A Case of Endophthalmitis

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A Case of Endophthalmitis

• Erlangga Ariadarma
• Medical Officer
• National University Hospital

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Mdm. TKM. 71 Y.O

• Hx of
• Asthma Bronchial
• Hypertension
• Had LE ECCE IOL in 1999 (NUH)

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• Underwent RE Phaco IOL 29.12.2004
• Op was uneventful
• No intraoperative complication noted.
• Post op Meds Gutt. Optodexine 3h RE

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POD 1

• POD 1 note
• VA RE 6/15 (ph 6/9)
• Cornea Clear
• Nasal Pterygium
• A/C Deep. Cells
• PC IOL insite.
• Planned to continue medicine and for another
  review in 5 days (03.01.2005)

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POD 10

• Did not come for appointment 5 days later.
• Walked in 3 days late.
• C/o
• Pain on the right eye since 2 days back
• The pain evolved to greater degree within a day
• Rapid deteriorating vision within a day
• Had been using eye drops TDS (only)

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Ophthalmic Examination

• Right Eye
• VA CF 1/2M. Good Projection of Light
• Cornea Fine keratic precipitate on endothelium
• Anterior Chamber
• Deep
• Cells
• Hypopion 0.9 mm
• PC IOL in site

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Ophthalmic Examination

• Posterior Segment
• Retrolental Cells
• Vitreous diffusely hazy
• Retina visible but not clear.
• Impression Acute postoperative Endophthalmitis

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Initial Management

• Vitreous tap
• Intravitreal Vancomycin 1mg/0.1mL
• Intravitreal Ceftazidime 2mg/0.1mL
• Specimen sent for
• Gram stain (as stat)
• Culture and Sensitivity
• G/S WBC , Gram ve Cocci-like organism
  occasional
• G. Cefazolin (50mg/mL) Hourly RE
• G. Gentamicin (14mg/mL) Hourly RE
• T. Ciprobay 500mg BD

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Follow Up/Progress

• Admitted for close follow up
• Culture grew Coagulase negative Staphylococcus
• Sensitive to Vancomycin Cefazolin,
  Ciprofloxacin and Clindamycin.
• Adjustment 5 days after admission
• Gutt. Vancomycin to replace Gutt. Gentamicin
• IV Vancomycin ( for 5 days) in addition to T.
  Ciprobay
• Start Gutt. Pred Mild with close monitor at start
• Repeated Intravitreal Vancomycin 10 days post 1st
  injection

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Clinical Improvement

• VA stable at CF 1 M. Maintain good PL
• Hypopion resolved, eventually
• Anterior segment reaction decreased
• Posterior segment view clearer
• (Hazy but vessels are seen)
• PCO
• Toxic Epithelopathy

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Outpatient Follow Up/Progress

• Followed up 3 days after discharge
• Lost in Follow up for 4 months
• Seen in SGH AE for acute BOV (3 days)
• Referred back to NUH.

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Ophthalmic Examination

• VR CF 1/2 m. Good PL
• Conjunctiva White
• Cornea Nasal Pterygium approaching paracentral.
  Otherwise clear.
• Anterior Chamber Deep. WBC
• Retrolental Cells RBC
• Posterior Segment Vitreous Haze, with limited
  view of retina, only disc visible.
• B Scan no RD.

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B SCAN
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Management

• RE Vitrectomy, after a month of observation
• Vitreous opacity removed
• RE Pterygium excission.
• No intraoperative complication noted
• So far, no postoperative complication
  encountered.

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?Postoperative Surprise

• Latest visit
• BCVA
• R S1.00 C-1.50x020 6/9
• L S0.75 C-2.50x005 6/9
• Recurrence of RE Pterygium
• Off Meds (officially)

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Summary

• Mdm.TKM. 71 y.o
• RE Acute postoperative endophthalmitis, presented
  2nd week post Phaco/IOL.
• Immediate intravitreal injection of antibiotics
• Coagulase negative Staphylococcus
• Conservative (and aggressive) treatment
  consisting topical and systemic antibiotics
• Lost in follow up after hospitalization,
  re-presented with Vitreous Haze
• Vitrectomy done,enventful
• Excellent visual outcome

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Points to note

• Symptoms developed about POD 6 (not POD 1)
• Organism Staph epidermidis (low virulence)
• VR CF
• Factors which suggest potentially good outcome

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Discussion

• Endophthalmitis-
• Acute Postoperative Endophthalmitis

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Endophthalmitis

• Endophthalmitis
• Defined as Intraocular Pyogenic Infections.
• Classification based on
• Etiologic agent
• Mode of entry
• Location in the Eye
• Localized vs Panophthalmitis

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Postoperative Endophthalmitis

• Acute post-cataract surgery
• Chronic pseudophakic-related
• Bleb-related
• Post-traumatic

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Causative Microorganism-Acute Postoperative
Endophthalmitis

• Endophthalmitis Vitrectomy Study
• 70 coagulase negative Staph
• 10 staph aureus, 9 strep, 5 other gr()
• 6 Gram negative rods
• 4 polymicrobial
• All gram () suspectible to vancomycin.
• 89 gram (-) suspectible to Amikacin or
  Ceftrazidime

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Pathogenesis

• Direct inoculation from normal conjunctival flora
• Contamination of sterilized instruments,
  disposable supplies, prepared solution, surgical
  field or the IOL.
• Surgical risk factor
• Rupture of post. Capsule
• Retained lens material
• Secondary IOL implants ? increased surgery time
  or ocular manipulation

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Treatment Modality

• Intravitreal antibiotic injection
• Surgical Vitrectomy
• Systemic Antibiotic (/-)
• Determining Factor
• VA

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• EVS
• Patient with PL (or worse)
• 3x chance to get 20/40 vision with Vitrectomy
• 56 to get 20/500 with Vitrectomy (vs 21 for
  tap)
• 5/200 80 for Vx, 53 with tap
• Patient with HM (or better)
• 20/40 66 Vitrectomy 62 Tap
• 20/100 86 84
• 5/200 53

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Systemic Antibiotic in Acute Postoperative
Endophthalmitis

• EVS
• no difference in VA or media clarity outcome
  with/out systemic antibiotics.
• No benefit of IV AB is questioned by many
  investigators ? not include vancomycin

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Final VA in relation to microorganism

• Final VA 20/100
• 80 no or equivocal growth
• 84 of gram () coagulase negative Staphylococcus
• 42 of other gram () organisms, such as S.
  aureus or streptocci
• 56 of those with gram (-) growth.

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The End

• Thank You