Pseudomonas Endophthalmitis:  Prevention and Treatment

Pseudomonas infections can be the most devastating we face in the eye care field.  Recently, systemic Pseudomonas infections have also been reported to cause loss of limbs and even life.  Here we review the risks factors for Pseudomonas ocular infections, the most devastating of which is endophthalmits, and how such infections may be prevented and managed.

Risk Factors

Pseudomonas infections of the eye usually follow trauma. P. aeruginosa is the usual culprit and produces an aggressive corneal ulcer that leads to rapid tissue destruction.  The infection will spread to the posterior segment causing endophtalmitis and eventually infect the entire eye – pan-ophthalmitis.  Further spread into the CNS may cause death.  Risk factors include: extended-wear contact lenses; topical and systemic corticosteroids; and history of serious medical conditions including comatose state, extensive burns, hospitalization in an ICU, tracheostomy or endotracheal intubation.

Prevention

Minimizing exposure to the bacteria and prophylactic treatment of high risk patients are key.  Pseudomonas skin infections can be prevented by avoiding hot tubs with cloudy water; public swimming pools at the end of the day; removing wet swimsuits as soon as possible; bathing after sharing a hot tub or using a public pool; cleaning hot tub filters every six weeks; and using appropriate amounts of chlorine in the water.  Advise your contact lens users to replace solutions before they expire.  Prophylactic treatment with topical 3^rd and 4^th generation fluorquinolones is now considered standard of care for most cataract surgeries.  In retina, we now utilize a similar approach when preparing our patients for intravitreal injections and vitrectomy surgery and have been not seen an infection in our center.

Treatment

Prompt identification and treatment is key.  Many ocular infections are caused by gram positive bacteria such as Staph and Strep.  Gram negative infections, such as Pseudomonas, must be suspected and aggressively treated.  A history of trauma, contact lens use, hots baths and swimming should put the eye doc on alert.  The organism is easily identified on gram stain and culture – immediate results are possible with the right laboratory.  For corneal  infections, in addition to fortified aminoglycoside and vancomycin drops, I also recommend adding a 3^rd or 4^th generation fluorqunolone.  Intraocular infections are managed with intravitreal vancomycin and ceftazadime plus a fluoquinione – compounded in the pharmacy or injected directly from the bottle of eye drops!  I add oral moxifloxacin since this can achieve therapeutic levels in the vitreous.   In severe cases, vitrectomy to debulk the vitreous fluid is utilized.

By working together we can minimize out patient’s risk of infection with Pseudomonas.  Careful review of contact lens practices, prophylactic treatment with 3^rd and 4^th generation fluorquinoles, and a high index of suspicion will help us prevent infection and achieve the best outcomes when it does occur.

Ron P. Gallemore, M.D, Ph.D.

Founder and Director

Retina Macula Institute and the

Retina Macula Research Center

South Bay 310-944-9393

Los Angeles 310-466-9393