Intraocular infections

In the late 1970s and early 1980s, Peyman and Baum et al. (19,20) popularized the use of intraocular antibiotics and this route of administration became the mainstay of therapy for intraocular infection. Intraocular antimicrobials are now given in essentially all cases of endophthalmitis some patients are also treated with vitrectomy. In the EYS, all patients received intraocular antibiotics but only half the patients received systemic therapy. Systemic antimicrobials did not improve prognosis in the EYS, but amikacin, which has poor intraocular penetration, was used for gram-positive coverage in the study (1). 

Miscellaneous—hypersensitivity reactions, hypokalemia, hypernatremia, increased susceptibility to infection, cushingoid appearance (eg, moon face, buffalo hump, hirsutism), cataracts, and increased intraocular pressure. 

Various types of preparations are used for the treatment of ophthalmic (eye) disorders such as glaucoma to lower the intraocular pressure (IOP), bacteria or viral infections of the eye, inflammatory conditions, and symptoms of allergy related to the eye... 

Loteprednol 1 drop in affected eye(s) four times daily Elevated intraocular pressure, cataracts, decreased wound healing, secondary ocular infections, systemic side effects possible... 

If mast cell stabilizers or multiple-action agents are not successful, a trial of a topical NSAID is appropriate. Ketorolac is the only approved topical agent for ocular itching. NSAIDs do not mask ocular infections, affect wound healing, increase intraocular pressure, or contribute to cataract formation like the topical corticosteroids. However, for allergic conjunctivitis, topical ketorolac is not as effective as olopatadine or emedas-tine in trials.15 Full efficacy of ketorolac takes up to 2 weeks.17... 

Trifluridine 1% topical agent used for acyclovir-resistant herpes infections for 7-14 days Transient burning or stinging, palpebral edema, superficial punctuate, keratopathy, changes in intraocular pressure... 

Intraocular irrigating solutions are required to be preservative-free to prevent toxicity to the internal tissues of the eye, particularly the corneal endothelium, lens, and retina [298,299]. These products are intended for single use only to prevent intraocular infections,... 

Eye Infections Infection, moderate to severe, caused by bacteria, fungi, or viruses, which occurs either on the external surface of the eye or intraocularly with probable inflammation, visual impairment, or blindness, [nih]... 

Another example of a biomaterial is the intraocular lens, which have been commonly used to treat cataracts. They were traditionally made of inflexible materials, but more recently consist of poly(methyl methacrylate) and soft flexible materials such as silicone and acrylic. The first person to successfully implant an intraocular lens was Sir Harold Riley at the St Thomas Hospital in London in 1949. The first lenses were made of glass, were heavy, and carried several risks including infection, inflammation, loosening of the lens, lens rotation, and night time halos (Thompson, 2007). These problems, now less frequent, still occur today in a small fraction of more than one million intraocular lenses that are implanted annually in the USA. 

The most commonly observed side effects associated with vidarabine are lacrimation, burning, irritation, pain, and photophobia. Vidarabine has oncogenic and mutagenic potential however, the risk of systemic effects is low because of its limited absorption. It should not be used in conjunction with ophthalmic corticosteroids, since these drugs increase the spread of HSV infection and may produce side effects such as increased intraocular pressure, glaucoma, and cataracts. 

Serious adverse reactions may include proteinuria (80%), nephrotoxicity (53%), neutropenia (31%), elevated serum creatinine levels (29%), infection (24%), anemia (20%), ocular hypotony (a decrease in intraocular pressure 12%), and pneumonia... 

Sustained delivery of ophthalmic medications is a novel approach in treating chronic intraocular infections in conditions where systemic administration is accompanied by undesirable side-effects and repeated intravitreal injections carry the risk of infection. The administration of medications by implants or depot devices is a very rapidly developing technology in ocular therapeutics. The various types of implant and mechanisms of drug release have been discussed in general in Chapter 4. 

Occasional development of Probable development of some adrenal adrenal suppression suppression Aggravation of a dendritic ulcer Discomfort with injection White residue possible Occasional white material, which is Epithelial keratopathy from cosmetically objectionable frequent applications Subconjunctival adhesions Occasional conjunctival infections Allergy to diluent Occasional orbital infection Occasional intraocular injection of steroid Ulceration of conjunctiva after repeated injections if not given behind the eye Exophthalmos and rugae in fundus Papilledema Adrenal suppression Occurrence of systemic side effects more likely... 

Conservative treatment of zoster-associated conjunctivitis, including cold compresses, lubricants, and decongestants, carries the lowest risk of treatment-related complications. Treatment of the acute conjunctivitis with topical broad-spectrum antibiotics may help to prevent secondary bacterial infection. Increased patient comfort by reduction of conjunctival inflammation may be affected by the use of topical steroids. Often, a combination antibiotic-steroid is used to accomplish both of these goals. In contrast to herpes simplex infection in which steroids are specifically contraindicated, topical steroids do not exacerbate herpes zoster infection. If steroids are used, the patient should be carefully monitored for intraocular pressure elevation. 

Although cataract surgery is a potential precursor to bullous keratopathy, there are many other causes. Fuchs endothelial dystrophy, infection, trauma, retained foreign body, posterior polymorphous dystrophy, chronic uveitis, chronically elevated intraocular pressure (lOP), and vitreous touch are all known causes of bullous keratopathy. Other less common causes of bullous keratopathy include corneal thermal injury secondary to carbon dioxide laser skin resurfacing, air bag trauma, the use of topical dorzolamide hydrochloride in glaucoma patients with endothelial compromise, and use of mitomycin C during trabeculectomy surgery. 

Primary eye care providers may collaborate with ophthalmic surgeons to comanage the cataract patient. This method of eye care delivery provides quality care for the patient in convenient familiar surroundings. In addition, it is efficient and cost-effective. The goals of the comanagement team during postoperative care are those of everyday optometric practice to educate and reassure the patient, to prevent infection, to control inflammation, to maintain desired intraocular pressure (lOP), to manage complications if they arise, to control pain, and to optimize vision. 

There is a preponderance of evidence that the incidence of postoperative endophthalmitis is reduced when antiseptics (povidone iodine) and antibiotics are used preoperatively.The use of balanced salt solution, to which an antibiotic has been added, to irrigate the eye during surgery is advocated by some but tempered by concerns of intraocular toxicity and questions of efficacy. Sub-Tenon s capsule injection of an antibiotic just before surgery or subconjunctival injection of antibiotic at the end of the surgery is also used to prevent infection, but risk of inadvertent intraocular injections resulting in retinal antibiotic toxicity must be considered. In addition, oral antibiotics may be used at the time of surgery and 1 day postoperatively as a prophylactic measure. 

The ocular side effects of corticosteroids are many and are related to the route of administration. The most common concerns are increased intraocular pressure (lOP) and cataracts, but delayed epithelial woimd healing and increased risk of infection due to immime modulation and decreased tear lysozyme levels are issues for the cornea. Changes to other ocular tissues have been noted (subconjunctival hemorrhages, blue sclera, eyelid hyperemia and edema, retinal emboUc events, central serous choroidopathy) and neurologic compUcations reported (diplopia, nerve palsies, intracranial hypertension) (see Appendix 35-1). 

The authors concluded that intraocular infection had resulted from a foreign body (the surgical implant) in the scleral gap. 

Lactoferrin, a protein contained in tears, increases the activity of vancomycin against biofilms of strains of Staphylococcus epidermidis and may be therapeutically helpful in the treatment of infections such as endophthalmitis associated with intraocular lenses (7). 

Very few injectable dosage forms have been specifically developed and approved by the FDA for intraocular use. However, the ophthalmologist uses available parenteral dosage forms to deliver anti-infectives, corticosterioids, and anesthetic products to achieve higher therapeutic concentrations intraocularly than can ordinarily be achieved by topical or systemic administration. These unapproved or off-label uses have developed over time as part of the physician s practice of medicine and include subconjunctival, retrobulbar, sub-Tenon s, and intravitreal injections. 

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