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
Acute onset
-Surgical
Delayed onset

Bleb Associated

- Non surgical Post traumatic

B. Endogenous Haematogenous spread

 Post surgeries :
Cataract extraction
secondary lens implantation
pars plana vitrectomy
Glaucoma filter
Penetrating keratoplasty
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
 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
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
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.
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]
Diagnosis
Early 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 Endophthalmitis
Visual Acuity

Hand motion or
better Light perception

Initial tap & Initial Vitrectomy

inject antibiotics Inject antibiotics

48 hrs 48 hrs

Good response No response

Good response No response

Tap & await

recuture results
Vitrectomy &
await reculture
results
Positive culture

Positive culture

Reinject antibiotics Negative culture

Reinject
antibiotics Negative culture