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EW SHOW DAILY 20 'Break the glass' in bleb infection cases Monday, April 28, 2014 ASCRS Symposia by Rich Daly EyeWorld Contributing Writer P revention and treatment of bleb-related infections are so critical that one sur- geon goes beyond hand- ing bleb patients a blebitis warning sign sheet. Blebitis usually leads to a bleb leak, which increases the rate of infection 26-fold. Garry Condon, MD, Pittsburgh, Pa., said during a symposium on bleb-related infections that if he is concerned about a patient with a "ridiculously thin" bleb, he gives the patient a fluoroquinolone prescription. "I say 'Do not break the seal on this, it's one of those break-the-glass things,'" Dr. Condon said. He instructs patients who develop red eye to begin self-admin- istering the drops at 15-minute intervals—even before calling the office. He instructs patients to call the office contact and have him or her tell the on-call physician that the patient has a thin wall and was instructed to immediately contact the physician if a red eye and infection developed. Steve Vold, MD, Fayetteville, Ark., underscored the need for edu- cating office staff to not dismiss such calls as viral conjunctivitis that could clear up within a week. "The staff has to know that these patients were told that they are at risk and need to get in right away," Dr. Vold said. "If the patient calls but the of- fice staff triages it or ignores it then it's no help." Douglas Rhee, MD, Boston, who prefers treatment with fortified vancomycin and tobramycin, said physicians should not hesitate to admit patients who may not be able to keep up with the drug regimen. "Sometimes we've had patients who were not getting better and maybe even getting a little worse, then we admit those patients for around-the-clock drops," Dr. Rhee said. "They'll then do better." In addition to aggressive topical treatments with fortified antibiotics, Keith A. Warren, MD, Independ- ence, Mo., urged obtaining good cultures and use of oral antibiotics. Gatifloxacin and ciprofloxacin are known to penetrate "quite well" into the vitreous, he said. "That's something that can po- tentially protect you from making a blebitis into an endophthalmitis," Dr. Warren said. The favored treatment for bleb- related infections by attendees at the bleb infection symposium was frequent topical antibiotics (57%), intravitreal injection of antibiotics (25%), referral to a retina specialist (13%), or intracameral (anterior seg- ment) injection of antibiotics (6%). "These patients warrant early and aggressive treatment because their outcomes are very poor," Dr. Warren said. A key step is looking for vitreous cells and debris, which are clues that intravitreal antibiotics are required. Most such infections are gram-positive but watching out for gram-negative pseudomonas also is important. After applying an anti- infection treatment for 48 to 72 hours, Dr. Warren uses steroids to help salvage the bleb. EW Dr. Rhee speaks at the "Clinical Challenges in the Co-Management of Glaucoma and Retinal Disease" symposium. Hotel Channel Boston Marriott Copley 74 Boston Marriott Long Wharf 76 Double Tree Downtown 54 Double Tree Suites 47 Embassy Suites 1001 Fairmont Battery Wharf 1 Hilton Boston Back Bay 42 Hilton Logan Airport 48 Hyatt Regency 76 InterContinental 3 Mandarin Oriental 89 Omni 65 Boston Park Plaza 71 Renaissance Waterfront 15 Seaport 69 Sheraton 52 Taj 42 W 56 Westin Waterfront 86 Westin Copley 55 Watch ASCRS•ASOA Today in many Boston hotels for the latest convention highlights

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