Infections nosocomiales endoculaires au CHNO des XV-XX de 2000 à 2002

A European perspective on topical ophthalmic antibiotics: current and evolving options

BACKGROUND

Eye infections can be vision-threatening and must be treated effectively by appropriate and safe use of topical ophthalmic anti-infectives. This review will essentially consider the current and evolving treatment options for the various types of bacterial eye infections. Ocular surface bacterial infections affect subjects of all ages with a high frequency in newborns and children.

METHODS

This article presents a review of the peer-reviewed published scientific literature in order to define the well-established uses of anti-infective eye drops in the field of ocular infections. A comprehensive search of the recent published literature including topical ophthalmic anti-infectives effective in bacterial ocular infections was performed. Clinical studies provide relevant data concerning the characteristics and clinical efficacy of antibacterial eye drops in ocular anterior segment infections or for perioperative prophylaxis. Publications were included to cover the current options of antibacterial eye drops available in Europe.

RESULTS

Several recent publications identified effective topical ocular antibacterials requiring a reduced dose regimen and a short treatment course. Additional literature reviewed included data on novel perioperative prophylaxis, indications for topical fortified antibiotics and innovative research including the risk of resistance.

CONCLUSIONS

Safe and effective topical antibiotic eye drops for the treatment and prevention of ocular infections must be adapted to the type of bacteria suspected. Usual topical antimicrobials should be replaced by more recent and more effective treatments. The use of highly effective fluoroquinolones should be reserved for the most severe cases to avoid resistance. Short treatment courses, such as azithromycin, can be easily used in children, thereby improving quality of life.

[Chronic postoperative endophthalmitis]

Chronic postoperative endophthalmitis designates delayed-onset postoperative endophthalmitis appearing more than two weeks after surgery, revealed by chronic intraocular inflammation with phases of inflammatory recurrence, which, at the beginning of the disease course, is partially sensitive to local corticosteroid treatment. It differs therefore from acute endophthalmitis in the immediate postoperative phase, from acute differed endophthalmitis after filtrating surgery, which appears years after the surgery, and from endogenous endophthalmitis. The most frequent presentation is granulomatous uveitis, often hypertonic, in an eye operated for cataract, presenting phases of recurrence sensitive to corticosteroid therapy but which recurs as soon as treatment is interrupted. Whitish condensations in plaques on the posterior capsule suggest the diagnosis and over several months the vitreous becomes inflamed. Ocular samples allow cytological analysis of an infectious process and bacteriological analysis in culture and with PCR. Treatment includes lavage of the sac with vancomycin and can be associated with posterior capsulectomy and intravitreal injections of antibiotics possibly associated with systemic antibiotic therapy. Treatment is prolonged because of the slow replication of the microorganisms involved. In approximately one-third of cases, the implant, the capsule, and the sac must be removed over 360° to permanently halt the intraocular infection. The diagnosis and specific treatment should be as early as possible since the aggressiveness of the treatment required is correlated with the time to management of the infection.

Endophthalmitis: a reappraisal of incidence and treatment

PURPOSE OF REVIEW

The current publications that address either the incidence or treatment of endophthalmitis are reviewed.

RECENT FINDINGS

A large body of published research has recently addressed the issue of potential increases in the incidence of endophthalmitis, especially postcataract endophthalmitis. Additional studies have evaluated relatively new antibiotics and their potential effect on the prevention and treatment of endophthalmitis.

SUMMARY

Although there appears to be a renewed effort to report the incidence and theorized risk factors for postcataract endophthalmitis, there are wide discrepancies in the rate and potential causes of postoperative endophthalmitis. In regards to endophthalmitis treatment, helpful findings regarding the potency of newer antibiotics and the appropriateness of subconjunctival antibiotics are reviewed.

Endophthalmitis and incision construction

PURPOSE OF REVIEW

The relationship between endophthalmitis after cataract extraction and type of incision has been under debate lately. In particular, clear corneal incisions have been connected with an increased incidence of postoperative endophthalmitis. This review discusses recent reports within this area.

RECENT FINDINGS

Experimental studies have demonstrated the poor integrity of a clear corneal incision under certain circumstances. A relationship between wound leakage the day after surgery and endophthalmitis has also been reported. Some large studies have shown an increase of endophthalmitis that in time coincide with the increasing use of clear corneal incision. One earlier randomized controlled study showed a higher incidence of endophthalmitis after clear corneal incision compared with superior incision. Other case series have shown an equal distribution of endophthalmitis between surgeries using different types of incision. Some studies point to the multifactorial nature of endophthalmitis and the importance of every step from antiseptic surgical field to postoperative treatment.

SUMMARY

There is no conclusive evidence of the relationship between clear corneal incision and endophthalmitis. It seems, however, that in certain situations clear corneal incision may play a role in the occurrence of endophthalmitis.