Adjunctive dexamethasone appears safe, effective for postoperative bacterial endophthalmitis

This prospective, double-masked study evaluated the use of intravitreal dexamethasone as adjunctive therapy for presumed bacterial endophthalmitis. Investigators randomized 62 patients with postcataract surgery-related or bleb-related endophthalmitis or endopthalmitis due to other causes to intravitreal ceftazidime (2.225 mg/0.1 ml), vancomycin (1 mg/0.1 ml), and either dexamethasone (0.4 mg/0.1) or placebo. Injections were repeated after 48 hours if necessary. The results suggest that this treatment appears safe and beneficial for patients with postcataract surgery bacterial endophthalmitis.

Finally this answers the question. I was trained to add steroids with the antibiotic since part of the damage is tissue reaction to the infection. It is clear that the immune system has failed in the face of endophthalmitis anyway so it never made sense to me that we would be more worried about potentiating the infection than reducing acute damage from endotoxins and inflammation.

At three months there was no statistically significant difference in the visual outcomes of either group, with a mean 2.79 lines of improvement in the dexamethasone group versus 1.8 lines in the placebo group. However, subgroup analysis suggested a clinical trend to better visual acuity in the postcataract steroid subgroup, which had a mean 4.1 lines of improvement versus 2.7 in the placebo group (P = 0.33). The very low numbers of patients in the bleb-related endophthalmitis group and the “other” endophthalmitis group made the results inconclusive, although these groups appeared clinically similar. No adverse events attributable to the use of dexamethasone were reported.

These results are in keeping with those of another randomized trial, which included 29 patients and demonstrated a trend to better visual acuity in the steroid group, with a statistically significant benefit shown in combined analysis. The current study’s findings suggest that consideration should be given to using intravitreal dexamethasone to treat postoperative endophthalmitis.

The authors note that the delayed presentation of patients highlighted the need for patient education regarding the symptoms of endophthalmitis. They have adapted their standard postcataract surgery data sheets to include a tick box that both reminds the surgeon to highlight the dangers to the patient and to document that the patient has been informed, and have improved the referral system from their secondary level units that perform high-volume cataract surgery.