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GRAND WARD ROUND Dr Heng Li Wei Dept of Ophthalmology, TTSH 23rd May 2007 History Mdm F.L.T., 66yo/C/F PMH: Asthma Ocular history: Left Phaco/IOL 26/3/04 Right Phaco/IOL 3/5/04 Presented on 1/2/07 c/o: - Right eye pain a/w tearing, itch x 1 day - No hx of trauma.

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GRAND WARD ROUND

Dr Heng Li Wei

Dept of Ophthalmology, TTSH

23rd May 2007


History

  • Mdm F.L.T., 66yo/C/F

  • PMH: Asthma

  • Ocular history: Left Phaco/IOL 26/3/04

    Right Phaco/IOL 3/5/04

  • Presented on 1/2/07 c/o:

    - Right eye pain a/w tearing, itch x 1 day

    - No hx of trauma.


Examination Findings

  • VR – CF closely, VL – 6/7.5

  • No RAPD

  • Conjunctiva injected

  • Cornea – hazy, stitch at 10 o’clock position a/w abscess

  • AC – deep, cells 4+, flare 2+, hypopyon 1.5mm

  • Pseudophakic


Examination Findings

  • IOP – 13mmHg both eyes

  • Right fundus – no view.

  • Left eye – pseudophakic. Otherwise NAD.

  • B-scan R eye – mild vitreous opacities, retina flat.

  • Impression?


  • Dx: R delayed-onset postop exogenous endophthalmitis.

  • Referred to VR team-on-call, planned for R TPPV and intravitreal antibiotics.

  • Asthma exacerbation, decr O2 saturation

    -> deemed unfit for GA.

  • Underwent R AC tap and washout, intravitreal vancomycin and ceftazidime on 1/2/07.

  • Cornea scrape and stitch sent for c/s.


Post-op Progress

  • Admitted from 2nd – 13th Feb 07.

  • VR - POD 1-2: HM, PL all 4 quadrants.

    No RAPD.

    Cornea abscess at stitch site 1.5mm.

    New stitch post-op at 12 o’clock position.

    AC cells 4+, fibrin +, hypopyon present.

    IOP 19mmHg.

    No view of posterior pole.


Post-op Photos


Post-op Progress

  • Rx : T. Ciprofloxacin 500mg bd

    G cefazolin 50mg/ml Q1H

    G gentamicin 14mg/mlQ1H

    G atropine bd

  • Rpt B-scan on POD 2 – no vitreous opacities, retina flat.

  • AC Tap/ Stitch culture – Staph aureus, sensitive to cloxacillin, erythromycin, cotrimoxazole. Resistant to penicillin.


Post-op Progress

  • POD 4 - G. Gentamicin decr to Q3H

    G cefazolin Q1H, G ciloxan Q1H.

  • VR – CF 1m

  • Cornea hazy. AC cells 2+, sliver of hypopyon. Cornea infiltrate at 10 o’clock still sloughy, active with very slight improvement.

  • Fundus – fairly clear view, retina flat.

  • Continued on same Rx regime.


Post-op Progress

  • POD 9 & 10 – AC shallow, IOP 9 mmHg.

  • Referred to Cornea team – AC reasonably deep, con’t Rx except G ciloxan switched to G cravit Q3H.

  • Over next 3 days – AC formed and deep, cells 1+, no hypopyon. Seidel’s negative.

  • On d/c (13/2/07) – VR 6/24. D/c with G cefazolin and cravit Q2H.


But…

  • R/v 3 days later – AC shallow.

  • Referred to Cornea – Cornea abscess no obvious leak but AC shallow.

  • Underwent urgent Right cornea patch graft 17/2/07. ( Grade A donor graft)


Post-Right cornea patch graft

  • 2nd admission 17th-22nd Feb 07.

  • Cornea graft clear – no leak or infiltrates.

  • AC deep, cells 1+. IOP normal.

  • D/c with G Cravit QDS, G Pred Forte Q3H.

  • R/v 4 days later – suture infiltrate seen. G Cravit and Pred Forte Q3H.

  • R/v 1 week later – No infiltrate, graft clear. AC occ cells.


Last review

  • 10/5/07 – Graft – slight edema. AC deep. IOP 16mmHg, 1 loose stitch – STO done.

  • G cravit / pred forte tailed down to tds and TCU in 2 mths.


Endophthalmitis

Endogenous vs Exogenous


Endophthalmitis Vitrectomy Study

  • Arch Ophthalmology 1995; 113: 1479

  • Objective:

  • Determine role of immediate pars plana vitrectomy in post cataract Sx endophthalmitis

  • Determine role of IV antibiotics in mgmt of endophthalmitis


EVS

  • 420 pts with post cataract Sx endopthalmitis

  • Randomly assigned to either

    1. Early vitrectomy & intravitreal antibiotics vs

    2. Vitreous tap/biopsy & intravitreal antibiotics

    In addition, all eyes randomised to treatment with or without IV antibiotics


EVS

  • Results :

  • Immediate vitrectomy only beneficial to pts p/w VA PL or worse.

  • No additional benefit of intravenous antibiotics.


Literature review on delayed onset post-operative endophthalmitis

  • Mainly related to glaucoma filtering surgery

  • Bleb related > tube implants

  • Risk factors for bleb related endophthalmitis:

    - blebitis

    - location of bleb ( inferior)

    - late onset bleb leakage

    - ? use of anti-fibrotic agents

    Average postop time til infection – 24.7 mths

    (Late-onset blebitis/endophthalmitis: incidence and outcomes with mitomycin C.Optom Vis Sci. 2004 Jul;81(7):499-504.)


Literature review cont’d

  • Late onset endophthalmitis a/w cataract Sx only – uncommon

  • (Late-onset endophthalmitis after cataract surgery caused by Propionibacterium acnes.J Hosp Infect. 1994 Aug;27(4):319-20.)

  • Case report of late onset Corynebacterium endophthalmitis following laser posterior capsulotomy

  • (Late-onset Corynebacterium endophthalmitis following laser posterior capsulotomy.Ophthalmic Surg Lasers Imaging. 2004 Mar-Apr;35(2):159-61.)


References

  • Late-onset blebitis/endophthalmitis: incidence and outcomes with mitomycin C.Optom Vis Sci. 2004 Jul;81(7):499-504.

  • Late-onset bacteria endophthalmitis following glaucoma drainage implantation.Ophthalmic Surg Lasers Imaging. 2003 Mar-Apr;34(2):128-30.

  • Incidence of late-onset bleb-related complications following trabeculectomy with mitomycin.Arch Ophthalmol. 2002 Mar;120(3):297-300.

  • Risk factors for glaucoma filtering bleb infections.Arch Ophthalmol. 2000 Mar;118(3):338-42.

  • Late-onset, bleb-associated endophthalmitis following glaucoma filtering surgery with or without antifibrotic agents.J Ocul Pharmacol Ther. 1999 Aug;15(4):283-93.


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