This document discusses the classification, incidence, clinical features, microbiology, prevention, and treatment of acute post-operative endophthalmitis. It classifies endophthalmitis based on onset and origin. Incidence is higher for post-traumatic compared to post-operative. Clinical features include decreasing vision, eye pain, redness, and photophobia. Treatment involves intravitreal antibiotics, vitrectomy, and adjunct topical/systemic antibiotics. The Endophthalmitis Vitrectomy Study showed vitrectomy benefits patients with light perception vision. Intravitreal and intravenous antibiotics are also recommended.
The basis of manual small incision cataract surgery is the tunnel construction for entry to the anterior chamber.
The parameters important for the structural integrity of the tunnel are the self-sealing property of the tunnel, the location of the wound on the sclera with respect to the limbus, and the shape of the wound.
Cataract surgery has gone beyond just being a means to get the lens out of the eye.
Postoperative astigmatism plays an important role in the evaluation of final outcome of surgery. Astigmatic consideration, hence, forms an integral part of incisional considerations prior to surgery.
The basis of manual small incision cataract surgery is the tunnel construction for entry to the anterior chamber.
The parameters important for the structural integrity of the tunnel are the self-sealing property of the tunnel, the location of the wound on the sclera with respect to the limbus, and the shape of the wound.
Cataract surgery has gone beyond just being a means to get the lens out of the eye.
Postoperative astigmatism plays an important role in the evaluation of final outcome of surgery. Astigmatic consideration, hence, forms an integral part of incisional considerations prior to surgery.
EMERGENCY PARS PLANA VITRECTOMY FOR ACUTE POST - CATARACT ENDOPHTHALMITIS WH...DrAbdelLatifsiam
Post Cataract Surgery Endophthalmitis
Endophthalmitis is the most devastating complication of cataract surgery
Immediate action should be taken once endophthalmitis is diagnosed
There should not be any time lost before diagnosis is made
TASS
Toxic solution enters the anterior chamber
Produce severe intraocular inflammation as well as corneal edema
Form of sterile, noninfectious endophthalmitis
Endophthalmitis
Present in an acute form or in a more indolent or chronic form the latter is associated with organisms of lower pathogenicity
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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3. Classification
According to onset:
Acute (Mostly within 1 week)
Chronic (>6 weeks)
According to origin:
Endogenous: From blood stream
Exogenous: Post-operative (Cataract, glaucoma..etc), or post-
traumatic
4. Incidence post traumatic endophthalmitis
Range from 1-20%, increased with retained foreign body and dirty
wounds from rural settings. (safneck, 2012)
Incidence of endophthalmitis
Post-op Traumatic
<1% >1% (average 5-10%)
5. Clinical features
Symptoms (within 1 week for acute)
Decreasing vision along with “Eye ache”
Later, severe redness, pain, photophobia.
Often afebrile
Signs
6. How to take culture samples
Should be kept for at least 14 days to culture slow growing organisms.
Prepare patient as if intra-ocular surgery, full draping.
Topical + peribulbar anaesthesia. If severe endophthalmitis (e.g. abscess), resistant to local
anaesthesia. Therefore general anaesthesia might be necessary.
Conjunctival swabs: Can be helpful if –ve tabs
Aqueous tab: 0.1-0.2mls aspirated using 25g needle
Vitreous tab (More likely to yield +ve results): 0.2-0.4mls aspirated using 23g needle or better using disposable
vitrector (scleral tunnelling)
Videos
http://simulatedocularsurgery.com/simulation/intraocular-injections/
7. Microbiology
Post op cataract Post-op Blebitis Post-op IVI Post traumatic
Acute:
Coagulase negative
staph
Chronic:
P.Acnes
Corynebacterium
Early onset:
Coagulase negative
staph
Delayed:
Strep/staph
- Coagulase negative
staph
- Streptococcus
-Coagulase negative
staph
- Bacillus
- Streptococcus
Always think about
fungi
Endogenous endophthalmitis: Many organisms, think about fungi in immunocompromised.
Exogenous Endophthalmitis
8. Prevention
The only evidence currently:
Povidone iodine
Intra-cameral cefuroxime
No evidence does not mean absence of evidence
9. Treatment
Things to consider:
1) Intravitreal antibiotics
2) Vitrectomy
3) Adjunct topical and systemic antibiotics
10. Intravitreal antibiotics
Empiric
Vancomycin 1 mg plus either :
Ceftazidime 2.25 mg OR
Amikacin 0.4 mg
Ceftazidime is preferred over amikacin due to aminoglycodie retinal toxicity and infarction.
Antibiotics last for an average of 48hrs. May need repeat injections. Do not inject amikacin twice!
Silicone oil and gas-filled eyes require a substantial dose reduction (1/4-1/10 of the standard dose has
been suggested) taking into account the reduced fluid distribution volume that remains in the eye
11. Landmark study: Endophthalmitis
Vitrectomy Study (EVS) 1990-1995
Purpose:
To investigate the role of initial pars plana vitrectomy in the managment of postoperative bacterial endophthalmitis
Determine the role of intravenous antibiotics in management;
Determine which factors, other than treatment, could predict outcomes in postoperative bacterial endophthalmitis.
Random Allocation:
1) Vitrectomy + intravenous antibiotic (Ceftazidime and amikacin)
2) Vitrectomy, no intravenous antibiotics
3) Tap-biopsy + intravenous antibiotic
4) Tap-biopsy, no intravenous antibiotic
All patients received intravitreal amikacin, vancyomycin + subconj vancomycin, ceftazidime and dexamethasone.
12. Landmark study: Endophthalmitis
Vitrectomy Study (EVS) 1990-1995
Results
Vitrectomy:
patients presenting with hand motion acuity or better showed NO benefit from
immediate vitrectomy, however;
patients presenting with light-perception-only VA had substantial benefit from
immediate vitrectomy, with:
3-fold greater frequency of achieving 20/40 vision or better
Twice the frequency of achieving 20/100 or better
Decrease by one-half in frequency of severe visual loss to < 5/200.
Debate!
14. ? Systemic antibiotics
Most studies after the EVS are retrospective and not conclusive.
Recommended by experts:
Ceftazidime, vancyomycin or linozolid.
Use similar to the IVI antibiotics
16. Treatment: Dexamethasone
Dexamethasone (preservative-free) is often given by intravitreal injection (dose = 400
μg in 0.1ml volume, using the commercial preparation containing 4 mg/ml)
Conflicting evidence from –ve to neutral to +ve effect.
Gan 2005, Shah 2000, Das 1999
17. After 48hrs
If no improvement:
Re-inject IVI OR
Vitrectomy
19. Consideration in other endophthalmitis
syndromes
Post IVI: same approach as post cataract
Chronic: Systemic antibiotics are not indicated
Endogenous, Post traumatic and Bleb related endophthalmitis:
Recommend 3 step approach: IVI, Vitrectomy and systemic antibiotics.
UpToDate: Bacterial enodphthalmitis. Accessed 25/12/15
20. My recommendation (as supported by
evidence)
Prevention:
Povidone
Intra-cameral cefuroxime
Post op antibiotic for 1 week.
Treatment:
Tap and inject (Vancomycin and ceftazidime)
Immediate vitrectomy if vitreoretinal surgeon available for VA LP
IV antibiotics for severe cases (Vancomycin/Linozlid and ceftazidime)
22. References
Shah GK, Stein JD, Sharma S, et al. Visual outcomes following the use of intravitreal steroids in the treatment of postoperative endophthalmitis. Ophthalmology 2000;107:
486 – 489
Das T, Jalali S, Gothwal VK, Sharma S, Naduvilath TJ. Intravitreal dexamethasone in exogenous bacterial endophthalmitis: results of a prospective randomised study. Br J
Ophthalmol 1999;83:1050 –1055
Gan IM, Ugahary LC, van Dissel JT, et al. Intravitreal dexamethasone as adjuvant in the treatment of postoperative endophthalmitis: a prospective randomized trial. Graefes
Arch Clin Exp Ophthalmol 2005;243:1200 –1205
Editor's Notes
What are you afraid off??
They might deny pain
Visual acuity is very improtant. HM or worse for abscess.
Send for microscopy, culture, pcr
Why vancomycin? Staph epidermidis are gram +ve
Vitrectomy vs mini vitrectomy rather than tap only
Amikacin and ceftazidime are both good for gram –ves. However the most common oraganism was staph epidermidis.
Also amikacin does not cross the blood-ocular barrier.
