When a post operative intra ocular infection occurs in a single operating day or with in a short period in the same hospital Pseudomonas is the most likely causative organism.
PATHOGENESIS OF POST OP ENDOPHTHALMITIS
CLINICAL FEATURES SYMPTOMS : Pain , redness, watering, diminision of visual acuity SIGNS : Conjunctival hyperaemia, lid swelling, chemosis, cells and flare in the anterior chamber, hypopyon, membrane formation on IOL, vitreous haze, scattered retinal haemorrhages, loss of red reflex, in extreme cases corneal infiltration and opacification.
3 RD DAY 1 WEEK
POST OP ENDOPTHALMITIS
Patient’s general condition should be good
Diabetes should be under control
Conjunctiva and the lacrimal tract should be free of any active infection
Routine use of topical and systemic antibiotics should be considered in patients have had recent or repeated infections.
Routine use of topical antibiotics for all patients is still a matter of debate.
Topical antibiotics administered reduce the amount of lid and conjunctival bacteria.
They rarely sterilise the external eye and do not provide significant concentration during surgery. Also the degree to which the flora are reduced depends on various factors(susceptibility of organism,frequency and duration of instillation,the bacteria present etc..) which makes the routine use debatable.
Usage of topical antibiotics preoperatively
Strict aseptic precautions should be taken by the operating surgeon and the assisting staff.
Routine use of sub conjunctival antibiotics at the end of surgery: gentamicin is preferred.(Adv: sub conjunctival antibiotics reach high levels of conc in anterior chamber for 3-5 hrs after surgery)
Recent trends( usage of hydrated collagen sheilds-sustained release of drug for 12hrs)
TREATMENT OF ESTABLISHED ENDOPHTHALMITIS
1% atropine eye drops 6 th hrly
ANTI FUNGALS: If culture reports suggest fungi.
ANTIBIOTICS TOPICAL SYSTEMIC Cefazolin 5% eye drops 1hrly. Or Tobramycin 1.3 % eye drops 1 hrly. Combination of Inj ceftazidime 2g iv tid and Inj vancomycin 1g iv 12 th hrly.
INTRA VITREAL ANTIBIOTICS
Vancomycin: 1mg in 0.1 ml
Ceftazidime: 2.25 mg in 0.1 ml
Amikacin: 400 micro gm in 0.1 ml
Dexamethosone: 400 micro gm in 0.1 ml
Amphotericin B: 5 micro gm in 0.1 ml.
STEROIDS TOPICAL SYSTEMIC Dexamethosone or Prednisolone eye drops 1 hrly. Inj dexamethosone 8mg iv 12 hrly. Oral steroids after discontinuiong the injections.
This problem is frequently not the the fault of the surgeon.
Improved aseptic technique in ophthalmic surgery is responsible for the decrease in the rate of infections.
Should we suspect endophthalmitis in every case of post operative redness ??
Post operative endophthalmitis Post operative reaction
History of improvement folowed by deterioration.
Corneal involvement present
Focal infiltrate present
Fundus glow is absent or very faint
Vitreous haze ++
Exudate yellow colour
Early deterioration only, early improvement with treatment
Corneal involvement absent
Present or faint
Mild haze or no haze
POST OPERATIVE REACTION
RETAINED LENS MATTER
Capsulo lenticular remains
Pigmentary, haemorragic, or inflammatory fibrous elements.
Phaco anaphlactic uveitis
Phaco toxic uveitis
Secondary angle closure glaucoma
Removal of retained lens material
The mode and the method of removal of the retained fragments depends on the size, site of the fragment.
It may vary from AC wash to pars plana vitrectomy.
RETAINED LENS MATTER
POST CAPSULAR OPACIFICATION
Incidence : Varies from 10-50 % following ECCE.
During the early days PCO was considered to be an untreatable cause. But after the advent of the lasers its management became easier.
Most PCO are formed by the proliferation of the equatorial lens epithelial cells.
Two forms of PCO are recognised:
Soemmering’s ring (PCO peripheral
to IOL optic)
E cells in the equatorial bow tend to migrate along the posterior capsule and form pearls to form post capsular opacification.
Fibrous form of PCO is due to the posterior proliferation of the A cells or due to the fibrous metaplasia of the posterior migrating cells.
Visually significant PCO is defined as the
decrease in BCVA by 2 snellan’s lines.
PCO score is calculated by multiplying the the density of opacification by the fraction of capsule behind the optic that is opacified
In the bag fixation of IOL. It enhances the IOL optic barrier.
Capsulorrhexis edge on the IOL surface.
Bio compatible IOL: Acry sof IOL is most biocompatible.
Maximum IOL OPTIC PC contact.
WHY TO PREVENT PCO FORMATION:
Nd-YAG laser has many complications
like IOL optic damage, IOP rise, CME and
increased risk of RD in high myopes.
High expectations of patients from modern day surgeries.
PCO causes a significant financial burden to the health care system.
PCO is the main complication in paediatric IOL implantation.
Nd YAG laser capsulotomy ( dis adv: damage to
IOL optic, post op IOL elevation, CME, RD, IOL
subluxation or dislocation)
Peeling or removal of the epithelial cells from
the posterior capsule in eyes with pearls type
of PCO with automated irrigation mode.
IOL WITH PCO AFTER Nd-YAG
LENS RELATED COMPLICATIONS
IOL malpositions :
IOL induced diseases :
Post operative: Trauma
INTRAOPERATIVE CAUSES OF MALPOSITIONS:
one haptic of IOL is out lying on the iris.
IOL with small optic placed in a large rhexis has not been properly centred at the time of surgery.
Poorly performed can opener capsulotomy where in the irregular capsular flaps may entangle the haptics of the IOL.
In envelope capsulotomy the IOL may be partially in the bag and partially in front of the anterior capsular flap.
In case of a large PC tear the IOL may appear well centred on the table but may slide downwards or sideways later. This condition is best prevented by fixing one haptic of the IOL in the scleral section while the lower haptic is placed on the anterior capsule remnants.
POST OPERATIVE CAUSES
Minor injury: the eye is soft with deep anterior chamber. Lens normally not displaced.
Severe injury: zonules are ruptured. Lens displaced anteriorly, into the vitreous, beneath the retina, subconjunctivally if the globe is ruptured.
POST OPERATIVE CAUSES(contd):
In old age weakened upper zonules.
Any condition that leads to stretching of the zonules(high myopia, sec to endophthalmitis etc)
DIFFERENT KINDS OF MALPOSITIONS
Pupil capture : When section of optic is anterior to the iris. Pupil should be dilated with 1% tropicamide. Pupil is then constricted with 2% pilocarpine.
Minor decentrations : Irregular adhesion of the residual anterior capsule to the underlying posterior capsule.It may also occur if a portion of the lens is in the capsular bag. It is also seen if the mid stromal portion of iris becomes adherent to the edge of the optic resulting in some pupil irregularity called REVERSE IRIS TUCK.
Wind shield wiper syndrome: When the implant is too small for the eye.Found when the loops are placed in the ciliary sulcus in the vertical position and also due to failure of adhesion of the superior loop to the posterior capsule.The superior loop moves to the left and right with the movements of the head. Corrected by McCunnels suture around the superior loop.
Sunset syndrome : Found within 6 weeks usually. Unrecognised inferior zonular dialysis during surgery. Forcible rubbing of eye may cause this problem in late stages. Less likely to occur if the loops are placed horizontally. Lens pulled superiorly and a McCunnel’s suture is placed. If it is not possible because of vitreous it is best to remove the lens and perform vitrectomy and place a ACIOL.
SUN RISE SYNDROME
Lost lens syndrome : refers to complete dislocation of an IOL into vitreous cavity .It is caused by severe zonular disinsertion or by posterior capsular rupture after accidental trauma.
An immobile IOL in the vitreous without any evidence of CME or RD does not need removal immediately.
Criteria for removal : RD, CME,mobile IOL in the vitreous, IOL in the macular region.
ACIOL : show least tendency towards malposition. Related to errors in lens size. If it is too small or large remove and replace with an appropriate size implant. If size is appropriate the haptic should be brought out and placed in a anew position.
Visual disturbance :
Amblyopia is considered the most
common cause of decreased vision in malpositioned lenses.
Myopia -in anterior displacement.
Astigmatism : tilting of the lens.
Diplopia : lens partly in partly out of the pupil.
The edge of the lens may be seen.
The edge of the lens may appear as a dark
curved line in the fundus reflex because of
internally reflected light.
IOL INDUCED COMPLICATIONS
Intermittent corneal touch : occurs in ACIOL if it is malpositioned or too small.
Secondary glaucoma : due to
Pseudophakic pupillary block.
Temporary block of aqueous outflow by cells
due to uveitis or inadequate removal of
viscoelastic. This is more sulcus fixating IOL,
blockage of iridectomy hole by IOL and in PC
lens without posterior angulation.
Chronic low grade inflammation may persist due to constant IOL uvea contact. Due to this there will be breakdown of blood aqueous barrier ultimately leading to corneal decompensation and later CME (corneal retinal inflammatory syndrome).
More in cases of sulcus fixation.
U veitis, G laucoma and H yphaema.
Etiology : multifactorial
Mechanical laceration or rubbing of the iris on
a rough or sharp edge---due to improper
finishing of the quality of the IOL.
Management : tropicamide or pilocarpine,
steroids, anti glaucoma agents.
Argon large vessel obliteration when the
bleeding source is identified near the haptic.
Cystoid macular edema :
Vitreous disturbance caused during the
surgery plays a very important role in CME
More common with secondary IOL
Management: No definitive treatment for CME.
Topical NSAIDS, Oral and Peribulbar steroids,
All the etiological factors should be kept in
mind and proper precautions should be taken
to prevent the complications.
MALPOSITIONED IOL :
Post operative management of a
malpositioned IOL is dictated mainly by the
symptoms of the patient .
Visual disturbances if severe IOL
repositioning should be done.
IOL repositioning through sideport is safe if PC is intact.
If the PC is absent/deficient postoperative maneuvering of the IOL is a delicate proposition and should be done with the best of the visco elastic material.
If nescessary one should fix the IOL transsclerally.
IOL induced glaucoma: Beta blockers, carbonic anhydrase inhibitors, hypertonic agents. YAG iridectomy if medical management fails.
Pupil is mid dilated and nonreactive to light, accommodation, and miotics between 1-60 days after surgery.
The pupil dilates with mydriatics and the iris shows no evidence of mechanical trauma.
It does not constrict with
0.1% pilocarpine(as seen
in post gang damage)
and 1% pilocarpine
(as seen in pre gang.damage).
Indirect damage to the sphincter muscle-
by raised IOP
Most surgeons feel that atonic pupil is mainly caused by ischaemia of iris sphincter muscle. Sphincter muscle is more susceptible because of its central location.
Symptoms are mild: no treatment is required.
Symptoms are severe: Narcissus contact lens with pupillary aperture similar to that in the opposite eye.
Rare cases a surgical pupilloplasty can be performed.
Most common potentially blinding complication of cataract extraction.
Incidence varies from 0.66% to 3.6%.
An IOL does not increase the rate of subsequent retinal detachment.
RD after cataract extraction is primkarily due to changes in the vitreous and the retina.
Anterior vitreous changes projection of vitreous into the AC greater traction at the vitreous base and other vitreoretinal attachments RETINAL TEARS.
The hyaluronic acid levels in vitreous is lower in ICCE cases than in ECCE cases.Hence the shock absorber action post ICCE is decreased which may lead to increased incidence of RD.
The absence/deficient posterior capsule plays an important role in RD development.
The anterior hyaloid membrane acts as an effective barrier to the forward displacement of vitreous. Its defect leads to RD.
RD in the opposite eye
Operative loss of vitreous
Anterior vitreous changes
Associated features: <50 yrs, open angle glaucoma, uveitis, marfans syndrome, atopic dermatitis, family history of RD etc..
Retinal breaks are more in the ora serata and the equator
They are more in the superotemporal quadrant.
TREATMENT OF RD
Pars plana vitrectomy and internal tamponade.
Sealing of retinal breaks.
Scleral buckling and encirclage
POST OPERATIVE STRABISMUS
Most of the time the superior rectus paresis or inferior rectus paresis are cited as major causes which is NOT true.
Exact etiology is difficult in most of the cases.
MOST PROPABLE CAUSES
An asymptomatic sensory deviation caused by dense cataractresulting in diplopia only after cataract surgery.
Chronic occlusion of eye due to dense cataract may convert a pre existing phoria into tropia that becomes symptomatic after visual rehabilitation of eye.
Optical factors are an important cause of a postoperative binocular diplopia ( brightness and colour disparity between phakic and pseudo phakic/aphakic eyes).
With positive forced duction tests surgical correction is successful.
Prismatic correction is helpful in some cases
Cataract surgery in the opposite eye is helpful in some cases.
EPITHELIAL INVASION OF AC
CORNEAL ENDOTHELIAL PROLIFERATION
EPITHELIAL INVASION OF AC
Causes: delayed wound closure, incarceration of ocular tissue in the wound, suture incarcerated the wound site.
Pathogenesis: the proliferating epithelial cells at the wound edges have the potential to form a downgrowth as a sheet or cyst behind the cornea and anterior to iris.
Symptoms and signs depend on the extent of
The cysts may be dormant for years.
If growth progresses they may cause iridocyclitis
and secondary glaucoma.
The cysts are usually thin walled ,transparent, filled
with straw coloured fluid containing some protein
and cholesterol. The posterior wall is often
The downgrowth appears as a transparent
layer creeping behind the cornea with a fine
gray line (due to piling up of cells) marking
the advancing border of the growth.
It has an irregular and wavy advancing edge.
Cryo surgical technique
Aspiration of the cyst contents followed by
cryothermy over the chamber angle and
photocoagulation of the cyst remnants.
Characterised by the ingrowth of connective
tissue elements into the anterior chamber.
Also called stromal ingrowth /stromal
overgrowth/ fibrocystic metaplasia/
Sub epithelial connective tissue.
Corneal or limbal stroma.
Unlike the epithelial downgrowth the fibrous
downgrowth does not have a well demarcated
advancing edge.It has irregular running strans
Thin ingrowth may be incised with a discission knife or with a NdYAG laser.
Secondary glaucoma may be treated by
cyclodialysis or cyclocryothermy.
Any progress of the growth involving the
posterior segment is an indication of very
If there is a descemets and endothelial tear
the healthy endothelial cells from the
surroundings grow and form a new
endothelial layer with in 48 hrs.
The growth of the endothelium is prolific and
it does not stop once the denuded area is
covered.This ultimately leads to the
Descemets tube formation : extend from the corneal wound to the pupillary area. A strand of vitreous acts a framework on which the endothelium produces the descemets.
Sometimes the endothelium undergoes fibroblastic change andd the susequent fibrous tissue that is produced is incorporated into the denuded area of the descemets. This leads to the formation of an atypical descemets also called glass membrane (as it is structureless)