the outpatient level: MRI/CT of the orbit (LE – C)[5]; autorefractometry (LE – C)[5]; perimetry (LE – C)[5].

Physical examination: General examination: inflammatory changes of eyelid skin (LE – C)[5]; tenderness on palpation of eyelids (LE – C)[5]. 12.3 Laboratory studies: CBC – presence of elevated leukocyte count (LE – C) [5].

Instrumental studies: visometry – decreased visual acuity; ophthalmoscopy – precipitates in the anterior chamber, hypopyon may be present, absence of red reflex from the fundus, vitreous opacities, inflammatory infiltrates of the retina, retinal hemorrhages; tonometry – possible elevation of intraocular pressure; perimetry – appearance of pathological scotomas, visual field constriction;

ultrasound examination of the eye – grayish-white vitreous opacity, possible diffuse vitreous opacity with yellowish tint; CT/MRI – presence and localization of foreign bodies, volume and localization of soft tissue damage to the orbit and eyeball.

Differential diagnosis. Table – 1. Differential diagnosis of purulent endophthalmitis.

Treatment goals: resolution of the inflammatory process; preservation of visual functions; preservation of the eyeball as an organ.

Treatment tactics: (Appendix 2)[2,3,6].

Non-pharmacological treatment: General regimen 3, diet No. 15 14.2 Pharmacological treatment: Purulent endophthalmitis, traumatic, postoperative: local: instillation of antibiotic drops moxifloxacin (LE –A) or levofloxacin (LE – B), alternating with gentamicin (LE – B) or tobramycin (LE – B)

(instill one or another drug every half hour - do not instill simultaneously) for 10 days; cycloplegics - atropine 1% 3 - 4 times a day for 10 days (LE – C) [5]; subconjunctival administration of antibiotics – gentamicin 40 mg (LE – C) and vancomycin 25-50 mg (LE – C), dexamethasone 4 mg (LE – C) [5]; intravitreal administration of antibiotics – amikacin 0.4 mg in 0.1 ml (LE – C) or ceftazidime 2.0 mg in 0.1 ml (LE – C) and vancomycin 1.0 mg in 0.1 ml (LE – C); dexamethasone 0.4 mg in 0.1 ml (LE – C); clindamycin 1 mg in 0.1-0.2 ml may be used instead of vancomycin during vitrectomy (Appendix 1) (LE – B) [3]. systemic: ceftriaxone 1.0 – 2.0 g IV every 8-12 hours (LE – C), or vancomycin 0.5-1.0 g IV 2–4 times daily at an infusion rate of 10 mg/min. (LE – C), and gentamicin 2.0 mg/kg IV as a single dose (LE – C), then 1.0 g/kg every 8 hours, add clindamycin 600 mg IV every 8 hours if anaerobic flora is suspected (LE – B) [5]. Fungal endophthalmitis: local: instillation of eye drops – cycloplegics (atropine 1% 3-4 times a day for 10 days (LE – C) [5]. systemic: fluconazole 200-400 mg per day orally (LE –B) [5]; Phacoanaphylactic endophthalmitis: local: instillation of corticosteroid drops (dexamethasone 0.1% 2 drops 3 times a day for 15 days) (LE – C) [5]; subconjunctival administration of corticosteroids (dexamethasone 4 mg) (LE – C) [5]; anterior chamber paracentesis – washout of lens masses and administration of antibiotic (cefuroxime 1.0 mg/0.1 ml) (LE – C) [3]. systemic: prednisolone 30 mg IV 2 times daily, dexamethasone 4.0 – 8.0 mg IV 2 times daily for 5-10 days (LE – C) [5].

Other types of treatment: none.

Further management: patient observation at the outpatient level once a week for one month; US of the eyeball once every two weeks for one month; antibacterial and anti-inflammatory treatment for up to 1 month.

Treatment effectiveness indicators: resolution of inflammation; preservation of visual functions; preservation of the eyeball as an organ.

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION: 16. List of protocol developers with qualification data: 1) Orazbekov Lukpan Nurlanovich – Candidate of Medical Sciences, Head of the Second Department of JSC "Kazakh Scientific Research Institute of Eye Diseases". 2) Zhakybekov Ruslan Adilovich – Candidate of Medical Sciences, Head of the Ophthalmology Department of the branch of JSC "Kazakh Scientific Research Institute of Eye Diseases" Astana branch. 3) Uldanov Oleg Galimovich – Candidate of Medical Sciences, Associate Professor of the Department of Ophthalmology of RSE on REM "Kazakh National Medical University named after S.D. Asfendiyarov". 4) Muravyeva Lyubov Anatolyevna – Candidate of Medical Sciences, Head of the Outpatient-Polyclinic Department of JSC "Kazakh Scientific Research Institute of Eye Diseases". 5) Zhusupova G.D. – Candidate of Medical Sciences, JSC "Astana Medical University", Assistant of the Department of General and Clinical Pharmacology.

Indication of absence of conflict of interest: none.

Reviewers: Shusterov Yuri Arkadyevich – Doctor of Medical Sciences, highest category physician, Head of Department of RSE on REM "Karaganda State Medical Institute".

Indication of conditions for protocol revision: Protocol revision after 3 years and/or upon emergence of new diagnostic/treatment methods with higher level of evidence.

7

List of references used (valid research references to listed sources in the protocol text are required): 1) Endophthalmitis, a review of current evaluation and management. Lemley et al. Retina 27:662-680, 2007. 2) Barry P. ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions 2013 / P. Barry, Cordoves L., Gardner S.; translated from English by B.E. Malyugin. Published by the European Society of Cataract and Refractive Surgeons, Temple House, Ireland 2013. — P. 1-37. 3) Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995;113(12):1479-96. 4) Gundorova R.A., Malaev A.A., Yuzhakov A.M. Eye Injuries. – M.: Medicine, 2009. – 368 p. 5) Nedzvetskaya O.V. Infectious Endophthalmitis (Intraocular Wound Infection). Emergency Medicine. 2010, 6(31) 6) Atkov O.Yu., Leonova E.S. Patient Management Plans "Ophthalmology" Evidence-Based Medicine, GEOTAR-Media, Moscow, 2011, P.83-99.

Appendix 1 Barry P. ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions 2013 / P. Barry, Cordoves L., Gardner S.; translated from English by B.E. Malyugin. Published by the European Society of Cataract and Refractive Surgeons, Temple House, Ireland 2013. — P. 31-32. Scheme for preparation of solutions for intravitreal administration: Vancomycin: 1.0 mg in 0.1 ml isotonic sodium chloride solution. Dilute one vial of vancomycin 500 mg dry substance in 10.0 ml isotonic sodium chloride solution for injections; Aspirate 1 ml (50 mg) into syringe No. 1; Pour contents of syringe No. 1 into syringe No. 2 and add 4 ml isotonic sodium chloride solution; Aspirate 0.1 ml from syringe No. 2 (1.0 mg vancomycin). Ceftazidime: 2.0 mg in 0.1 ml isotonic sodium chloride solution. Dilute one vial of ceftriaxone 500 mg dry substance in 10.0 ml isotonic sodium chloride solution for injections; Aspirate 2.0 ml (50 mg) into syringe No. 1; Pour contents of syringe No. 1 into syringe No. 2 and add 3.0 ml isotonic sodium chloride solution; Aspirate 0.1 ml from syringe No. 2 (2.0 mg).

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Purulent endophthalmitis, traumatic,

postoperative

Diagnostic puncture with collection of aqueous humor or liquid portion of vitreous body and/or vitrectomy

Instillations of antibiotics

Subconjunctival administration of antibiotics

Intravenous systemic antibiotic therapy

Intravitreal administration of antibiotics

Appendix 2 Algorithm for endophthalmitis treatment tactics Fungal endophthalmitis Phacoanaphylactic endophthalmitis

Diagnostic puncture with collection of aqueous humor or liquid portion of vitreous body and/or vitrectomy

Instillations of cycloplegics

Intravenous systemic antifungal therapy

Instillations of corticosteroid drops

Subconjunctival administration of corticosteroids

Intravenous systemic corticosteroid therapy

Anterior chamber paracentesis – washout of lens masses and

administration of antibiotic

Consider the possibility Consider the possibility of performing of intravitreal administration complete vitrectomy and repeated of dexamethasone (corticosteroid) intravitreal administration of antibiotic 10

Basic (mandatory) diagnostic examinations performed at the inpatient level during emergency hospitalization and after a period of more than 10 days from the time of test submission in accordance with the Ministry of Health order:

• complete blood count; - general urinalysis; - Wassermann reaction in blood serum; - biochemical blood analysis (ALT, AST, blood glucose); - determination of blood group according to the ABO system; - determination of Rh factor; - blood test for HIV by ELISA method; - determination of HBsAg in blood serum by ELISA method; - determination of total antibodies to hepatitis C virus in blood serum by ELISA method; - electrocardiographic examination; - fluorography (2 projections); - visometry (without correction and with correction) (LE – C); - autorefractometry (LE – C); - tonometry (non-contact) (LE – C); - biomicroscopy (LE – C); - ophthalmoscopy (LE – C); - ultrasound of the eyeball (LE – A).

11.4 Additional diagnostic examinations performed at the inpatient level during emergency hospitalization and after a period of more than 10 days from the time of test submission in accordance with the Ministry of Health order:

• partial vitrectomy (material is taken for smear and culture);
• anterior chamber puncture (material is taken for smear and culture);
• perimetry.

Indications for consultation with narrow specialists:

• therapist – for assessment of the general condition of the body; - neurosurgeon – when the inflammatory process spreads to the cranial cavity; - otorhinolaryngologist – when the inflammatory process spreads to the paranasal sinuses.

Surgical intervention:

14.4.1 Surgical intervention provided in inpatient settings: Vitrectomy (ICD 9 – 14.74) Indications: - when visual acuity decreases to the level of light projection (LE – A) [1].

Phacoemulsification of cataract (ICD 9 –13.73)

Indications:

• when opacification develops in the lens (LE – A) [1].

14.5. Preventive measures:

• examination by an ophthalmologist;
• timely sanitation of infection foci (otorhinolaryngological, odontogenic, etc.);
• irrigation of the lacrimal pathways;
• instillation of antibiotic 3 days before planned operations on the eyeball.