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Post Operative Endophthalmitis
 Endophthalmitis is a potentially severe intraocular
inflammation due to complication of
- intraocular surgery
-non surgi...
Classification:
 Infectious:
A . Exogenous
-Surgical
Delayed onset
BlebAssociated
- Non surgical –Post traumatic
B. Endog...
 Post surgeries :
Cataract extraction
secondary lens implantation
pars plana vitrectomy
Glaucoma filter
Penetrating kerat...
Acute infectious Postop
endophthalmitis
 Within 6 weeks of surgery
 Common organisms:
- Coagulase negative staphylococcu...
 Preoperative risk factors:
-Active ocular surface infections/colonization
-Contaminated eye drops
 Operative risk facto...
Delayed –onset infectious
endophthalmitis
 More than 6 weeks following surgery
 Low virulent organism trapped within cap...
Bleb Associated infectious
Endophthalmitis
 Following glaucoma filtering surgery
 Blebitis purulent endophthalmitis
 Co...
Blebitis:
Symptoms :-
Mild discomfort & redness
Signs:-
- White bleb
- No anterior uveitis
- Normal Red reflex
Treatment :...
Endophthalmitis:
 Symptoms :-
- Rapidly worsening vision, pain,redness ,stickiness
 Signs :-
-White milky bleb with pus
...
Ocular manifestations:
Symptoms:
-Blurred vision
-Red eye
-Pain
-Photophobia
 Signs :
-Decreased visual acuity
-Eyelid edema
-Erytema
-Conjunctival hyperemia
-Chemosis
-Corneal edema & Opacification...
Diagnosis
 Early recognition & suspicion is critical
 A complete ocular and medical history
 Thorough Ophthalmic examin...
 Ultrasonography :
-Anterior segment media Opacity
-Vitreous cells , posterior segment detachment
- Retained lens remnant...
 Vitreous Biopsy :
-Trans –pars plana aspiration – 0.2 ml of liquid vitreous
- 23 G needle – 3 mm posterior to pseudophak...
 Aqueous andVitreous samples plated on
- Blood agar, Saurand dextrose agar , thioglycollate broth,
- Do Gram & Giemsa sta...
Prophylactic measures :
 Preoperative :
1.Careful assessment of external ocular surface
Conjunctival culture if external ...
 Intraoperative
-Sterile draping to exclude eyelids & lashes from operative
field
- 5 % povidone iodine to prepare ocular...
 Post operative :
- Postoperative instillation of topical 2.5 % , 5% povidone
iodine solution
- Antibiotic drops
- Closer...
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...
 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...
 There was no difference in final visual acuity or media clarity
with or without the use of systemic antibiotics.
 In pa...
Conclusion:
 Routine immediateVIT is not necessary in patients with
better than light perception vision
 VIT is of subst...
Management of Endophthalmitis
Visual Acuity
Light perception
Initial Vitrectomy
Inject antibiotics
48 hrs
No response
Tap ...
Post operative endophthalmitis
Post operative endophthalmitis
Post operative endophthalmitis
Post operative endophthalmitis
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Post operative endophthalmitis

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Post operative endophthalmitis

  1. 1. Post Operative Endophthalmitis
  2. 2.  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
  3. 3. Classification:  Infectious: A . Exogenous -Surgical Delayed onset BlebAssociated - Non surgical –Post traumatic B. Endogenous – Haematogenous spread Acute onset
  4. 4.  Post surgeries : Cataract extraction secondary lens implantation pars plana vitrectomy Glaucoma filter Penetrating keratoplasty
  5. 5. Acute infectious Postop endophthalmitis  Within 6 weeks of surgery  Common organisms: - Coagulase negative staphylococcus (S. epidermidis) -S.aureus , Streptococcus spp ,Pseudomonas,..  Source: lid & conjunctival flora
  6. 6.  Preoperative risk factors: -Active ocular surface infections/colonization -Contaminated eye drops  Operative risk factors: -Wound abnormalities -Vitreous loss - Prolonged combined surgeries - Contaminated irrigating solutions
  7. 7. Delayed –onset infectious endophthalmitis  More than 6 weeks following surgery  Low virulent organism trapped within capsular bag[cataracts]  Following NdYAG capsulotomy – release into viteous.  Common organisms- -Propionibacterium acnes -S.epidermidis -fungi  Persistent /recurrent uveitis following surgery
  8. 8. Bleb Associated infectious Endophthalmitis  Following glaucoma filtering surgery  Blebitis purulent endophthalmitis  Common organisms -Streptococcus spp -Haemophilus influenza Risk Factors : - Local antimetabolite therapy [thin walled drainage bleb] - Blepharitis - Nasally or inferior placed & leaky bleb.
  9. 9. 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
  10. 10. Endophthalmitis:  Symptoms :- - Rapidly worsening vision, pain,redness ,stickiness  Signs :- -White milky bleb with pus - Severe anterior uveitis with hypopyon -Vitritis , poor red reflex..
  11. 11. Ocular manifestations: Symptoms: -Blurred vision -Red eye -Pain -Photophobia
  12. 12.  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]
  13. 13. Diagnosis  Early recognition & suspicion is critical  A complete ocular and medical history  Thorough Ophthalmic examination
  14. 14.  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
  15. 15.  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 portVitrectomy.
  16. 16.  Aqueous andVitreous samples plated on - Blood agar, Saurand dextrose agar , thioglycollate broth, - Do Gram & Giemsa stains
  17. 17. 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
  18. 18.  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 -
  19. 19.  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.
  20. 20. 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
  21. 21.  Topical : -Vancomycin 5 % - Ceftazidime 5% - Dexamethasone 0.1 %
  22. 22. 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.
  23. 23.  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 immediateVIT 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.
  24. 24. Conclusion:  Routine immediateVIT is not necessary in patients with better than light perception vision  VIT is of substantial benefit in patients with vision of light perception only.
  25. 25. Management of Endophthalmitis Visual Acuity Light perception Initial Vitrectomy Inject antibiotics 48 hrs No response Tap & await recuture results Negative culture Positive culture Reinject antibiotics Good response Hand motion or better Initial tap & inject antibiotics 48 hrs No response Vitrectomy & await reculture results Negative culture Positive culture Reinject antibiotics Good response

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