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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

GRAND WARD ROUND

Dr Heng Li Wei

Dept of Ophthalmology, TTSH

23rd May 2007

history
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
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 findings4
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?
slide5
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
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 progress10
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.
post op progress11
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 progress12
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.
slide13
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
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
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
Endophthalmitis

Endogenous vs Exogenous

endophthalmitis vitrectomy study
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
slide19
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

slide20
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
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
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
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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