POST-OPERATIVE INFECTIVE ENDOPHTHALMITIS AUDIT

1. POST-OPERATIVE INFECTIVE ENDOPHTHALMITIS AUDIT Dr G Papanikolaou Mr G. Zohdy Mr J Roberts-Harry DEPARTMENT OF OPHTHALMOLOGY WEST WALES GENERAL HOSPITAL CARMARTHEN

2. BACKGROUND Acute onset endophthalmitis post catact surgery Frequency: 7-8/10,000 < 6/52 post-op Pathogens: endogenous flora [ Staph., Strept., G(-) ] Symptoms and signs: Pain, loss of vision, swelling or redness of the eye and discharge, even asymptomatic. Injection or chemosis, corneal oedema, flare and cells, hypopyon, fibrin clot, RAPD, Vit cells or abscess, no view of posterior segment, sheathing of vessels IF IN DOUBT TREAT AS ENDOPHTHALMITIS

3. OBJECTIVES • to compare frequency to national standards (RCOPHTH) • to compare prevention and treatment to the national standards • to assess patient profile • to assess surgeon profile • to evaluate the results of treatment Conducted because of 4 cases within 4 months of moving to new day case site.

4. MATERIAL AND METHODS • Period: May 2000- April 2002 ( Casualty book) • Total No: 10 (1 private hospital) • No. available: 9 • Data sheet Total No. of operations: 3,166 WWGH: 2,263 PPH+AVH: 903

5. RESULTS I FREQUENCY: Total: 9/3,166 (28.4/10,000) WWGH: 3/2,263 (13.25/10,000) PPH: 6/903 (66.5/10,000) 1 Private hospital PRESENTATION: Mean: 7.7 days Range: 1-28 d If outliers excluded 4.4 days

6. RESULTS II CONSULTANT IN CHARGE: 6 DJ 3JRH SURGEON: 6/9 identified 3 no record 4 Consultant 2 Middle grade

7. RESULTS III AGE: Mean: 83.7y ( only 1 <80) SEX: F: 8, M: 1 TYPE OF CARE: DC: 8, IP: 1 EYE: 1st: 5, 2nd: 4

8. RESULTS IV PRE-OP VA: 1 no data 5 < 6/36 3 6/18, 6/12, 6/24 VA ON ADMISSION: NLP: 4 HM: 2 PL: 3 VA DISCHARGE: 5 better, 1 worse, 3 no change but none better than CF

9. RESULTS V VA ON FU COMPARED TO DISCHARGE: 4/9 improvement (45%) 2/9 worse (22%) 3/9 same (33%) Finally 2 patients have better VA than pre-op so far!! ACTIVE INFECTION/ IMMUNOSUPRESSION: 45% Risk factor 1: blepharitis (preassessment) 2: DM 1: steroids 1: colostomy (-ve vit. culture)

10. RESULTS VI MICROORGANISM: 66,6% Str. Pneu: 3 Staph aureus: 1 Str. Viridans: 1 G (+): 1

11. RESULTS VII MANAGEMENT: Vit tap: 7/9 (78%) 5 positive result (71%) No enucleations Tertiary Refs: 1 (on FU) Inpatient: mean 12.7 days (range: 7-25) No of FU: mean 4.85pp (data 8/9)

12. RESULTS VIII PERIOPERATIVE ANTISEPSIS: 6/9 PI 3/9 no data POST-OP: 7/9 Maxitrol 2/9 No data VARIATION/COMPLICATION: 1 no data 3/8 ( 37.5%): 1 sutures+IP, 1ECCE (planned), 1 IP

13. RCOPHTH TREATMENT GUIDELINES EVS STUDY (VA) >LP: Vit tap + intravitreal antibiotics iv antibiotics of no advantage Repeat Vit tap after 48-72h if needed LP: TPPV No intensive topical antibiotics (wound problems/ keratitis) ? Intravitreal steroids 60- 80mg systemic steroids reducing to zero over 7-10/7 NO FUNGAL INFECTION Vit tap: OPD ASAP/ OPD FU

14. PREVENTION STANDARD BETTER THAN TREATMENT Pre-op selection of patients (blepharitis, mucocoele, conjuctivitis treated pre-op) PREASSESMENT Povidone Iodine 5% pre and post –op (5 min) Antibiotics on irrigating solutions: condemned No vancomycin if I/C antibiotics Post-op: Maxitrol/ other combination

15. PROPHYLACTIC MEASURES INSTITUTED • PI 1 drop pre-op to all patients • Routine dipstick urinalysis to all • Exclude patients with overt infection • High risk patients to receive I/C antibiotics • Swab the bottles of PI and Trusopt at beginning and end of list • FU within 1 week • Maxitrol tds 2/52

16. HIGH RISK PATIENTS • >80 • Immunosuppresssed • DM • Colostomies • Complicated surgery • Pressure sores/ leg ulcers • KC, atopy, psoriasis • Residential homes

17. RECOMMENDED MANAGEMENT • Vitreous and A/C tap to all ASAP+ repeat in 2-3/7 • Tab Clarithromycin 500mg bd in culture (-) cases • Systemic steroids from day 2 for 10 days • Intensive local treatment (steroids+antibiotics+atropine) • Tab Ciprofloxacin 750mg bd