What is the management of blebitis and bleb-associated endophthalmitis?

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, as well as vitreous tap or vitrectomy to obtain samples for culture and sensitivity testing 1. The treatment approach should prioritize the prevention of vision loss and address the underlying cause of the infection. For blebitis, immediate treatment includes:

• Intensive topical antibiotics such as fortified vancomycin (25-50 mg/mL) and fortified ceftazidime (50-100 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 treatment is necessary, including:
• Intravitreal antibiotics (vancomycin 1.0 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 Systemic steroids may be considered after infection control is established, and close monitoring with daily follow-up is essential until clinical improvement is observed, as supported by the 2024 study on blepharitis preferred practice pattern 1. The underlying mechanism involves bacterial colonization of the bleb following trabeculectomy surgery, with Streptococcus species and Haemophilus influenzae being common pathogens, and early recognition and aggressive treatment are crucial as bleb-associated infections can progress rapidly and have worse visual outcomes compared to other forms of endophthalmitis. It is also important to note that addressing moderate to severe blepharitis with topical antibiotics and eyelid hygiene prior to an intraocular surgical procedure may be helpful in preventing postoperative endophthalmitis, as suggested by the 2024 study 1. However, long-term antibiotic treatment may result in the development of resistant organisms, highlighting the need for careful consideration and monitoring in the treatment of blebitis and bleb-associated endophthalmitis.

From the Research

Management of Blebitis and Bleb-Associated Endophthalmitis

• The management of blebitis and bleb-associated endophthalmitis involves prompt treatment with antibiotics, with the goal of preserving vision and preventing further complications 2, 3, 4, 5, 6.
• For blebitis, intensive topical antibiotic treatment is often effective in returning visual acuity and intraocular pressure to pre-infection levels 3, 6.
• In cases of bleb-associated endophthalmitis, treatment may involve intravitreal antibiotics, vitrectomy, and topical and systemic antibiotics 2, 4, 5.
• The choice of antibiotic therapy may depend on the suspected or confirmed causative organism, with vancomycin and ceftazidime being commonly used intravitreal antibiotics 2.
• The use of topical corticosteroids in conjunction with antibiotic treatment is also common, with 62% of respondents in one survey using them to reduce inflammation 6.
• Surgical bleb revision may be necessary in cases of persistently leaking blebs or recurrent infection 6.

Treatment Outcomes

• The prognosis for blebitis is generally good, with prompt treatment often resulting in complete recovery 3, 5.
• However, the outcomes for bleb-associated endophthalmitis are often poor, with significant visual morbidity and potential for complications such as retinal detachment and phthisis bulbi 2, 4, 5.
• Early detection and treatment of risk factors, as well as thorough patient education, are essential in preventing and managing bleb-related infections 5.

Variations in Management

• There is variation in the management of blebitis among glaucoma subspecialists, with different approaches to antibiotic therapy, surgical intervention, and use of topical corticosteroids 6.
• Treatment recommendations generated from randomized clinical trials are needed to standardize the management of blebitis and bleb-associated endophthalmitis 6.