A lecture by Prof Dr Fadel Abou Shousha

1. Five year experience in the
treatment of Endophthalmitis
ASCRS 2005
Prof. Fadel AbouShousha
Ass. Prof. Ahmed Shama
Alexandria University

3. 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

4. • 84 eyes of 83 patients.
• 34 females – 49 males
• With an age ranging from 8 to 79,
mean age was 43.5
• Only one case was bilateral.

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

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

7. Viscodissection and Peeling of AC membranes
(V.D.P)

8. Viscodissection and Peeling of AC membranes
(V.D.P)

9. Peeling of AC membrane by needle

10. • Vancomycin 100 mg/ml ( 1999- March 2004 )
• Gatifloxacin 160 mg/ml ( from March 2004 )
Intracameral Injection of Antibiotics
(I.C)

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

12. Intravitreal Injection
(I.V)
• 0.1 ml containing 1 mg Vancomycin
• 0.1 ml containing 0.4 mg Dexamethasone
• 0.1 ml containing 2.25 mg Ceftazidime
or 0.4 mg Amikin
Using separate syringes
Without mixing drugs

13. Patients with PL vision
Immediate Triple
Procedure with
Vitrectomy
No PVD
PVD
Removal of 50% of the vitreous gel
Removal of more than 50 %
Tap &
Biopsy +

14. Vitrectomy

15. Subconjunctival Injections
• 0.5 ml containing 25 mg Vancomycin
• 0.5 ml containing 100 mg Ceftazidime
• 0.25 ml containing 6 mg Dexamethasone
Without mixing drugs

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

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

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

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

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

21. %
No. of
Eyes
38 %
(32/84)
Confirmed Growth
62.5 %
(20/32)
1- Coagulase –ve Staphylococci
12.5 %
(4/32)
2- Staphylococci Aureus
6.25 %
(2/32)
3- Streptococci
9.4 %
(3/32)
4- P. Acnes
9.4 %
(3/32)
5- Pseudomonas
62 %
(52/84)
Culture Negative
Microbiological Isolates
Of
the
confirmed
growth

22. Visual Acuity
No.
of Eyes
Organism
No PL
1/60≥
1/60≤
≤6/60
6/18≤
(3/20)
15%
(2/20)
10 %
(3/20)
15 %
(7/20)
35%
(5/20)
25%
(20/32)
62.5%
Coagulase – ve
Staphylococci
(2/4)
50%
Nil
(1/4)
25 %
(1/4)
25 %
Nil
(4/32)
12.5%
Staphylococci Aureus
(1/5)
50 %
(1/5)
50 %
Nil
Nil
Nil
(2/32)
6.25%
Streptococci
Nil
Nil
Nil
(2/3)
66.6 %
(1/3)
33.3 %
(3/32)
9.4%
P Acnes
(3/3)
100 %
Nil
Nil
Nil
Nil
(3/32)
9.4%
Pseudomonas
(2/52)
3.8%
(1/52)
1.9 %
(27/52)
51.9 %
(16/52)
30.8 %
(6/52)
11.5%
(52/84)
62%
Culture Negative
(11/84)
13.5%
(4/84)
4%
(31/84)
36.5 %
(26/84)
31 %
(12/84)
14.8 %

23. Visual Acuity Outcomes
No.
of Eyes
No PL
1/60≥
1/60≤
≤6/60
6/18≤
Nil
0%
(2/32)
6.3%
(8/32)
25%
(13/32)
40.6%
(9/32)
28%
(32/84)
38%
Triple
Procedure
Presenting
with HM
(11/52)
21%
(2/52)
3.8%
(23/52)
44%
(13/52)
25%
(3/52)
5.7%
(52/84)
61.9%
Triple
Procedure
with
Vitrectomy
presenting
PL
(11/84)
13.5%
(4/84)
4%
(31/84)
36.5 %
(26/84)
31 %
(12/84)
14.8 %

24. Additional Procedure
Visual Acuity Outcomes
No.
of Eyes
No PL
1/60≥
1/60≤
≤6/60
6/18≤
Nil
0%
(2/7)
28.6%
(3/7)
42.9%
(2/7)
28.6%
Nil
0%
(7/32)
21.8%
ADPROC*
after Triple
procedure
(2/11)
18.2%
(3/11)
27.3%
(4/11)
36.4%
(2/11)
18.2%
Nil
0%
(11/52)
21%
ADPROC*
after triple
procedure
with
vitrectomy

25. Conclusion
• Abou Shousha Triple Procedure may be
considered an effective modality of the
treatment of post-operative endophthalmitis
with or without Vitrectomy according to the
visual acuity of the patient on presentation.

26. • 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
• Even in the additional procedure The
Triple Procedure should be considered

27. Thank you