A lecture by Prof Fadel Abou Shousha and Prof Ahmed Shama

1. Five year experience in the
management of endophthalmitis
BY
Prof. Fadel AbouShousha
Dr. A. shama
Alexandria University
ASCRS 2005

2. Endophthalmitis
• Postoperative
• Acute
• Delayed onset
• Bleb associated
• Post-traumatic
• Endogenous

3. Incidence by surgical category
• Cataract: 0.08%
• Secondary IOL: 0.37%
• PPV: 0.05%
• Glaucoma: 0.12%
• PK: 0.18%

4. From year 2000 to 2003
____________________________
• The endophthalmitis rate after cataract
surgery increased
0.08 %
0.27%

5. • Clear corneal incision was associated
with 2.5 fold increased risk of
endophthalmitis compared with
scleral incision and more than a 3
fold increase versus limbal incision

6. In the year 2001
• 2.5 million cataract surgeries in the U.S.A
• 10 million cataract surgeries worldwide
The recent increase in endophthalmitis rate
• 4000 additional cases in the U.S.A
• 16000 additional cases worldwide annually

7. Theory explaining this
_______________________________
• Poorer stability of the surgical wound
• Defect in the clear corneal wound may
not be readily apparent intraoperatively

8. Clinical presentation
• Pain
• Conj. Injection
• Lid oedema
• Note that low virulence organisms may
present without pain or external
inflammation

9. Clinical presentation
• Loss of vision
• AC and Pupillary membranes
• Vitreous opacification
• Hypopyon
• Ultrasonography!!!

10. Diagnosis
• Early diagnosis is crucial and
requires high index of suspicion
in patients with postoperative
inflammation greater than
expected.

11. Time of presentation
• 1-3 days:
• Staph. aureus
• Strept species
• Gram negative
• One week: Staph. epidermidis.
• 3-4 weeks: Late onset
• P Acnes
• Fungal
• Staph. epidermidis

12. The aim of the work
• A retrospective analysis of all cases of post-
operative endophthalmitis following cataract
surgery in AbouShousha Ophthalmic Center ,
Alexandria Egypt ,over a 5 year period ( 1999 -
2004 )
• The aim of this study is to evaluate the
effectiveness and visual outcome of
Abou Shousha Triple Procedure with and without
Vitrectomy in the management of post-operative
endophthalmitis after cataract surgery

13. Subjects and Methods

14. • 74 eyes of 73 patients.
• 29 females – 44 males
• With an age ranging from 8 to 79,
mean age was 43.5
• Only one case was bilateral.

15. If hand motion or better vision
Immediate
Tap and biopsy
Triple Procedure without
Vitrectomy
Surgical Techniques

16. Aqueous tap

17. Vitreous tap

18. Mechanized vitreous biopsy
• 20 G pars plana sclerostomy
• Vitreous cutter attached to syringe
• 0.1 – 0.3 ml
• Manual aspiration

19. Vitrectomy cassette fluid
• 3 - port vitrectomy
• Specimen may be suction filtered or
centrifuged

20. Triple Procedure
Intravitreal
injection of
Antibiotics
(I.V)
Viscodesection
and Peeling of
AC membranes
(V.D.P)
Intracameral
injection of
Antibiotics
(I.C)

21. Visceodesection and Peeling of AC membranes
(V.D.P)

22. Visceodesection and Peeling of AC membranes
(V.D.P)

23. Peeling of AC membrane by needle

24. Viscodesection and Peeling

25. Peeling of AC membrane
(Membranorrhexis)

26. Peeling of Membranes by Cutter

27. • Vancomycin 10 mg/ml
• Gatifloxacin 160 ug/ml ( Tequin )
Intracameral Injection of Antibiotics
(I.C)

28. Gatifloxacin more effective than Vancomycin
• Kills organisms much faster
• Eradicate gram +ve and gram –ve bacteria
Robert Snyder MD
Euro Times March 2004

29. Intravitreal Injection
(I.V)
• 0.1 ml containing 1 mg Vancomycin
• 0.1 ml containing 2.25 mg Ceftazidime
or
0.1 ml containing 0.4 mg Amikin
• 0.1 ml containing 0.4 mg Dexamethasone
With separate syringe and needle
Do not mix drugs

31. Intravitreal injection

33. Do not mix drugs

34. Patients with PL vision
Immediate Triple
Procedure with
Vitrectomy
No PVD
PVD
Removal of 50% of the vit. gel
Removal of more than 50 %
Tap &
Biobsy +

35. Vitrectomy

36. Subconjunctival Injections
• 0.5 ml containing 25 mg Vancomycin
• 0.5 ml containing 100 mg Ceftazidime
• 0.25 ml containing 6 mg Dexamethasone
Do not mix drugs

37. Topical Antibiotics
(fortified)
• Vancomycin 50 mg/ml
Alternating with either
• Ceftazidime 50 mg/ml
or
• Amikacin 20 mg/ml

38. The patient should also be treated with
• Pridnisolone acitate drops 1% every hour
• Atropine sulphate twice daily
• Pridnisolone orally 30 mg twice daily for
10 days

39. My Prescription
R Vancomycin E.D 50mg/ml
R Quinolone E.D
R Fortum E.D 50 mg/ml
or Amikin E.D 20mg/ml
R Steroid E.D
R Antibiotic eye oint bed time
R Cycloplegic E.D
R Anti-Glucoma eye drops
R Gatifloxacin oral 400mg daily for 5 days
R Systemic Steroid 30 -60 mg daily for 10 days
N.B Vancomycin and Amikin to be stored in refrigirator 4C
Alternating
every
¼ -½ hour
According to
the condition

40. Close follow up
If on the second postoperative day
No Improvement
Persistant Pain
Hypopion
Clouding of the media
Additional Procedure

41. If the initial procedure was
• Vitreous and AC tap Reculture
• Triple Procedure with Vitrectomy
• Shifting to another group of antibiotic
Triple Procedure without
Vitrectomy

42. If the initial Procedure was
Triple Procedure with Vitrectomy
Vitreous and AC tap Reculture
Triple Procedure
Using another groups of antibiotic

43. Results

44. Visual Acuity Outcomes
No.
of
Patients
No PL
1/60≥
1/60≤
≤6/60
6/18≤
Nil
0%
(2/22)
9%
(4/22)
18.1%
(9/22)
40.9%
(7/22)
31.8%
(22/74)
29.7%
Triple
Procedure
(1/39)
2.6%
(4/39)
10.3%
(18/39)
46.2%
(12/39)
30.8%
(4/39)
10.3%
(39/74)
52.7%
Triple
Procedure
with
Vitrectomy
Nil
0%
(1/4)
25%
(2/4)
50%
(1/4)
25%
Nil
0%
(4/74)
5.4%
ADPROC*
after Triple
procedure
(2/9)
22.2%
(3/9)
33.3%
(3/9)
33.3%
(1/9)
11.1%
Nil
0%
(9/74)
12.1%
ADPROC*
after triple
procedure
with
vitrectomy
(3/74)
4%
(10/74)
13.5%
(27/74)
36.5%
(23/74)
31.1%
(11/74)
14.9%
74/74
* Additional Procedure

45. %
No. of
Patient
68.9 %
(51/74)
Confirmed Growth
64.7 %
(33/51)
1- Coagulase –ve Staphylococci
11.8 %
(6/51)
2- Staphylococci Aureus
9.8 %
(5/51)
3- Streptococci
5.9 %
(3/51)
4- P. Acnes
7.8 %
(4/51)
5- Pseudomonas
31.1 %
(23/74)
Culture Negative
Microbiological Isolates

46. 0
5
10
15
20
25
30
35
Coagulase –ve
Staphylococci
Staphylococci
Aureus
Streptococci P Acnes Pseudomonas Culture Negative
No of
Patients

47. Visual Acuity
No.
of Pat.
Organism
No PL
1/60≥
1/60≤
≤6/60
6/18≤
Nil
(3/33)
9.0 %
(9/33)
27.2 %
(13/33)
39.4%
(8/33)
24.2%
(33/51)
64.7%
Coagulase – ve
Staphylococci
Nil
(3/6)
50 %
(1/6)
16.6 %
(1/6)
16.6 %
(1/6)
16.6 %
(6/51)
11.8%
Staphylococci Aureus
(1/5)
20 %
(2/5)
40 %
(2/5)
40 %
Nil
Nil
(5/51)
9.8%
Streptococci
Nil
Nil
Nil
(2/3)
66.6 %
(1/3)
33.3 %
(3/51)
5.9%
P Acnes
(2/4)
50 %
(1/4)
25 %
(1/4)
25 %
Nil
Nil
(4/51)
7.8%
Pseudomonas
Nil
(1/23)
4.3 %
(14/23)
60.9 %
(7/23)
30.4 %
(1/23)
4.3 %
(23/74)
31%
Culture Negative
(3/74)
4.1 %
(10/74)
13.5 %
(27/74)
36.5 %
(23/74)
31.1 %
(11/74)
14.5 %
74/74
100 %

48. 0
10
20
30
40
50
60
70
80
90
100
Triple Procedure Triple Procedure with
Vitrectomy
Additional Procedure
after triple procedure
Additional Procedure
after Triple Procedure
with Vitrectomy
≤6/18
≤1/60
≥1/60

49. 0
10
20
30
40
50
60
70
80
90
100
Coagulase – ve
Staphylococci
Staphylococci
Aureus
Streptococci P Acnes Pseudomonas Culture Negative
≤6/18
≤1/60
≥1/60

50. Causes of visual acuity < 6/60 (37/74)
– Macular ischemia
– Pigmentary degeneration of the macula
– Retinal detachment
– Macular distortion or preretinal membrane
– Vitreous opacification
– Other miscellaneous

51. Fundus Changes
after treatment of endophthalmitis

52. Fundus Changes
after treatment of endophthalmitis

53. Fundus Changes
after treatment of endophthalmitis

54. Fundus Changes
after treatment of endophthalmitis

55. Conclusion
• Abou Shousha Triple Procedure is
mandatory in all cases of Endophthalmitis
with or without Vitrectomy according to the
visual acuity of the patient on presentation

56. • Cases presented with hand motion or
better visual acuity are treated with
The Triple Procedure without
Vitrectomy
• Cases presented with light perception
visual acuity are treated with The
Triple Procedure plus parsplana
Vitrectomy

57. Thank you
www.aboushousha.8m.com
hmfadel@yahoo.com