CLINICAL MANAGEMENT GUIDELINES

Endophthalmitis (post-operative) (Exogenous endophthalmitis)

Endophthalmitis (post-operative) Exogenous endophthalmitis Version 9 16.09.11 1 of 2

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Aetiology History of ocular surgery eg cataract, corneal, glaucoma, retinal Bacterial endophthalmitis occurs after 1.4:1,000 cataract operations Organisms (examples only, in descending order of frequency):

Staphylococcus sp. (approx 70% of culture-positive cases)

Streptococcus sp.

Pseudomonas sp.

Proteus sp.

fungi Onset may be acute (in first week) or chronic (in first month) Post-operative endophthalmitis may also be non-infective (retention of foreign material, eg cotton fibres, or caused by toxic substances, eg component of unsuitable irrigating fluid)

Predisposing factors Sources of contamination:

patient’s own bacterial flora (skin, lids, conjunctiva, lacrimal apparatus)

contaminated instruments, solutions, drapes, dressings, gloves

(in corneal transplants) donor cornea Patient factors:

diabetes, immunosuppression, HIV infection

Symptoms Acute presentation:

visual loss

pain

redness

photophobia Chronic presentation: similar, usually milder, delayed

Signs Acute presentation:

lid oedema

conjunctival chemosis and hyperaemia

corneal haze

cells and flare in AC; fibrinous exudate and/or hypopyon if severe

pupil light reflex may be sluggish or absent

IOP can be normal, low or raised

vitritis (inflammation of the vitreous) may eliminate red reflex and preclude view of fundus

Chronic presentation: similar, usually milder, delayed

Differential diagnosis Post-operative inflammation without infection Other causes of acute red eye, for example acute anterior uveitis Vitreous haemorrhage

Management by Optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere Non pharmacological None

Pharmacological None

Management Category A1: emergency referral to Ophthalmologist, no intervention. Telephone on-call Ophthalmologist Acute bacterial endophthalmitis is a rare but severe sight-threatening complication of ocular surgery

Possible management by Ophthalmologist

Admission to hospital Ultrasound scan Anterior chamber/vitreous tap, or vitrectomy (see evidence base),

CLINICAL MANAGEMENT GUIDELINES

Endophthalmitis (post-operative) (Exogenous endophthalmitis)

Endophthalmitis (post-operative) Exogenous endophthalmitis Version 9 16.09.11 2 of 2

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followed by microbiology of specimen Antibiotics: topical, subconjunctival, intravitreal, systemic as indicated Steroids: topical, intravitreal, systemic as indicated

Evidence base Flynn HW, Scott IU: Legacy of the Endophthalmitis Vitrectomy Study.

Arch Ophthalmol 2008;126:559-61 Authors’ conclusion: When patient’s presenting visual acuity was HM or better, there was no difference in visual outcomes whether or not an immediate pars plana vitrectomy was performed. When presenting visual acuity was PL, immediate pars plana vitrectomy was associated with a three-fold increase in the frequency of achieving 6/12 or better acuity. Endophthalmitis Study Group. European Society of Cataract and Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007;33:978-88 Authors’ conclusion: Use of intracameral cefuroxime at the end of surgery reduced the occurrence of postoperative endophthalmitis (The Oxford 2011 Levels of Evidence = 2)