Post Operative Endophthalmitis

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

Classification:Infectious: A . Exogenous -Surgical Delayed onset

Bleb Associated

- Non surgical –Post traumatic

B. Endogenous – Haematogenous spread

Acute onset

Post surgeries : Cataract extraction secondary lens implantation pars plana vitrectomy Glaucoma filter Penetrating keratoplasty

Acute infectious Postop endophthalmitisWithin 6 weeks of surgeryCommon organisms: - Coagulase negative staphylococcus (S. epidermidis) -S.aureus , Streptococcus

spp ,Pseudomonas,.. Source: lid & conjunctival flora

Preoperative risk factors: -Active ocular surface infections/colonization -Contaminated eye drops

Operative risk factors: -Wound abnormalities - Vitreous loss - Prolonged combined surgeries - Contaminated irrigating solutions

Delayed –onset infectious endophthalmitisMore than 6 weeks following surgeryLow virulent organism trapped within

capsular bag[cataracts] Following Nd YAG capsulotomy – release

into viteous. Common organisms- -Propionibacterium acnes -S.epidermidis -fungiPersistent /recurrent uveitis following

surgery

Bleb Associated infectious EndophthalmitisFollowing glaucoma filtering surgeryBlebitis purulent endophthalmitisCommon organisms -Streptococcus spp -Haemophilus influenza

Risk Factors : - Local antimetabolite therapy [thin walled

drainage bleb] - Blepharitis - Nasally or inferior placed & leaky bleb.

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

Endophthalmitis:Symptoms :- - Rapidly worsening vision,

pain,redness ,stickiness

Signs :- - White milky bleb with pus - Severe anterior uveitis with hypopyon - Vitritis , poor red reflex..

Ocular manifestations:

Symptoms: -Blurred vision -Red eye -Pain -Photophobia

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]

DiagnosisEarly recognition & suspicion is critical

A complete ocular and medical history

Thorough Ophthalmic examination

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

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 port Vitrectomy.

Aqueous and Vitreous samples plated on - Blood agar, Saurand dextrose agar ,

thioglycollate broth, - Do Gram & Giemsa stains

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

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 -

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.

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

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 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.

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 immediate VIT 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.

Conclusion:Routine immediate VIT is not necessary in

patients with better than light perception vision

VIT is of substantial benefit in patients with vision of light perception only.

Management of EndophthalmitisVisual Acuity

Light perception

Initial Vitrectomy

Inject antibiotics

48 hrs

Hand motion or better

Initial tap & inject antibiotics

48 hrs