Post Operative Endophthalmitis
Post Operative Endophthalmitis
Endophthalmitis is a potentially severe intraocular inflammation due to complication of
- intraocular surgery
-non surgical trauma
-systemic infection
Inflammation within anterior & posterior segment or both
-infectious/Non infectious
Classification:Infectious: A . Exogenous -Surgical Delayed onset
Bleb Associated
- Non surgical –Post traumatic
B. Endogenous – Haematogenous spread
Acute onset
Post surgeries : Cataract extraction secondary lens implantation pars plana vitrectomy Glaucoma filter Penetrating keratoplasty
Acute infectious Postop endophthalmitisWithin 6 weeks of surgeryCommon organisms: - Coagulase negative staphylococcus (S. epidermidis) -S.aureus , Streptococcus
spp ,Pseudomonas,.. Source: lid & conjunctival flora
Preoperative risk factors: -Active ocular surface infections/colonization -Contaminated eye drops
Operative risk factors: -Wound abnormalities - Vitreous loss - Prolonged combined surgeries - Contaminated irrigating solutions
Delayed –onset infectious endophthalmitisMore than 6 weeks following surgeryLow virulent organism trapped within
capsular bag[cataracts] Following Nd YAG capsulotomy – release
into viteous. Common organisms- -Propionibacterium acnes -S.epidermidis -fungiPersistent /recurrent uveitis following
surgery
Bleb Associated infectious EndophthalmitisFollowing glaucoma filtering surgeryBlebitis purulent endophthalmitisCommon organisms -Streptococcus spp -Haemophilus influenza
Risk Factors : - Local antimetabolite therapy [thin walled
drainage bleb] - Blepharitis - Nasally or inferior placed & leaky bleb.
Blebitis: Symptoms :- Mild discomfort & redness Signs:-- White bleb- No anterior uveitis - Normal Red reflex
Treatment :-- Topical ofloxacin & Vancomycin - Tab Co-amoxiclav 500/125 mg tid - Tab Ciprofloxacin 750 mg bd - 5 days
Endophthalmitis:Symptoms :- - Rapidly worsening vision,
pain,redness ,stickiness
Signs :- - White milky bleb with pus - Severe anterior uveitis with hypopyon - Vitritis , poor red reflex..
Ocular manifestations:
Symptoms: -Blurred vision -Red eye -Pain -Photophobia
Signs : -Decreased visual acuity -Eyelid edema -Erytema -Conjunctival hyperemia -Chemosis -Corneal edema & Opacification - AC flare and cells ,Keratic preciptates [low grade in
delayed] - Hypopyon [not in delayed] - Vitritis -Scattered retinal haemorrhages -Periphlebitis if retina visible -Loss of red refex - Capsular plaque[ in delayed]
DiagnosisEarly recognition & suspicion is critical
A complete ocular and medical history
Thorough Ophthalmic examination
Ultrasonography : - Anterior segment media Opacity - Vitreous cells , posterior segment
detachment - Retained lens remnants
Anterior Chamber Paracenthesis : - 0.1 ml of aqueous – 25 or 27 gauge
needle
Vitreous Biopsy : - Trans –pars plana aspiration – 0.2 ml of
liquid vitreous - 23 G needle – 3 mm posterior to
pseudophakic limbus, 4 mm posterior to phakic
limbus.
- Three port Vitrectomy.
Aqueous and Vitreous samples plated on - Blood agar, Saurand dextrose agar ,
thioglycollate broth, - Do Gram & Giemsa stains
Prophylactic measures :Preoperative : 1.Careful assessment of external ocular
surface Conjunctival culture if external
inflammation & discharge 2.Treatment of eyelid infections [lid hygiene,topical /systemic antibiotics] 3.Syringing of lacrimal system if
infection/obstruction 4.Topical antibiotics 24 hrs prior to surgery 5.Systemic antibiotic prophylaxis in high
risk cases
Intraoperative -Sterile draping to exclude eyelids &
lashes from operative field - 5 % povidone iodine to prepare ocular
surface,lid margin -10 % povidone to clean surrounding skin - Irrigation of IOLS before insertion - Minimum exposure time of IOL - Careful wound closure -
Post operative : - Postoperative instillation of topical 2.5
% , 5% povidone iodine solution - Antibiotic drops - Closer postoperative follow-up for
patients in diabetes,prolonged surgery, vitreous loss.
Medical therapy:
IntraVitreal
Vancomycin 1.0 mg in 0.1 ml
Amikacin 0.2-0.4 mg in 0.1 ml or
Ceftazidime 2.25 mg in 0.1 ml
Dexamethsone 400 ug in 0.1 ml [optional]
Oral
Prednisolone 30 mg twice daily for 10 days if no contraindications
Moxifloxacin 400 mg daily
Clarithromycin 500 mg twice daily
Topical :
-Vancomycin 5 %
- Ceftazidime 5%
- Dexamethasone 0.1 %
Endophthalmitis Vitrectomy Study [EVS]From Arch Ophthalmol. 1995
Dec;113(12):1479-96.
A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis.
A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery.
A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically.
There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics.
In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed.
However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity , approximately a twofold chance of achieving 20/100 or better acuity , 50 % reduction in severity of vision loss.
Conclusion:Routine immediate VIT is not necessary in
patients with better than light perception vision
VIT is of substantial benefit in patients with vision of light perception only.
Management of EndophthalmitisVisual Acuity
Light perception
Initial Vitrectomy
Inject antibiotics
48 hrs
Hand motion or better
Initial tap & inject antibiotics
48 hrs