From the Guidelines
Management of blebitis and bleb-associated endophthalmitis requires prompt intervention to prevent vision loss, with the most recent and highest quality study suggesting that immediate treatment includes intensive topical antibiotics and possibly intravitreal antibiotics in more severe cases 1. The approach to managing blebitis and bleb-associated endophthalmitis involves a combination of topical and oral antibiotics, with the goal of preventing vision loss and addressing the underlying bacterial colonization of the bleb.
- For blebitis, immediate treatment includes intensive topical antibiotics such as fortified vancomycin (25-50 mg/mL) and fortified ceftazidime (50 mg/mL) or fluoroquinolones like moxifloxacin 0.5% every hour.
- Oral fluoroquinolones (ciprofloxacin 750 mg twice daily or moxifloxacin 400 mg daily) should be added for 1-2 weeks.
- For bleb-associated endophthalmitis, more aggressive management is necessary, including intravitreal antibiotics (vancomycin 1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL) along with the topical and oral regimens.
- Vitreous tap or vitrectomy should be performed to obtain samples for culture and sensitivity testing, as recommended by the most recent study 1.
- Systemic steroids may be considered after infection control is established.
- Close monitoring with daily follow-up is essential during the acute phase. The underlying mechanism involves bacterial colonization of the bleb, which can progress to intraocular infection if not promptly treated, with risk factors including bleb leaks, thin-walled blebs, and inferior bleb location, so addressing these issues may help prevent recurrence, as noted in the study 1.
- Patients with filtering blebs should be educated about symptoms of infection and the need for immediate evaluation if redness, discharge, or vision changes occur.
- It is also important to consider the potential for fungal infections, such as Candida endophthalmitis, which may require antifungal treatment, as discussed in the study 1.
- However, the most recent and highest quality study 1 suggests that the primary concern is bacterial colonization, and that prompt treatment with antibiotics is essential to prevent vision loss.
From the Research
Management of Blebitis
- Blebitis is a limited form of bleb-related infection that responds to intensive topical antibiotic treatment, returning visual acuity and IOP to preinfection levels 2.
- The prognosis of blebitis is usually good, unless infection has progressed to endophthalmitis, which signifies a poorer prognosis 3.
- Treatment of blebitis may include topical fluoroquinolone alone or in combination with other antibiotics, with some physicians using fortified topical agents or oral antibiotics 4.
- Topical corticosteroids may be used in conjunction with antibiotic treatment, but the timing of their use varies among physicians 4.
Management of Bleb-Associated Endophthalmitis
- Bleb-associated endophthalmitis is a more virulent form of bleb-related infection with a poor visual prognosis despite immediate intensive topical, systemic, and intravitreal antibiotic administration combined with core vitrectomy 2.
- Visual preservation in the setting of bleb-associated endophthalmitis has been difficult with existing management strategies, but new systemic antibiotics and novel surgical techniques may improve visual outcomes 5.
- The outcomes of bleb-associated endophthalmitis remain unsatisfactory, especially with virulent organisms and low initial visual acuity, highlighting the need for early detection and treatment of risk factors and thorough patient education 3.
- Prophylactic use of fourth-generation fluoroquinolone antibiotics, such as gatifloxacin and moxifloxacin, may not prevent acute endophthalmitis, and gram-positive organisms causing acute endophthalmitis are frequently resistant to all fluoroquinolones 6.