RU2610408C1 - Method for treatment of acute bacterial postoperative endophthalmitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to ophthalmology, and is intended for treatment of acute bacterial postoperative endophthalmitis. Method includes removal of vitreous cavity content by subtotal vitrectomy with simultaneous replacement of vitreous with BSS solution, sampling content of vitreous cavity and anterior eye chamber for microflora inoculation, determination of sensitivity to antibiotics and the following intravitreal introduction of two antibacterial preparations: 1 mg/0.1 ml of vancomycin and 2.0-2.25 mg/0.1 ml of ceftazidim. First antibiotic to be introduced into vitreous cavity is vancomycin in dose 1 mg/0.1 ml. After that, content with diluted vancomycin in volume 0.2 ml is sampled from vitreous cavity. Then ceftazidim is introduced in dose 2.0-2.25 mg/0.1 ml. Taken sample with vancomycin is directed to spectrophotometry in ultraviolet part of spectrum with wavelength 280 nm to determine concentration of vancomycin in vitreous cavity. If concentration value is 130 mcg/ml and higher, it is concluded that concentration of antibiotic is sufficient for elimination of bacterial flora. If concentration value is lower than 130 mcg/ml, it is concluded that concentration of antibiotic is insufficient and introduction of 1mcg/0.1 ml of vancomycim and 2.0-2.25 mg/0.1 ml of ceftazidim into vitreous cavity is repeated on the following day. From the following day after vitrectomy until results of bacteriological inoculation are received, 25 mg/0.25 ml and 100 mg/0.5 ml of ceftazidim are introduced 2 times per day into subconjunctival space. After receiving the results of bacteriological inoculation on 2-3 day, the antibiotic that possesses activity with respect to identified pathological agent, is continued to be used for postoperative subconjunctival introduction.

EFFECT: method ensures elimination of infectious process in eye, preservation of eye structures and maximal preservation of visual eye functions.

2 dwg, 1 tbl, 2 ex

Description

The invention relates to medicine, in particular to ophthalmology, and is intended for the treatment of acute bacterial postoperative endophthalmitis by introducing antibiotics into the vitreous cavity.

Endophthalmitis is an inflammation of the inner membranes of the eyeball with the formation of exudate in the cavity of the eye. Endophthalmitis can be exogenous (an infectious agent enters the eye cavity through damaged structures of the eyeball), these include postoperative and post-traumatic endophthalmitis. Also, endophthalmitis can be endogenous (the infection enters the eye cavity while the membranes of the eyeball are intact, for example, from foci of a chronic infection in the body). In turn, postoperative endophthalmitis is classified according to the rate of onset of acute (occurs up to 6 weeks after surgery) and chronic (occurs after 6 weeks). According to pathogens, endophthalmitis is classified as bacterial, fungal, viral, parasitic.

The invention relates to the treatment of acute bacterial postoperative endophthalmitis.

A known method of treating endophthalmitis, including the introduction of an intravenous broad-spectrum antibiotic in a single dose, obtaining autoserum and introducing it into the cavity of the eye after vitrectomy. For irrigation, ozonized physiological saline is used twice for 10 minutes, then the eye cavity is washed with physiological saline for 2-3 minutes, and then serum is introduced into the eye cavity to replenish the volume (RF Patent No. 2460501).

However, with this method of treatment, the systemic use of antibiotics with an inferior course of treatment is required, which affects the selection of resistant strains of microorganisms, as well as the systemic use of the antibiotic can cause undesirable drug reactions. Ozonized saline does not cause the death of resistant microflora due to its rapid inactivation. In turn, the serum concentration of the antibiotic in the vitreous cavity is often not enough to obtain the necessary therapeutic effect.

One way to treat endophthalmitis is to use ozonated PFOS (organofluorine compound) for vitrectomy. At the end of vitrectomy, fluid is exchanged for ozonated PFOS at a concentration of 0.3-6.0 mg / L. Through one of the scleral punctures, a blunt-ended cannula with a diameter of 0.6 mm is inserted into the vitreous cavity on the syringe and the distal end is placed in the region of the optic nerve. Then, 2-3 ml of ozonated PFOS is introduced into the vitreous cavity, circular retinal argon barrier argon endolasercoagulation is performed. The operation ends with suturing of the scleral and conjunctival sections with PFOS left in the vitreal cavity for a period of 1-2 weeks. PFOS is removed by aspiration with replacement with physiological saline (RF Patent No. 2187984).

The disadvantage of this method is that a small range of therapeutic concentrations of ozonated PFOS retains a high risk of toxic damage to the retina at an excessive concentration and an insufficient effect at a low concentration. Also a negative aspect of treatment is the need for repeated surgery to remove PFOS from the vitreous cavity.

A known method of treating endophthalmitis, which consists in performing a vitrectomy through a three-port access with vitreous cavity tamponade with silicone oil without intravitreal administration of antibiotics (AB). Silicone is removed from the vitreous cavity after 3-4 months (Lebedev Ya.B., Egorov V.V., Khudyakov A.Yu., Zhigulin A.V., Rudenko V.A., Mashchenko N.A. // Long-term results the use of silicone tamponade in the treatment of endophthalmitis. // Modern technologies for the treatment of vitreoretinal pathology. // 2013 - S. 122-124).

The disadvantage of this method is the lack of chemotherapeutic agents that have a bactericidal effect on the causative agent of infection. Between the bubble of silicone oil and the retina there is a layer of intraocular fluid (a phenomenon associated with the physical properties of silicone oil), in which an increased concentration of microbes, pathogens, forms after silicone tamponade.

Today, both Russian vitreoretinal surgeons and Western surgeons have developed a “gold standard” in the treatment of acute bacterial postoperative endophthalmitis.

The closest technology for the treatment of acute bacterial postoperative endophthalmitis, based on the "gold standard", is the technology consisting in the following. In the eyes with acute bacterial postoperative endophthalmitis, as soon as possible from the moment of diagnosis (within 1 h), a subtotal three-port vitrectomy is performed with the contents of the vitreous cavity and anterior chamber taken for inoculation of microflora and determination of its sensitivity to antibiotics. Immediately after removal of the vitreous body, two antibiotics are intravitreal (IVV) administered: 1 mg / 0.1 ml of vancomycin, which is active against gram-positive microflora, in combination with an antibiotic, active against gram-negative microflora: 2-2.25 mg / 0. 1 ml of ceftazidime or 0.4 mg / 0.1 ml of amikacin, or 0.4 mg / 0.1 gentamicin. Thus, almost the entire spectrum of possible pathogens of bacterial infection is blocked. However, many surgeons avoid the use of aminoglycosides (amikacin, gentamicin) to eradicate gram-negative bacteria due to the risk of retinal toxicity (gentamicin at a dose of 200 μg can be effective, and at a dose of 400 μg it can cause macular infarction). Therefore, today the first choice: 1 mg / 0.1 ml of vancomycin in combination with 2-2.25 mg / 0.1 ml of ceftazidime. Both antibiotics are administered at the final stage of vitrectomy through one of the scleral sections using a 25-30 G needle in separate syringes. If necessary, a combination of antibiotics is administered again after 48-72 hours, depending on the clinical response. According to the EVS (Vitrectomy with Endophthalmitis) study in 1995, 7% of patients received repeated intravitreal antibiotic injections from 36 to 60 hours (Malyugin B.E., Shpak A.A., Morozova T.A. Pharmacological support of modern cataract surgery . - M.: Ophthalmology, 2010. - 15 pp. - PROTOTYPE), (Barry P., Cordoves L., Gardner S. ESCRS Guidelines for Prevention and Treatment of Endopthalmitis Following Cataract Surgery. Co Dublin: Temple House, Temple Road, Blackrock, 2013 .-- P. 21-22.).

The disadvantage of this technology is that it does not take into account the individual anatomical features of the patient’s eyeball, in particular the length of the eyeball, which has a direct effect on the volume of the vitreous cavity and accordingly affects the concentration of antibiotics administered in the eye. Lack of consideration of these parameters can lead to insufficient concentration of antibiotics in the eye and, accordingly, affect the results of treatment. Another drawback of this technology is a wait-and-see tactic for 48-72 hours, which can be detrimental to the eye in the absence of positive dynamics at an earlier date.

The objective of the invention is to develop a more effective technology for the treatment of acute postoperative endophthalmitis, allowing the surgeon not to passively observe the reaction of the eye after the initial injection of antibiotics into the vitreous cavity, and immediately obtain information on the concentration of the antibiotic in the vitreous cavity and quickly decide on the need for an additional portion of the antibiotic, if the concentration is insufficient.

The technical result obtained by solving this problem is to eliminate the infectious process in the eye, preserving the structures of the eye and maximally preserving the visual functions of the eye.

The specified technical result can be obtained if in the method for the treatment of acute bacterial postoperative endophthalmitis, including the removal of the contents of the vitreous cavity by subtotal vitrectomy with the simultaneous replacement of the vitreous body with a BSS solution, sampling the contents of the vitreous cavity and anterior chamber of the eye for inoculation of microflora and determination of sensitivity to antibiotics, and subsequent intravitreal administration of two antibacterial drugs: 1 mg / 0.1 ml vancomycin and 2.0-2.25 mg / 0.1 ml ceftazidime, according to According to the invention, vancomycin is the first of the antibiotics to be injected into the vitreous cavity, and then the contents from the vitreous cavity are diluted with diluted vancomycin in a volume of 0.2 ml, then ceftazidime is administered, and the sample taken with vancomycin is sent for spectrophotometry in the ultraviolet region of the wavelength of 280 nm to determine the concentration of vancomycin in the vitreous cavity, and with a concentration of 130 μg / ml or more, it is concluded that the concentration of the antibiotic is sufficient to destroy the bacterial microflora and when the concentration is less than 130 μg / ml, a conclusion is drawn about the insufficient concentration of the antibiotic, and the next day, re-administer 1 μg / 0.1 ml of vancomycin and 2.0-2.25 mg / 0.1 ml of ceftazidime into the vitreous cavity in this case, from the day after vitrectomy to obtain the results of bacteriological culture, 25 mg / 0.25 ml of vancomycin and 100 mg / 0.5 ml of ceftazidime are injected into the subconjunctival space, 2 times a day, and after receiving results on the 2-3rd day bacteriological culture, leave for postoperative subconjunctival administration of the antibiotic that is active against a specific pathogen.

Among the essential features characterizing the method, the distinguishing ones are:

- the first of the antibiotics to enter the vitreous cavity is vancomycin;

- then make a fence from the vitreous cavity of the contents with diluted vancomycin in a volume of 0.2 ml;

- then ceftazidime is administered;

- the sample taken with vancomycin is sent for spectrophotometry in the ultraviolet region of the spectrum with a wavelength of 280 nm to determine the concentration of vancomycin in the vitreous cavity;

- at a concentration of 130 μg / ml or more, a conclusion is drawn about the adequacy of the concentration of the antibiotic to destroy the bacterial microflora;

- at a concentration value of less than 130 μg / ml, an antibiotic concentration is insufficient, and the next day, 1 μg / 0.1 ml of vancomycin and 2.0-2.25 mg / 0.1 ml of ceftazidime are reintroduced into the vitreous cavity;

- in this case, from the day after vitrectomy to obtain the results of bacteriological culture, 25 mg / 0.25 ml of vancomycin and 100 mg / 0.5 ml of ceftazidime are administered into the subconjunctival space, 2 times a day;

- having received the results of bacteriological culture on the 2-3rd day, they leave for the postoperative subconjunctival administration that antibiotic that has activity against the identified pathogen.

Between the totality of the essential features and the claimed technical result, there is a causal relationship.

It is known that the “gold standard” for the treatment of acute endophthalmitis is the intravitreal administration (after vitrectomy) of two antibacterial drugs in volumes of 1 mg / 0.1 ml of vancomycin and 2.0-2.25 mg / 0.1 ml of ceftazidime. These standards are satisfied with an average length of the eyeball (23.4 mm). However, practice shows that such a dose is not enough to stop the inflammatory process in a situation where the eyeball has a large eye length (high myopia). A large length leads to a larger volume of the eyeball, therefore, a larger volume of the vitreal cavity. In a larger eye, the concentration of the antibiotic (if we introduce 1 mg / 0.1 ml of vancomycin according to the "gold standard") will be less than in the eye with average parameters, the effect of the antibiotic will be weaker, and the expected effect will not be obtained. That is why in our method, after the introduction of the antibiotic vancomycin into the vitreous cavity, its concentration in the vitreous cavity is determined and this conclusion is made about the sufficiency or insufficiency of the amount of antibiotic to eliminate the inflammatory process, or one more portion of antibiotics should be introduced.

Initially, two antibiotics are administered, and the concentration is determined only relative to vancomycin. This is due to the characteristics of one and the other antibiotic.

In 94% of cases, the causative agent of intraocular infection is known to be a gram-positive bacterial flora ([No authors Listed]. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group Arch Ophthalmol. 1995 Dec; 113 (12): 1479-96).

The main antibiotic in the treatment of acute bacterial, postoperative endophthalmitis is vancomycin, because it is active against gram-positive bacterial microflora.

M.I., Pastor J.C., Nozal M.J. Pharmacokinetics of intravitreal vancomycin in normal and infected rabbit eyes. J Ocul Pharmacol Ther. 1998 Dec; 14(6):555-63).Vancomycin is a time-dependent glycopeptide antibiotic. This means that its therapeutic activity does not increase with increasing dose in solution, but depends on a stable therapeutic concentration over a long period of time (Piguet B., Chobaz C., Grounauer PA Toxic retinopathy caused by intravitreal injection of amikacin and vancomycin. Klin Monbl Augenheilkd. 1996 May; 208 (5): 358-9). It follows that repeated intravitreal injections of vancomycin can most effectively destroy the bacterial flora in the eye. At the same time, repeated injections of vancomycin on the next day are safe, given the fact that vancomycin is a cationic drug with a large molecule size and leaves the eyeball structure by passive diffusion through the corner of the anterior chamber of the eye for 24 hours (Coco RM,

MI, Pastor JC, Nozal MJ Pharmacokinetics of intravitreal vancomycin in normal and infected rabbit eyes. J Ocul Pharmacol Ther. 1998 Dec; 14 (6): 555-63).

The second antibiotic for intravitreal administration is ceftazidime. Ceftazidime is a small anionic molecule with a short period of excretion from the eye (within 8 hours) by active diffretinal diffusion (Maurice DM. In: Symposium on ocular therapy. Leopold IH, Burns RP, editor. Wiley, New York; 1976. Injection of drugs into the vitreous body; pp. 59-72). Repeated intravitreal administration of ceftazidime (simultaneously with vancomycin on the next day) if an insufficient concentration of vancomycin is detected is not dangerous for the structures of the eye (retina). Its introduction together with vancomycin will allow to cover the whole spectrum of possible causative agents of intraocular infection, and this should be done, since by this moment the result of sowing has not yet been obtained (it takes 2-3 days to prepare).

For the complete destruction of bacterial microflora, a certain concentration of vancomycin in the vitreous cavity is necessary. We determined this concentration, it should be 130 mcg / ml or more.

In determining the sensitivity of bacteria to various antibiotics, several concepts are used. The minimum inhibitory concentration (MIC) is an indicator of the effect of an antibiotic on a bacterial culture, equal to its minimum concentration, at which complete inhibition of bacterial growth occurs.

The minimum bactericidal concentration (MBC) is the lowest concentration of antibiotic that causes the death of 99.9% of microorganisms from the initial level over a period of time.

According to the literature, for most strains for which vancomycin has moderate activity and which are often the causative agents of acute bacterial postoperative endophthalmitis, MIC varies between 0.03 and 16 μg / ml (Beloborodova N.V. Antibiotics glycopeptides: clinical significance. Russian Medical Journal, 1998. - N 13. - S. 832-836). In turn, for the complete destruction of the bacterial flora, the minimum bactericidal concentrations (MBC) of vancomycin should be 2-8 times higher than the minimum inhibitory concentrations (MIC) (Zeckel ML A closer look at vancomycin, teicoplanin, and antimicrobial resistance. J. Chemother 1997 Oct; 9 (5): 311-31; discussion 332-5).

From this it follows that the multiplication of 16 μg / ml (the highest MIC for pathogens) by 8 (maximum threshold MBC) leads to a concentration of 128 μg / ml. Accordingly, the concentration of vancomycin in the vitreous cavity of 128 μg / ml and above will absolutely accurately destroy the causative agent of intraocular infection. Given the mathematical calculation and analyzing our practical experience, we, being safe, overestimate this border a little and set it equal to 130 μg / ml. Thus, with a concentration of 130 μg / ml or more, a conclusion is made that the concentration of the antibiotic is sufficient to destroy the bacterial microflora, and with a concentration of less than 130 μg / ml, a conclusion is drawn that the concentration of the antibiotic is insufficient and the next day, 1 μg / 0 is repeated. 1 ml of vancomycin and 2.0-2.25 mg / 0.1 ml of ceftazidime in the vitreous cavity.

These calculations determined the boundary between the sufficiency and insufficiency of the amount of antibiotic in the vitreous cavity, which is determined by its concentration.

The very concentration of the antibiotic specifically in the vitreous cavity was not previously determined and this also has the novelty and non-obviousness of the technical solution. A known method for determining the concentration of vancomycin by spectrophotometry in the ultraviolet (UV) region under laboratory conditions, which consists in heating the sample in a water bath for 15 minutes to form the nitroso derivative of the antibiotic, followed by measuring the topical absorption with a wavelength of 240 nm. Linearity is recorded in the range of 4-32 μg / ml, and the detection limit is 2.7 μg / ml (Belal F., El-Ashry SM, El-Kerdawy M.M., El-Wasseef DR Voltametric determination of vancomycin in dosage forms through treatment with nitrous acid. Arzneimittel-Forschung / Drug Research, 2001, Volume 51, Issue 9, Pages 763-768).

In our method, we are dealing with a much higher concentration of vancomycin in the vitreal cavity than in the above source. Our studies and the construction of calibration dependences showed that a wavelength of 280 nm is more accurate for working with such concentrations as in our case.

In FIG. 1 shows the experimental optical absorption spectra (OD), measured in the region of 190-400 nm at room temperature. The concentration of vancomycin in saline solution varied in the range C = 0-1000 μg / ml. It is seen that with increasing concentration, an increase in the optical density D is recorded in the spectral regions of 270-290 nm. In FIG. Figure 2 shows the calibration dependences D (C) for a wavelength of 280 nm. The dependences are satisfactorily described by the equation of the line D = k⋅C with the determination coefficient R ² > 0.999. The approximation parameters are given in the table.

The approximation parameters of the calibration dependences D (C)

From the obtained experimental calibration dependence D (C) (Fig. 2), it is possible to determine the unknown C _x concentration of vancomycin in the sample taken from the vitreous cavity of the eye by measuring the optical density of the sample D _x at a wavelength of 280 ± 10 nm for the concentration of vancomycin C _x = 30-1000 mcg / ml. Thus, having loaded the obtained calibration dependence into the spectrophotometer device and placed in it a test tube with a sample taken from the vitreal cavity, the device automatically determines the concentration of vancomycin and gives the result.

Thus, we have shown that between the set of essential features and the claimed technical result, there is a causal relationship.

The method is as follows. After the diagnosis is established - acute bacterial postoperative endophthalmitis, immediately (within 1 h) begin to perform a three-port vitrectomy through micro-accesses (25G-27G).

All ports should have valves to prevent fluid reflux during manipulations, including with antibiotics. After setting the ports, through paracentesis, the contents of the anterior chamber are sampled for microflora culture, the contents are placed in a sterile tube. Next, the suction line is disconnected from the vitreotome system and connected to the syringe that the assistant holds. Proceed to the stage of sampling the contents from the vitreous cavity for sowing.

To do this, using a vitreotome, a part of the vitreous body is removed in the optical zone, and at this time the assistant pulls the piston of the connected syringe onto itself and aspirates the fragmented vitreous into the syringe. The contents are then placed in a separate tube for bacteriological examination. Vitreotom again connects to the suction line of the device. Irrigation is switched on, they begin the main stage - the removal of the pathologically altered vitreous body and replacing it with a BSS solution. Manipulations are performed under visual control to reduce the risk of iatrogenic retinal damage. An obligatory step is the isolation of the posterior hyaloid membrane and the removal of exudative membranes.

Then proceed to the stage of intravitreal administration of antibiotics through the port with the valve. Start with vancomycin. Vancomycin is slowly introduced into the center of the vitreous cavity at a dose of 1 mg / 0.1 ml. This method of administration allows the drug to quickly and evenly distribute throughout the entire vitreous cavity. Then carry out the sampling of the contents of the vitreous cavity, that is, the sampling of the BSS solution with vancomycin diluted therein. This procedure is performed using a single 1 ml syringe with a 30 G needle. The needle is inserted into the vitreous cavity through the port and contents are taken in a volume of 0.2 ml. This volume is necessary and sufficient for spectrophotometry and determination of the concentration of vancomycin. At the same time, this volume is safe for the eye and will not cause hypotension. The taken solution is placed in a specially prepared glass tube of a spectrophotometer and sent for examination.

The surgeon continues the operation: intravitreal administration of the second antibiotic ceftazidime in a volume of 2.0-2.25 mg / 0.1 ml. Ceftazidime is injected in a separate syringe into the center of the vitreal cavity, slowly.

At the final stage, the last port is removed, a sealing seam is applied (with endophthalmitis, all micro-accesses should be sutured).

The contents of the anterior chamber and vitreous cavity are sent to the laboratory for sowing microflora and determining its sensitivity to antibiotics

A tube with the contents taken from the vitreous cavity after vitrectomy is sent to the laboratory to determine the concentration of vancomycin. The tube is installed in a spectrophotometer of the Shimadzu UV-2450 model and spectrophotometric analysis is carried out in the ultraviolet region of the spectrum with a wavelength of 280 nm. After 4-5 minutes, the device displays the concentration of vancomycin in the test tube, and therefore in the vitreous cavity of this patient. Upon receipt of a concentration of vancomycin of 130 μg / ml or more, it is concluded that the concentration is sufficient to remove the inflammatory process in the eye. At a concentration of less than 130 μg / ml, it is concluded that the concentration of vancomycin in the vitreous cavity is insufficient, and the next day they repeat intravitreal injection of the same two antibiotics and in the same dose, without waiting for a change in the clinical picture.

Before the results of bacteriological culture, the patient from the day after vitrectomy in the subconjunctival space are injected with 25 mg / 0.25 ml of vancomycin and 100 mg / 0.5 ml of ceftazidime 2 times a day.

In accordance with the standards of bacteriological studies, the seeding data is ready for 2-3 days. Having received the results of the sowing, we conclude which of the 2 antibiotics is etiopathogenetically directed in relation to the identified pathogen. It is this antibiotic that remains in the conservative treatment regimen (subconjunctival injection), and the second antibiotic is canceled. In the event that the results of culture are negative (laboratory error, transportation violation, etc.), then both antibiotics are left in the conservative treatment regimen.

Example 1. Patient S., 68 years old, was operated on for immature cataract in the right eye. In accordance with preoperative emmetropic refraction and an axial length of the eyeball of 23.5 mm (corresponding to the average length of the eyeball of the emmetrop), an IOL with optical power of 22 D was implanted. The operation was performed without complications. The patient was discharged from the hospital, Vis OD = 0.95 with corr.

On the 3rd day after the operation, the patient complained of decreased visual acuity and pain in the operated eye. Examination data: Vis OD = pr / certae, edematous cornea, Tyndall inflammatory disease, art. III, hypopion 2 mm, according to ultrasonography: intense hyperreflective suspension in the vitreous cavity.

The patient was diagnosed with acute postoperative endophthalmitis of the right eye.

An urgent treatment was carried out using the claimed method: vitrectomy with sampling of the contents of the vitreous cavity and anterior chamber for sowing microflora and determining its sensitivity to antibiotics (AB) with intravitreal administration (IVV) of two ABs: 1 mg / 0.1 ml vancomycin and 2.0 mg / 0.1 ml ceftazidime. After administration of 1 mg / 0.1 ml of vancomycin, the contents of the vitreous cavity were taken in a volume of 0.2 ml to determine the concentration of vancomycin. Then 2.0 mg / 0.1 ml of ceftazidime was administered. The concentration of vancomycin was determined by spectrophotometry in the UV region of the spectrum (wavelength 280 nm). The concentration was 200 μg / ml. The obtained concentration of vancomycin in the vitreous cavity in this patient is more than 130 μg / ml and according to the invention is sufficient to destroy the bacterial microflora and obtain a stable therapeutic effect.

The next day, there was a significant positive trend, Vis = 0.1. On the same day, 25 mg / 0.25 ml of vancomycin and 100 mg / 0.5 ml of ceftazidime were introduced into the subconjunctival space, 2 times a day.

According to a bacteriological study obtained on the 2nd day after vitrectomy, methicillin-resistant Staphylococcus aureus (MRSA) was detected, in relation to which vancomycin has moderate activity. Ceftazidime, which is not active against MRSA, has been removed from the treatment regimen. This was followed by a conservative treatment of the eye, consisting of subconjunctival injections: 25 mg / 0.5 ml of vancomycin 2 times a day, until complete recovery. Intravitreal injection of antibiotics was not required. On the 6th day, the patient was discharged from the hospital, Vis = 0.7. When viewed after 3 months, Vis = 0.9.

Example 2. Patient D., 71 years old, was operated on for immature cataracts in the left eye. In accordance with preoperative myopic refraction and an axial length of the eyeball of 29.5 mm (corresponding to a high degree of myopia), an IOL with an optical power of 3 D was implanted. The operation was performed without complications. The patient was discharged from the hospital, Vis = 0.55 s corr.

On the 4th day after the operation, the patient complained of decreased visual acuity and pain in the operated eye. Examination data: Vis OS = pr / certae, edematous cornea, Tyndall inflammatory phenomenon, art. III, hypopion 1.5 mm, according to ultrasonography: intense hyperreflective suspension in the vitreous cavity.

The patient was diagnosed with acute postoperative endophthalmitis of the right eye.

An urgent treatment was performed according to the claimed method: vitrectomy with sampling of the contents of the vitreous cavity and anterior chamber for sowing microflora with determination of its sensitivity to antibiotics with the intravitreal administration of two antibiotics: 1 mg / 0.1 ml vancomycin and 2.25 / 0.1 ml ceftazidime . After administration of 1 mg / 0.1 ml of vancomycin, the contents of the vitreous cavity were taken in a volume of 0.2 ml to determine the concentration of vancomycin. Then 2.25 mg / 0.1 ml of ceftazidime was administered. The concentration of vancomycin was determined by spectrophotometry in the UV region of the spectrum (wavelength 280 nm). The concentration was 85 μg / ml. The obtained concentration of vancomycin in the vitreous cavity of this patient is less than 130 μg / ml, therefore, according to the invention, this concentration is insufficient to destroy the bacterial microflora and obtain a stable therapeutic effect (eye length is more than average).

On the next day we have: there is no positive clinical dynamics, Vis OD = pr / certae, swollen cornea, Tyndall III inflammatory disease, hypopion 1.5 mm, according to ultrasonography: intense hyperreflective suspension in the vitreous cavity is preserved.

Given the absence of positive clinical dynamics after vitrectomy with intravitreal administration of antibiotics and the obtained result of vancomycin concentration of 85 μg / ml (less than 130 μg / ml), repeated intravitreal administration of the above drugs in the initial dose was performed.

Also, on the first and second days after vitrectomy, before receiving the results of bacteriological culture, 25 mg / 0.25 ml of vancomycin and 100 mg / 0.5 ml of ceftazidime were injected into the subconjunctival space, 2 times a day.

On the third day, there was a positive trend in relation to the reverse development of symptoms, Vis = 0.05.

According to bacteriological culture obtained on the 3rd day after vitrectomy, MRSA was detected, in relation to which vancomycin has moderate activity. Ceftazidime, which is not active against MRSA, has been removed from the treatment regimen. Subsequent conservative treatment consisted of subconjunctival injections of 25 mg / 0.5 ml of vancomycin 2 times a day, until complete recovery. Intravitreal antibiotic injections were no longer performed. On the 7th day, the patient was discharged from the hospital, Vis = 0.3. When viewed after 3 months, Vis = 0.45.

In the Yekaterinburg Center, the claimed method operated on 11 patients with acute postoperative bacterial endophthalmitis, in all cases positive anatomical and functional results were obtained. In 7 patients with an average length of the eyeball, after intravitreal administration of vancomycin, its concentration was more than 130 mcg / ml and indeed the dynamics in these patients was positive on day 2. In 4 patients with an eyeball length above average, and therefore with a large volume of the vitreous cavity, the obtained concentration of vancomycin was less than 130 μg / ml. This required repeated intravitreal injections of AB on the second day (in the same dose). The repeated administration of antibiotics was carried out on 4 eyes and a positive result was obtained: the infection process in the eyes was eliminated, eye structures were preserved, and the visual functions of the eyes were maximally preserved.

Claims (1)

A method for the treatment of acute bacterial postoperative endophthalmitis, including removal of the contents of the vitreous cavity by subtotal vitrectomy with simultaneous replacement of the vitreous body with a BSS solution, sampling of the contents of the vitreous cavity and anterior chamber of the eye with microflora culture and determination of sensitivity to antibiotics, and subsequent intravitreal administration of two antibacterial drugs: 1 mg / 0.1 ml of vancomycin and 2.0-2.25 mg / 0.1 ml of ceftazidime, characterized in that the first of the antibiotics in the vitreous cavity in vancomycin is dressed and then a sample is taken from the vitreous cavity of the contents with diluted vancomycin in a volume of 0.2 ml, then ceftazidime is administered, and the sample taken with vancomycin is sent for spectrophotometry in the ultraviolet region of the spectrum with a wavelength of 280 nm to determine the concentration of vancomycin in the vitreous cavity , and at a concentration of 130 μg / ml or more, they conclude that the concentration of the antibiotic is sufficient to destroy the bacterial microflora, and at a concentration of less than 130 μg / ml, they conclude that the antibiotic concentration is sufficient, and the next day, 1 μg / 0.1 ml of vancomycin and 2.0-2.25 mg / 0.1 ml of ceftazidime are reintroduced into the vitreous cavity, and from the day after vitrectomy until the results of bacteriological culture 25 mg / 0.25 ml of vancomycin and 100 mg / 0.5 ml of ceftazidime are injected into the subconjunctival space, 2 times a day, and after receiving the results of bacteriological culture on the 2-3rd day, leave the antibiotic that has the postoperative subconjunctival administration activity in from Ocean a specific pathogen.

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