The Fellow Eye: Episode 8

Justin C. Muste, MD :

Good afternoon, morning, whatever time it is that you're listening. Welcome to another episode of the Fellow Eye. Today we're doing endgame endophthalmitis. With us, we have Dr. Deaner from Will's Eye. Also, my co-fellows, Dr. Richards, and Dr. Massenzio, to discuss some sort of head-scratching cases. As always, Dr. Fell will be with us to help us through this challenging episode. So with that, let's get started. I think Erik, you had a case to talk about or a few topics that you wanted to discuss.

Erik Massenzio, MD :

Yeah, sure. So thanks for having me on, Justin. I just wanted to ask about the nitty-gritty details of how you treat your standard post-injection or post-cataract endophthalmitis. So you have a patient come in, they're about two or three days after their injection, intravitreal injection, and they have hypopyon, some evidence of vitritis. Let's say their vision is hand motions at this time, count fingers or hand motions. Dr. Deaner, do you always start with a tap and inject? At this time, do you ever consider going straight to the operating room or are you mostly always starting with a tap and inject and are you using vancomycin and ceftazidime?

Jordan Deaner, MD :

Yeah, I think you're setting up for very important questions. So I think the important highlights here are the patient's clinically presenting with pretty classic endophthalmitis. The vision is hand motions or better. It's following a intravitreal injection in this particular case, which I think we can get into more important details because our greatest guidance really comes from post-cataract surgery endophthalmitis. But really in general, I tend to extrapolate the endophthalmitis vitrectomy study, the EVS studies data on all types of endophthalmitis. And so in this case, which sounds like pretty moderate endophthalmitis following an intravitreal injection, I would make sure to do things like a B scan to make sure that there's no other indication to do surgery here. But I think it would be very appropriate to do a vitreous tap and inject. We'd love to get a vitreous sample. We'd love to know what the bug is.

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We'd love to know the sensitivities of that bug, and then we'd like to inject with broad spectrum antibiotics, typically something like vancomycin and ceftazidime, and then we'd follow that patient very closely. I would start them on very aggressive topical steroids. I think I'm a uveitis specialist as well as a vitreoretinal surgeon, so I'll show my bias here, but I think not only is part of the poor outcomes of endophthalmitis following any type of intraocular procedure from the infection and the endotoxin that the bacteria or the microorganism brings, but a lot of it comes from the aftermath of the infection, the inflammation. And so treating that very aggressively I think is important. So I talk about doing topical steroids every hour. If the patient wakes up overnight, please put a drop of steroids in the eye. I think about cycloplegia in these patients, typically a Cyclogel to keep the iris from moving and prevent posterior synechiae.

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I put them on topical antibiotic drops. We don't have great evidence for that, but I think it all makes us feel better about that. And in particular, if it was after some sort of incisional surgery, we would prefer that. And then I know, again, I'm drifting off topic here. Of course, if it was after a filtering surgery here, we'd want to have them on some sort of topical antibiotics, typically fortified antibiotics. So some role for it there. You need to see this patient very closely. You want to see them the next day. And then depending on how that patient looks the next day, the things that I want to hear from that patient, the very first question I go is, how does the eye feel? If the eye feels better, I feel better. The next thing I look for is clinical signs of improvement, but I would be very honest that sometimes the eye actually looks a little worse the following day, and that's because we've now kind of killed the microorganism.

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We've taken that antigenic burden, and I'm making these numbers up, but say there's a hundred microorganisms in the eye, we kill them with the antibiotics, we logically increase the amount of antigen in the eye, and so the inflammatory response follows. And so sometimes it actually looks a little bit better, but as long as the patient feels better, I'm feeling better. I very personally feel that hitting these patients, if they don't have a contraindication to oral steroids, putting them on aggressive oral steroids as well, trying to control that inflammatory response is really important.

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I see them that day after, I'm usually seeing them, depending on how they're doing, two or three days following that, they're doing better, I'm seeing them four days to a week after that, slowly tapering the steroids, both topical and oral with the inflammatory response. I think that would be the best case scenario.

Erik Massenzio, MD :

Great. Yeah, thank you, Dr. Deaner, for the detailed response. You preempted a lot of my questions here. When are you starting those oral steroids? Do you start it at the time of the injection or do you give it a day or two before you start that?

Jordan Deaner, MD :

I give them one day. I really want to hear them say the pain is better. The other careful scenario you want to be with oral steroids is say that they're kind of reaching the edge of what you would consider typical endophthalmitis. They're presenting maybe two weeks or more following an intravitreal injection or procedure, and then you may be putting fungal on your differential. And we know that fungal, if you give fungus a lot of steroids, it will really drastically get worse very quickly. And so you just want to be careful. So I usually give them one day. I want to see that appropriate clinical response first, and then I hit them hard with the steroids.

Erik Massenzio, MD :

Awesome. Thank you, Dr. Deaner. And I also want to really get into the specifics about your decision making for repeat tap and inject or surgical decision making. As we know from the EVS, you have that LP vision cutoff, which is famous, which oftentimes drives our decision making. Do you use that cutoff on presentation to decide whether or not you'd consider doing a vitrectomy? If the patient worsens, do you try to get a repeat injection or do you go straight to vitrectomy? Yeah, go ahead.

Jordan Deaner, MD :

I think let's just remember that the EVS is 30 years old. We don't use 30-year-old data to support any of our actions anymore except for maybe this, which really should make us question, do we need to repeat EVS either in a very formal way, like a multicenter clinical trial, which would be an astronomical feat or in a more AI large data centered kind of emulated kind of instance. But I think we need new data on management of endophthalmitis because I'm not sure that 30-year-old data is safe to extrapolate at this point in time. Organisms are different, surgery is different, antibiotics are different, everything's almost different. So let's have a grain of salt when we're talking about this. Certainly if the patient presents with LP vision, I think a vitrectomy is the way to go. I think more so these days, if the patient presents with significant endophthalmitis following any sort of procedure, should we move to an earlier vitrectomy?

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That's always on my mind. And so I think you are safe from a medical legal standpoint as long as their hand motion or better to do a tap and inject, but I'm very quick to want to take this person to the operating room. I think there's something to be said for going in, removing all of the endotoxin, removing any infectious element that's left after a tap and... And let me say this, if you want to do a vitrectomy, you should still do a tap and inject. At presentation, you should do the tap and inject and then you can quickly move them to the operating room. But taking them to the operating room, removing all of this blood, all of this toxic stuff in the back of the eye, preventing hopefully a large robust inflammatory response I think can only be helpful here. We don't have great data to support it, but our European colleagues are very vitrectomy forward for endophthalmitis, and I think we should start to adopt that.

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My personal and anecdotal and very biased experience is that they have better outcomes.

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You brought up a great point of when to repeat a tap and inject. I think the answer should probably be pretty rarely. So let me give you the scenario of where I would repeat a tap and inject. You have a patient with classic endophthalmitis following a procedure, you do a tap and inject, they clinically get better one day afterwards, three days afterwards. They're showing some improvement, both on a pain scale, both on a vision scale, both on a clinical exam scale. And then a week later it's like, oh, they're starting to look a little worse. The pain's a little worse. And so maybe you just haven't given quite enough antibiotic to completely sterilize the eye. You've kind of sterilized it mostly but not completely and you're worried. I think that would be one instance and probably the only instance where I would consider a repeat tap and inject.

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But let's give you the other scenario. We do a tap and inject. The next day the eye is not feeling better, the eye looks worse, or the next day it's kind of equivocal and you say, come back the next day and it's definitely worse. Those are eyes where I'm like, no, we got to go to the operating room. We're not even sure that we are giving the correct antimicrobials here. We need to be more aggressive. We need to know A, what the bug is and then B, how to best treat it.

David Fell, MD :

Yeah, I agree. I'll just jump in and say, I think one of the most important things that tell me about is this person going to have to go to the OR, is this person possibly going to need a second injection, is what bug it is. And that usually translates to how quickly after the event they come in. So when someone comes in with endophthalmitis within the first two days, often their pressure is high and those are people that in the back of my head, if they're not LP or with a pressure of 50 and going to the operating that day in the back of my head is we're probably going to the operating room within the next week or two if I can control their pain with injections. And I was just talking to Jordan about this last week, actually. I've been helping one of my colleagues manage a post-injection endophthalmitis with a very bad bug Streptococcus mitis.

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And she came in two days after the injection. The pressure wasn't bad, but her pain was terrible. She had a hypopyon, terrible corneal edema. They got a positive tap that showed strep. mitis and they got susceptibilities and the bug was susceptible to vancomycin and ceftazidime that they got. And they showed an initial response, but they never got all the way. Usually after two days or so after the initial tap and inject, their pain is pretty much gone if you've killed it. And she still had some persistent corneal edema that wasn't going away. And she came in a week after the first time I saw her and she had been woken up in extreme pain the night before, after it had been getting better, but not that kind of total resolution. And so if we hadn't had that positive tap that told us exactly what the bug is and susceptibilities, I probably would've said that that was when we go to the operating room because are we dealing with a polymicrobial infection?

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Did we not give them the right antibiotics? But because I knew what the bug was and that we had at least partially treated it, I just re-injected her with vancomycin and she came back the next day and the pain was totally gone. And that was probably the second time I've ever second tapped a bacterial endophthalmitis.

Erik Massenzio, MD :

Very interesting.

Collin Richards, MD :

I have a brief question. Dr. Deaner, you brought up the importance of steroids for inflammatory control in these cases. I know at Will's we typically are not putting intravitreal steroid at the time of initial injection, but I know other places nationally and probably internationally are doing so. What are your thoughts on for a classic slam dunk endophthalmitis putting in intravitreal steroid?

Jordan Deaner, MD :

I think if you want to do it and you have it available, I think it's a great addition. But remember, you're going to need something with a short half-life. So most of the studies out there use dexamethasone. In particular, you need it to be preservative-free dexamethasone. So that's the biggest problem is we have dexamethasone lying around, but most of it has preservative in it. And then the one in the United States that is most readily available that doesn't have preservatives in it, you have to dilute it in a particular fashion. So just be aware of what you're going to be getting. So you need it to be preservative-free and then make sure you're giving the correct concentration and dosage into the eye. I'm okay with dexamethasone. You want something with a short half-life. You want a steroid that doesn't outlive your antibiotics, and so you just never want to be giving unopposed steroid in an infectious or a possible infectious scenario.

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I love topical steroids. I like oral steroids because if you need to stop them because the infection is getting worse for whatever reason, you can just stop them. But again, we have scenarios very vividly. A scenario when I was in fellowship at Duke, we had a patient in the ICU, direct contraindications to getting oral steroids who I was pulling up the correct dosage and concentration of preservative-free dexamethasone and giving it in the ICU to control her endophthalmitis, and she did quite well. So I think it's another way to treat and control this. We have multiple ways of doing it, and I think that's always great to have multiple ways of doing it.

David Fell, MD :

Yeah. I always think back to this patient that I saw who was a post-Ozurdex endophthalmitis, and it was a very nasty presentation very quickly after the injection, but as soon as she got those antibiotic injections, two days later, the eye was quiet.

Jordan Deaner, MD :

So it's great.

David Fell, MD :

Yeah. And that was actually the other person that I ended up re-injecting, mostly because of what you're talking about. I was afraid at one point, maybe her pain was getting a little worse or her cell was getting a little worse, and I was worried about that unopposed just steroids sitting in the eye. But I mean, I've never seen an endophthalmitis eye clear up so quickly, but I'm still most of the time not brave enough to put steroids in the eye unless I need to.

Justin C. Muste, MD :

I hate the feeling of these cases when you have patients that come in with little to no pain, lots of pigmented cell, some cell in there, they're within the window of the appropriate window for endophthalmitis. And there isn't that great feeling you have when you're seeing a proper endophthalmitis with hypopyon and you're like, "Okay, I know what I'm doing here." There's these kind of gray area ones. I'm thinking to one that we recently encountered where the patient had a submacular hemorrhage, was getting Avastin for submacular hemorrhage, already had pigmented cell documented, and they came in with more pigmented cells saying, "Something is off, but no pain." And we proceeded with a tap and inject anyway because one of the things that we've talked about before, I know I brought this forward a couple of times and it's eating at me still, is pain is a great sign.

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If it's ambiguous and you see pain or the patient is endorsing pain, it's probably a good trigger to inject. But this person we injected and I saw him the next day and he said whatever was weird went away, but there wasn't a hypopyon and much of the exam looked relatively similar. So did I just placebo him with vancomycin and ceftazidime or placebo myself with vancomycin and ceftazidime? It's still a gray area case, so I just wanted to talk a bit about that. And his vision did improve a little bit after that.

Jordan Deaner, MD :

I think I have Sunil Srivastava's voice in the back of my mind whenever I see these kind of borderline cases and he's saying to me, "You will never regret injecting. You may regret not injecting. And so I think we should really have a low threshold to inject these cases that we're concerned may have or suspect have possible endophthalmitis." And so maybe you'll hear my voice moving forward, but I think that's a great rule and a great line of thought. I think look closely for signs on clinical exam. So the signs on clinical exam that really make me think that there is some sort of infection going on in the eye is are there chronic precipitates, particularly granulomatous, keratic precipitates? And then the other thing is, is there any amount of fibrin in the anterior chamber? Those two things really should tip you off to some sort of infectious etiology.

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People certainly can get just cellular inflammatory reactions to injections. We know that they can get more than that. People can get a very large spectrum of allergic reaction or hypersensitivity reaction to injections, and where that's kind of top of line thinking now ever since brolucizumab. But a little bit of a cellular reaction is far less concerning than a fibrin reaction or a granulomatous keratic precipitate.

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The other thing is you can watch these eyes very closely. I think it's about, hey, there's a little bit of trace to one plus cell in the AC, maybe you see a cell or two in the vitreous. You can always watch these patients closely and put them on aggressive topicals. Say, "Hey, it's 4:00 PM today. Let me put you on topical steroids. I want you to use them every hour. I want to see you first thing tomorrow morning. And if they look better tomorrow morning, great, they're in the clear. And if they look worse the next day, then you say, well, low threshold for a tap and inject." But then you have someone that comes in on Friday, it's always Friday, the last patient, and you're like, "I can't come the next day." I mean, my personal thought is just tap and inject them. The risk of a tap and inject, not zero, but low.

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But I mean, if this person develops endophthalmitis over the weekend, you and the patient are going to be sad, and I think that's just not a scenario that you should consider. And so those are kind of my thoughts on it. I think low threshold for treatment of something that is suspicious for endophthalmitis is the correct final answer.

David Fell, MD :

Yeah, I think about it similar to... I also have the same voice in the back of my head, and I think about it similar to globes. There are plenty of times as a resident where someone comes in with subconjunctival heme, but intact vision, and there's no real obvious evidence of a globe, but you still take them to surgery to explore, and you should have a certain number of negative explorations to tell you that you're actually appropriately exploring everything that needs to be explored. You should have a few extra tap and injects that maybe didn't need a tap and inject, but I used to do that move if it's kind of just cell and no pain, but it's within the window and you start them on frequent topical steroids and see them the next day. I will say since my uveitis fellowship, I have probably done that much less and less, just because if I think about tap and injecting someone, and if I don't do it and they come back with endophthalmitis, I will never forgive myself and I'll wish I had listened to the voice in my head the first time.

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So I pretty much just will tap and inject if I think about it on the presentation.

Erik Massenzio, MD :

I love this model of being aggressive with the tap and injects if you suspect even a small chance of infection. The only thing that does give me pause is the tap part, the vitreous tap.

David Fell, MD :

I don't do vitreous tap usually.

Erik Massenzio, MD :

You do not do a vitreous tap for any of your endophthalmitis or just these equivalent cases?

David Fell, MD :

No. So post-vitrectomy I always do, but I do it like basically an AC tap from the pars plana. So it's like a 30-gauge needle at the pars plana and you're not really worried about vitreous traction. Anyone under 65 or so, I almost never vitreous tap anymore just because my yield is so low and I think the risk is pretty high for causing traction and retinal pathology. So I most of the time will do an AC tap unless I'm convinced of how liquified their vitreous is or their post-vitrectomy.

Jordan Deaner, MD :

David, I like that kind of risk reduction kind of model. I think I follow that, not quite exactly, but say you have this patient that Justin just presented where you're like question mark endophthalmitis, I would tap the AC there. You're presenting with more anterior chamber reaction. If anything's going to be positive, it's going to be where the inflammation or the reaction is. So there's certainly a scenario where I would do an AC tap. I will attempt a vitreous tap if it's kind of classic endophthalmitis presentation. But again, I do it with a 25 gauge short needle, three cc syringe. I give it one or two attempts, and then I just move on to an AC tap. The yields of these taps, as we know, are not high in either scenario. Yes, they're a little bit higher when we do vitreous taps, but not greatly. And I do worry about pathology that I'm inciting.

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If this is a true infectious endophthalmitis, the retina very quickly can become necrotic, and if they've not already had a PVD, inducing any traction on any amount of necrotic retina, as we know from, let's say, acute retinal necrosis, probably the best model for that is a recipe for retinal detachment and disaster. So I try not to create my own pathology as best as I can.

David Fell, MD :

One more thing I'll add just about Justin's scenario is I also think about what's the worst case, best case scenario. And if someone is coming in after a possible endophthalmitis creating event with questionable signs and you do treat them like you did Justin, and their symptoms get better, then you have just literally prevented almost the entire cascade of someone going through endophthalmitis. If you catch someone really early in endophthalmitis a week later, maybe two weeks later, that eye can be back to normal and back to their baseline vision. I don't know, I've had a few patients where they've had no pain when they came in, but just a lot of cell, or they've had just pain and almost no cell where I've treated them with a tap and inject and their symptoms or their exam have improved. Those are almost the most satisfying ones because then endophthalmitis, once you're treating a fulminant case of it, it's a weeks long, possibly multiple surgeries long course, and it can end with complete loss of vision and loss of an eye.

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So if you can head that off really early on with a little tap and inject procedure, that is one of the best things I think you can do for patients.

Justin C. Muste, MD :

Collin, do you want to take us away to the world of... I actually have kind of a transition to this because we're heading to the world of fungal, I believe, and I think there's a case we're all involved in with a fungal endophthalmitis. And one of the things that we did was try and directly vit tap and get to the lesion.

David Fell, MD :

That was the week after I started.

Justin C. Muste, MD :

Yeah. And I was watching with the 28, and you just see the needle just suck everything and spit it out. So if in doubt, just watch the needle tip. But that gives us a good transition to what I think Collin is going to talk about.

Collin Richards, MD :

Yeah, thanks Justin for having me on. Dr. Fell, Dr. Deaner, Erik, good to see everybody again. So I guess what I wanted to talk about, I have a couple things that kind of segue into each other, but we could start with the world of fungal endophthalmitis, endogenous endophthalmitis. I think one of the tougher things, and I've talked with both of you about this before, but is how do we develop a treatment algorithm a priori when we see these people so that we can identify treatment failure, treatment success, what is our threshold to re-inject these very sick patients in the hospital who can't get some of the things that you're talking about like oral steroids? Yeah, so we could start there. What is your threshold to re-inject a fungal or an endogenous endophthalmitis that you know is going to have continued seeding from the body?

Jordan Deaner, MD :

I think just so we're laying out the groundwork, you're talking about a completely different patient scenario. So you're talking about someone that has a severe infection somewhere else in the body that is having at least one bacteremic or fungemic or septicemic event where they are seeding microorganisms from that location into the bloodstream to the eyes and maybe to other places. So goal number one of these patients, you see this patient in your office, you see them in the emergency room, is to get this patient into the hospital where not only do they have good whole body healthcare and infectious disease specialist, probably you want cardiology on board because we know how high the risk of endocarditis is here, but they also have ophthalmology.

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You see this patient in your office and you have the clinical supplies to do a tap and inject in the office, that's excellent, go ahead, proceed. But then the next thing is getting whole body control here. And so getting this patient into the hospital, starting them on empiric IV antibiotics, and if you're concerned, IV antifungals as well, that suspicion is really guided by the ophthalmologist. We can't understate our role in trying to help these patients, and sometimes that's as easy as saying, "I don't know." It could be anything. Sometimes these eyes just look like crap, and you're just like, "I don't know, it looks bad, probably should do antibiotics and antifungals altogether, and we'll see how they respond and see what the cultures show us." And so things that could lead you one way or another though. So fungus, it tends to be kind of an indolent infection, right?

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So think about your classic, let's start with classic bacterial endophthalmitis, just usually a brutal infection, right? So hypopyon, keratic precipitates, cell, flare, the aqueous looks fibrinoid, it's like a non-moving aqueous. There's lots of vitritis. Oftentimes, you can't see to the back of the eye. Fungal endophthalmitis tends to not be quite as bad. Yes, there'll be some cell. Yes, there can be some KP, but it's usually more subacute, more indolent. Oftentimes, you can see to the back of the eye. It can be a little hazy, but it's like it's an okay view for the amount of stuff going on. We look for things like pearls on a string, that can oftentimes be very classic. We see pearls on a string, we oftentimes think about yeast. I think you guys have heard me say about yeast loving to be vitreo-invasive versus something like aspergillus being more of a subretinal kind of fungus, and so you see a subretinal kind of abscess, maybe that leads you more towards fungus with a clear view to the back of the eye.

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But remember, you can get subretinal abscesses with bacteria too. And so these are just things that can kind of sway you and say, "Hey, I'm really suspicious for fungus," versus, "Hey, I'm suspicious for bacteria," versus, "Hey, I don't know, you should probably treat them for everything," and we'll try to figure this out as we get cultures, both blood cultures back and eye cultures back, and we do a whole systemic workup. And then remember where the infection starts can also be helpful in letting us know what this is. Yeast, aspergillus. Yeast oftentimes comes from urinary infections, aspergillus from the lungs, from the liver, bacterial infections come from IV drug use, other sorts of infections as well, the urinary tract as well. So just knowing where the source is from as well can help guide us here. Kind of went on a tangent. Did I answer your question?

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Do you have a follow-up on that?

Collin Richards, MD :

Well, I think these patients more so than any other patient, typically we get consulted, the resident sees them, the residents are switching every week. We're seeing them longitudinally, and there's so many exams that we have. We are examining this person every other day, and you are like the frog in the water that's boiling and you have no idea when it's hot. It's tough to tell change when you're evaluating them so frequently. So what is your threshold to re-inject? Let's just say a known etiology where they have candidemia with fungal endophthalmitis and pretty bad fungal endophthalmitis, what is your threshold to say, this needs more intravitreal therapy?

Jordan Deaner, MD :

And let's also just state, sometimes these people are really sick, so they don't even have visual acuity. You can't even check their visual acuity to see if they're doing better. So they're out of it. You're switching every day with someone else looking at the eye. You need a marker to judge success, to judge improvement. If you're in the office, we have fundus photos, we have OCTs. I'm constantly telling my residents and fellows to find something to be your marker to trend your treatment, to treat towards that goal. But here it's very hard. So if there's vitreous involvement with a fungus, you know you have to inject until that vitreous involvement is gone. IV antifungals, IV antimicrobials in general don't do a great job of penetrating into the vitreous. There's always this theory of if there's an active lesion or active inflammation, yeah, there's breakdown of the blood ocular barrier, but in general, they still don't penetrate.

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So you want to inject until all of the fungal balls are gone. So I do once weekly voriconazole injections until the fungal balls are gone. Then the next thing you want to treat to is the chorioretinal lesions or sometimes they're subretinal lesions. Those are a little more tricky because in general, chorioretinal lesions or subretinal lesions should get enough antifungal or antibacterial concentration to eliminate them. So you can start. Usually we want to treat them. We see them on acute presentation. We really want to give them a kick in the butt to start. And so you can attack it from both intravitreal injections and from IV. But again, in these scenarios where these cases are also higher risk for retinal detachment, I like to stay out of this eye as much as possible. I don't want to be causing a problem. And so the moment that I start to see clinical improvement, I usually stop injecting and then just watch to see if they continue to clinically improve on the systemic antimicrobial.

David Fell, MD :

Yeah. I'll just say it's very different when you're treating someone in the hospital and you can't really get a good exam on them and you can't get any imaging on them versus someone who's coming into your clinic and you're getting fundus photos and OCTs every time. And when you're switching people, examining them every time when they're in the hospital, I think you will end up injecting a little more often because you don't have those objective markers to follow and that's okay. Same as with bacterial, you always want to stay ahead of it and not watch hopefully that it's getting better if you're not confident that it is. So having some way to gauge whether it's turning a corner before you stop treating intravitreally. But going from talking to you guys about people you're managing on the service to a patient that I've been managing recently who's very subacute in the clinic, I gave him one injection in one of his eyes that had near foveal involvement and everything else has been systemic.

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And I've felt because I can see the OCT getting better, the macular edema getting better, the fundus photos getting better, I feel much more confident just watching him on the systemic.

Collin Richards, MD :

I wanted to segue into surgical questions. And specifically I'm thinking of this guy that we had, he was a mid - 50s guy that came in, known klebsiella bacteremia from a GI source. NLP in the left eye had large four to five disc diameter subretinal abscess. And we obviously treated him aggressively with intravitreal therapy, but every time we saw him, we were wondering when and if do we do surgery on this guy and when we do surgery, if we do surgery, do you drain that abscess? Do you touch that thing? Or what is your surgical approach and when do you proceed?

David Fell, MD :

Did you know what the bug was? I didn't hear what you said. Did you say what the bug?

Collin Richards, MD :

Yeah, it was klebsiella.

David Fell, MD :

Yeah. Oh, klebsiella. Yeah, sorry.

Jordan Deaner, MD :

What's his vision?

Collin Richards, MD :

In this eye, I think he was like 20/100 when he came in. He was somewhere, he had a lot of vitritis and the lesion was extramacular. It was at the edge of the macula extending into the periphery.

Jordan Deaner, MD :

Yeah. I mean, what a difficult scenario, right? Because he's already lost one eye. We need to be careful here. We need to be as aggressive as we need to be, but we also don't want to be the cause of vision loss in this patient. And we don't even want to... The other thing is I don't think patients quite understand. I mean, it's just not within their perspective to understand how high risk this eye already is. And so he's high risk for something like a retinal detachment. But if we go into this eye and operate and then he gets a retinal detachment, he'll forever think that it's us. And part of it may have been us, but it might've happened anyway. And so that's kind of the scenario that we're playing with here. I agree. I would hit this eye hard. Subretinal abscesses, we don't have great evidence for intravitreal injections, but we don't have great evidence that IV antibiotics are getting to that abscess.

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It's a whole pussball containing bad microorganisms that we're not sure that the IV antibiotics are getting into it from the backside and we're not sure the intravitreals are getting it from the inside. And so giving them both trying to sterilize, I think that makes the most sense. You would like to watch that closely and make sure that it's not growing in size. I think I'd have an early conversation with the patient that if it continues to grow or get worse, and certainly if it would start to grow and get worse of, "Hey, do you want us to take you to the operating room to go in?" Of course, if it's getting worse while we're giving intravitreal antibiotics and IV antibiotics that should be susceptible to this, I think that's a pretty clear indication to not only drain, but also to culture it. You're going to drain this subretinal abscess, you're going to make a hole in the retina.

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That retina is likely necrotic and unviable anyway, so you're going to need to drain it laser, probably multiple rows of laser around it. So you'd love for it to knock it into the macula before you do that because you're going to have to extend the amount of lost retina when you do that. I would certainly put in a silicon oil bubble. Not only is this patient monocular, but silicon oil bubbles have bacteriostatic properties to them as well.

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You may cross that line where you need to do it. I would lay out that line early and revisit it frequently. And if it got worse with very frequent, that's someone I would probably inject twice weekly, but it's quite possible. And then if it's getting worse with IV and intravitreal injections, it also brings up, sure, you've got a bug that you've identified via, I don't know, blood cultures, but is there something else going on inside the eye entirely that you're not targeting correctly?

David Fell, MD :

What antibiotic were you guys injecting for this?

Collin Richards, MD :

Yeah, I believe that he... Was it ceftazidime susceptible? I think it was actually amikacin because I think there's a pretty high resistance to cephalosporins with Klebsiella and his was resistant.

David Fell, MD :

Yeah, no, I agree. It's such a tough scenario. I would personally try everything to not go into the eye. So I would really have to have an objective evidence that the abscess was growing probably, because I feel like I've seen abscesses remain stagnant as inflammation is getting better and maybe all that stuff that still looks elevated under that area is not really active infection. I think that it can be really hard to judge with subretinal abscesses. But yeah, I agree with everything else Jordan said.

Jordan Deaner, MD :

I'll ask a question that I'm actually not sure the answer to. Would you consider lasering around that abscess?

David Fell, MD :

I don't know what I would be trying to do in case it got a tear through the abscess.

Jordan Deaner, MD :

Yeah, I mean, I guess it would depend for me on hyaloid status, where it was in the retina. If it was posterior to the equator and there was already a PVD, I would say there's probably not going to be much traction on it. I'd probably get an OCT over it too, see if the retina was truly necrotic. Likely at the edges, there's going to be so much inflammation that it's going to scar down and pexy itself down, but that's just a question that crossed my mind.

David Fell, MD :

No, with this, I also have Sunil's voice in the back of my head, but mostly thinking about iron and people who like to laser areas of retinal necrosis. And I think that if I'm thinking about lasering something because I'm worried that it's spreading or because I'm worried that it's going to detach, that's probably just me telling myself that I should be taking them to surgery. And then that area that you were going to laser around, whatever retinotomy you have to make to drain it is now bigger and more into the macula.

Collin Richards, MD :

Awesome. Thank you. Yeah, I think that this guy ended up not getting surgery and I think he had 12 or 13 injections, and then we saw him two weeks after his admission in the clinic and he looked beautiful. Well, beautiful, all things considered.

David Fell, MD :

That's the other thing that Sunil used to say specifically about fungal, but it's so hard when you're seeing people so frequently to judge change. And in some ways you have to with a lot of these cases because things can go bad so quickly. But if you keep seeing them quickly enough, you're going to keep wanting to inject them. And sometimes you do need to be like, "I'm going to see you in two weeks and I'm going to think about you every day, but I'm not going to inject you in two weeks unless you come to the emergency room, and then I'll inject you in two weeks again just to make myself feel better again."

Justin C. Muste, MD :

It's interesting. I know we're well over time, but that's actually one of the issues that I've run into, especially when you're handing off patients or if you're on the floor constantly is if you're looking at a lesion, a subretinal abscess or something like that, being absolutely sure it's not the same as having Optos sequentially over and over and over again. And sometimes when you have somebody that's admitted for a month, two months, and you're seeing them every other day or every three or four days, how do you know that it's actually getting better, getting worse? And I mean, to the fantastic residents and Will's culture here, we do the photos with the indirect, with the holding the lens on the phone and that usually gets something, but if it's out in the periphery and the patient can't cooperate and you're staring at this peripheral goomba, you don't really have a good gauge for what it is.

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I don't know if you guys have any tips, tricks, or thoughts about what to do in those cases.

Jordan Deaner, MD :

No, I think the peripheral fundus photos, the residents are way better at that than I ever was. I took a couple when I was a resident. They're so good at them now. I think that's a great starting point. I think there's something to be said about handoff, which we know we would love, in a perfect world, we'd love to have a handoff of these high-risk patients where it would be great to be like, "Oh, you're coming on service tomorrow, just come real quick and see this patient today so that you know what they look like and you know that I think they're doing better today or I think they're doing worse today." So you'd love to have that handoff, but in the real world, that always can happen. I mean, I think the correct answer is we do our very best. We document exams as best as we can.

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We have good verbal handoff. We have a true traditional patient handoff when that's possible. And then you have a low threshold to do what you think is in the interest of the best patient. If you are concerned that the patient's getting worse, ultimately that's what we're here for is to make sure that we are taking care of this in the best way possible and making sure that the eyes are continuing to get better. And so again, I don't think you'll ever regret treating, but you may regret not treating here. And so keeping that in the back of your mind, seeing the patient that day and then being like, "Well, is he getting worse?" You see them the next day, see what you think the next day. You can have close follow-up. I understand we're making a little bit more work for ourselves, but the number of times I see patients, I'm like, "I just can't tell.

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Come back in a week or two and just see me one more time before we make a big treatment change to your plan." I do that all the time, and I think the patients appreciate it because they know you're invested in their eye care, you're invested in their vision, and you just don't make snap decisions willy-nilly. I think you're doing all the right things. I don't know. I'll come back to one of my favorite pieces of advice before I became an attending. Xi Chen, MD, told me, "Dr. Deaner, sometimes all we can do is our very best." And I think if you can walk away from your job every day and say, "I don't know if I did everything perfect, but I did my very best. I learned a lot. I'm going to do even better the next time," you're doing a great job.

David Fell, MD :

I think that is a beautiful way to end the podcast.

Collin Richards, MD :

Yeah, it's inspirational. Thanks.

Justin C. Muste, MD :

Yeah. Thank you everybody for tuning in.

David Fell, MD :

We hope this is helpful. And for any fellows watching or listening, please reach out with any suggestions for future topics or if you want to be a part of an episode.

Justin C. Muste, MD :

And remember to watch out for new episodes of The Fellow Eye on New Retina Radio.