Evidence for and Against Intravitreous Corticosteroids in Addition to Intravitreous Antibiotics for Acute Endophthalmitis

Diem K. Bui, MD; Petros E. Carvounis, MD, FRCSC

Disclosures

Int Ophthalmol Clin. 2014;54(2):215-224. 

In This Article

Introduction

Endophthalmitis is a serious complication of ocular surgery, penetrating trauma, and occasionally hematogenous spread of organisms from a distant source. Multiple advances in the treatment of this condition have been made in the last 20 years beginning with the Endophthalmitis Vitrectomy Study (EVS). The EVS found that needle vitreous biopsy obviated the need for prompt vitrectomy in patients with clinical evidence of endophthalmitis after cataract surgery or secondary intraocular lens (IOL) implantation and initial visual acuity better than light perception.[1] In addition, the EVS showed that systemic antibiotics provided no additional benefit over the standard regimen of intravitreous (IVT) vancomycin and amikacin with subconjunctival and topical antibiotics combined with subconjunctival and topical corticosteroids.[1] Reports of cases of macular infarction induced by aminoglycoside (including amikacin) led to the replacement of IVT amikacin by IVT ceftazidime, which had been shown to be effective against gram-negative organisms.[2–4] The administration of adjunctive subconjunctival antibiotics was abandoned when subsequent studies showed no influence on the final visual outcomes.[5,6] Finally, the practice of administering corticosteroid orally was abandoned because of concerns about systemic safety with some retina specialists replacing these with IVT corticosteroids in the treatment of acute endophthalmitis.
Twenty years since the publication of the EVS, there is still no consensus regarding the role of IVT corticosteroids such as prednisolone, dexamethasone, or triamcinolone acetonide in the treatment of acute endophthalmitis. In fact, the 2004 American Society of Retina Specialists Preference and Trend Survey reported an almost 50:50 split in the use of IVT corticosteroids with or without systemic corticosteroids in addition to IVT antibiotics for postcataract endophthalmitis (43% of respondents routinely used IVT corticosteroids).[7] The rationale for using adjunctive IVT corticosteroids mostly centers on their ability to attenuate inflammation that could theoretically lead to improved visual outcomes. The arguments against their use involve possible interference with infection control, decreased concentrations of vitreous antibiotics, and increased volumes of fluid administered, which may become an issue when vitreous tap cannot be obtained. Moreover, the extremely short half-life of dexamethasone makes any sustained beneficial effect unlikely. In this paper, we reviewed the evidences for and against the use of IVT corticosteroids in addition to IVT antibiotics as initial treatment for acute endophthalmitis.

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