Internal Medicine

0521779407-10 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:44

Intraocular Infection 857

■B-scan ultrasound to confirm vitreal/retinal inflammation if view of

posterior pole is poor

differential diagnosis

■Immune-mediated uveitis: history, exam and absence of risk factors

for ocular infection will help

■Tumor: rule these out by age, history, exam and cytology of vitreous

fluid

➣Primary: melanoma, retinoblastoma, large cell lymphoma

➣Metastatic: primarily to choroid

management

What to Do First

■Assess likelihood of postop or endogenous endophthalmitis, since

these will require immediate vitreous biopsy and intravitreal antimi-

crobial therapy.

■Determine if visual acuity is hand motions or worse. Postop endoph-

thalmitis with hand motions or worse will require emergency vitrec-

tomy for best visual outcome.

■Determine if ocular inflammation fits pattern of acute retinal necro-

sis syndrome (rapidly progressive necrotizing peripheral retinitis,

mid-peripheral vasculitis and vitiritis), since this will require imme-

diate, intravitreal injection of foscarnet.

General Measures

■Topical prednisolone acetate (1%) to control anterior segment

inflammation after specific therapy is instituted

■Cycloplegia (e.g., cyclopentolate 1%) to reduce development of pos-

terior synechiae

specific therapy

■Depends on diagnosis:

➣Bacterial endophthalmitis – intravitreal vancomycin & cef-

tazidime. Intravitreal dexamethasone may also be used. Con-

sider amikacin or gentamicin as alterantives for gram-negative

coverage and cefazolin as alternative for gram-positive coverage.

Vitrectomy indicated for visual acuity of hand motions or worse.

Intravitreal aminoglycosides are potentially toxic to retina.

■Fungal endophthalmitis

➣Intravitreal amphotericin and oral flucytosine. Check elec-

trolytes and renal function before starting flucytosine.

■Acute retinal necrosis