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  1. GRAND WARD ROUND Dr Heng Li Wei Dept of Ophthalmology, TTSH 23rd May 2007

  2. 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.

  3. 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

  4. 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?

  5. 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.

  6. 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.

  7. Post-op Photos

  8. Post-op Progress • Rx : T. Ciprofloxacin 500mg bd G cefazolin 50mg/ml Q1H G gentamicin 14mg/ml Q1H 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.

  9. 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.

  10. 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.

  11. 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)

  12. 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.

  13. 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.

  14. Endophthalmitis Endogenous vs Exogenous

  15. 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

  16. 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

  17. EVS • Results : • Immediate vitrectomy only beneficial to pts p/w VA PL or worse. • No additional benefit of intravenous antibiotics.

  18. 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.)

  19. 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.)

  20. 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.