1. Post Operative Endophthalmitis

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. Classification:
 Infectious:
A . Exogenous
-Surgical
Delayed onset
BlebAssociated
- Non surgical –Post traumatic
B. Endogenous – Haematogenous spread
Acute onset

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

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.  Preoperative risk factors:
-Active ocular surface infections/colonization
-Contaminated eye drops
 Operative risk factors:
-Wound abnormalities
-Vitreous loss
- Prolonged combined surgeries
- Contaminated irrigating solutions

9. 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

11. 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.

12. 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

13. Endophthalmitis:
 Symptoms :-
- Rapidly worsening vision, pain,redness ,stickiness
 Signs :-
-White milky bleb with pus
- Severe anterior uveitis with hypopyon
-Vitritis , poor red reflex..

15. Ocular manifestations:
Symptoms:
-Blurred vision
-Red eye
-Pain
-Photophobia

16.  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]

17. Diagnosis
 Early recognition & suspicion is critical
 A complete ocular and medical history
 Thorough Ophthalmic examination

18.  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

19.  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.

20.  Aqueous andVitreous samples plated on
- Blood agar, Saurand dextrose agar , thioglycollate broth,
- Do Gram & Giemsa stains

21. 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

22.  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
-

23.  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.

24. 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

25.  Topical :
-Vancomycin 5 %
- Ceftazidime 5%
- Dexamethasone 0.1 %

26. 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.

27.  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.

28. 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.

29. 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