In The Name of God

1. In The Name of God

2. Infectious Endophthalmitis Symptoms ,Signs, Differential Diagnosis MR.Ansari MD

3. Infectious endophthalmitis is a condition in which the internal structures of the eye are invaded by replicating microorganisms . • Exogenous endophthalmitis occurs when the outer wall of the eye sustains a break as a result of surgery or trauma. • Exogenous endophthalmitis is the most common subtype. • 90% of all cases are caused by bacteria.

4. In certain clinical settings ,there is an increased likelihood of infection by certain groups of bacteria . • Endophthalmits following cataract surgery is most often caused by staphylococcus epidermidis. • Injured eyes → Gram-positive Bacillus spp.

5. Allen reviewed 30000 ICCE from 1964 to 1977 and found an incidence of endophthalmitisof 0.057% . Review of 23625 cases of ECCE in Bascom Palmer Eye Institute revealed an incidence of 0.072% Phaco→incidence of 0.03% to 0.04% In Sweden & Norway →0.1% to 0.16% Following open globe injuries→4.2% to 7% .

6. Symptoms of Acute Endophthalmitis ( within 6 weeks ) • Sudden increase in pain 1-7 days after surgery . • ↓VA • Redness and conjunctival injection. • Lid swelling

7. In EVS 98% with acute endophthalmitis presented with one or more of the four classic symptoms. • ↓VA ( 93% ) • Conjunctival injection ( 81% ) • Pain ( 75% ) • Lid swelling ( 33% )

8. Signs of acute endophthalmitis • In fulminant cases conjunctival chemosis and increased injection often with a significant amount of yellowish exudates in the conjunctival cul - de - sac • Edematous lids often difficult to open • Corneal edema ( variable degrees ) • Pigmented cells may accumulate on its posterior surface of cornea. • Surgical wound may show signs of dehiscens and in advanced cases exudates can stream from the wound.

9. AC reaction ( heavy flare and cells ) • Hypopyon ( mixed with a tinge of red blood ) • Fibrin membrane is usually present over both surfaces. • Heavy cellular debris is present in the vitreous . • Focal accumulations of whitish material or sheets of opacification within the vitreous .

13. IOP → low , normal or high . • Pupil often dilates poorly . • Retinal prephlebitis has been reported an early sign but in most cases the retinal vessels are seen poorly . • Red reflex ?

14. Notice to risk factors • Leakage of wound • Rupture of posterior capsule • Vitreous wick • Time of operation • Diabetes mellitus • Cutting of sutures too early • A case – control study demonstrated a threefold greater risk of endophthalmitis with clear corneal incisions than with scleral tunnel incisions .

15. Continuation • Temporal incisions were noted to have a higher incidence of infection than superior incision . • Transcleral suture fixation of posterior – chamber IOL. • Polypropylene haptics • Preoperative eyelid abnormalities and blepharomeibomitis . • Re – entry of the eye through a previous wound .

18. Differential Diagnosis • Postoperative inflammation • Retained lens material →respond to corticosteroids. • Chronic , low grade endophthalmitis may occur secondary to coagulase – negative Gram – positive organisms such as s.epidermidis and also result from infections with the anaerobic species Propionibacterium acnes . ( 40% of cases ) • Propionibacterium can present with mild iritis and pigmented KP .

19. Continuation • On examination , the most common findings are vitritis , white plaques on the posterior capsule or the IOL , beaded fibrin strands , hypopyon ?,granulomatous KP .

20. TASS • Toxic substance enters the anterior chamber • Causes Acute sterile postoperative inflammation • Photophobia , ↓VA , corneal edema and marked anterior chamber reaction with hypopyon • TASS presents within hours of surgery • Pathologic changes limited to AC • Pain is much less than that of endophthalmitis • ↑IOP • Tainted BSS , reusable double cannula , se of preserved solution , subconjunctival injection near the wound .

21. Thank you for your attention