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Ciprofloxacin ophthalmic (Ciloxan)



Fluoroquinolone with activity against pseudomonas, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but may have limited activity against anaerobes. Inhibits bacterial DNA synthesis, and consequently growth. Provides gram-positive coverage. Uncertain benefit in noncataract causes.

Ofloxacin ophthalmic (Ocuflox)

A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect, ofloxacin inhibits bacterial growth by inhibiting DNA gyrase. It is indicated for superficial ocular infections of the conjunctiva or cornea caused by susceptible strains of microorganisms.

Levofloxacin ophthalmic (Iquix, Quixin)

Levofloxacin is an S (-) enantiomer of ofloxacin. It inhibits DNA gyrase in susceptible organisms, thereby inhibiting relaxation of supercoiled DNA and promoting breakage of DNA strands.

Gatifloxacin ophthalmic (Zymaxid)

A fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis, gatifloxacin elicits a dual mechanism of action by possessing an 8-methoxy group, thereby inhibiting the enzymes DNA gyrase and topoisomerase IV. DNA gyrase is involved in bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial cell division. Gatifloxacin is indicated for bacterial conjunctivitis.

Moxifloxacin ophthalmic (Moxeza, Vigamox)

Indicated to treat bacterial conjunctivitis. Elicits antimicrobial effects. Inhibits topoisomerase II (DNA gyrase) and IV enzymes. DNA gyrase is essential in bacterial DNA replication, transcription, and repair. Topoisomerase IV plays a key role in chromosomal DNA portioning during bacterial cell division.

Corticosteroids

Class Summary

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Prednisolone acetate (Pred Forte, Omnipred, Pred Mild)

Treats acute inflammations following eye surgery or other types of insults to eye.

 

Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability.

 

In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely. Dosage dependent on severity of inflammation.

Dexamethasone (Ozurdex, Maxidex)

For various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Triamcinolone (Triesence)

Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Anticholinergic Agents, Ophthalmic

Class Summary

Reduces ciliary spasm that may cause pain. Anticholinergic agents are also mydriatics, and the practitioner should make sure that the patient does not have glaucoma. This medication could provoke an acute angle-closure attack.

Atropine ophthalmic

DOC; acts at parasympathetic sites in smooth muscle to block response of sphincter muscle of iris and muscle of ciliary body to acetylcholine, causing mydriasis and cycloplegia.

 

Follow-up

Further Outpatient Care

Patients should receive follow-up care on a daily basis. Clinical features indicating improvement include the following:

· Reduced pain

· Decreased inflammation and hypopyon

· Increased red reflex

· Retraction of any fibrin

· Improved visual acuity

If no improvement occurs in 48-72 hours, consider the following:

· Repeat tap/biopsy and antibiotic injections

· Vitrectomy and injection of antibiotics, if no previous vitrectomy exists

If view is poor, B-scan ultrasound is useful to rule out retinal detachment.

Further Inpatient Care

Patients may be admitted or may be treated as outpatients depending on the following:

· Severity of endophthalmitis and treatment modalities

· Underlying systemic diseases

· Patient reliability and compliance

Inpatient & Outpatient Medications

Topical antibiotic coverage with dosage dependent on severity, as follows:

· Vancomycin 50 mg/mL 1 gtt qid to q1h

· Ceftazidime 50 mg/mL 1 gtt qid to q1h

· Prednisolone 1 gtt qid to q1h

· Atropine 1 gtt bid

Deterrence/Prevention

See the list below:

· Identify high-risk patients before elective surgery (see below)

o Blepharitis

o Abnormal lacrimal drainage

o Active infection elsewhere

· Preparation of operative field (see below)

o Prep with 5-10% povidone-iodine solution in preoperative area

o Prep with 5-10% povidone-iodine immediately before draping and allow solution to dry

o Drape to cover lashes and lid margins

· Prophylactic topical and/or periocular antibiotics [14, 43]

· Prophylactic intravitreal antibiotics in trauma cases

Complications

See the list below:

· Retinal necrosis

· Retinal detachment (see below)

o Retinal necrosis

o Vitreous tap

o Vitrectomy

· Increased intraocular pressure

· Retinal vascular occlusion

· Optic neuropathy

· Panophthalmitis

· Hypotony (see below)

o Ciliary body shutdown

o Wound leakage

o Retinal detachment

o Cyclodialysis cleft

o Medication

Prognosis

The prognosis depends on the following:

· Duration of endophthalmitis

· Time to treatment

· Virulence of bacteria

· Etiology of entry

· Existing ocular diseases

From the EVS, the percentage of patients achieving a final visual acuity of 20/100 or better were as follows:

· Gram-positive, coagulase-negative micrococci - 84%

· S aureus - 50% [44]

· Streptococci - 30%

· Enterococci - 14%

· Gram-negative organisms - 56%

A statistically significant number (P < 0.001) of poorer visual outcomes occurred with a positive Gram stain or when bacteria other than gram-positive, coagulase-negative cocci were found. [13]

Patient Education

Direct patients to maintain hygienic practice after surgery.

 

 

References

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