|Year : 2004 | Volume
| Issue : 1 | Page : 65-66
First contact management of post-operative endophthalmitis. A retro-spective analysis
L Verma, R Patil, D Talwar, Hem K Tewari, K Ravi
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Records of 37 consecutive patients of postoperative endophthalmitis referred to our centre from North India were retrospectively analysed to study the first contact management profile. Ten (27%) patients had received intravitreal antibiotics as a primary mode of treatment, and 27 (73%) had received only parenteral antibiotics. The outcome was worse in the latter group. This suggests that general ophthalmologists lack the capability to provide adequate treatment to patients with endopthalmitis in Northern India.
Keywords: Endophthalmitis, management, first contact
|How to cite this article:|
Verma L, Patil R, Talwar D, Tewari HK, Ravi K. First contact management of post-operative endophthalmitis. A retro-spective analysis. Indian J Ophthalmol 2004;52:65-6
|How to cite this URL:|
Verma L, Patil R, Talwar D, Tewari HK, Ravi K. First contact management of post-operative endophthalmitis. A retro-spective analysis. Indian J Ophthalmol [serial online] 2004 [cited 2019 Aug 24];52:65-6. Available from: http://www.ijo.in/text.asp?2004/52/1/65/14625
Postoperative endophthalmitis is the most frequently encountered form of endophthalmitis in a clinical setting. The Endophthalmitis Vitrectomy Study (EVS) has established guidelines for the management of post-cataract/post-secondary IOL endophthalmitis. At present, intravitreal injection of antibiotics (IOAB) constitutes the main treatment modality in patients of postoperative endophthalmitis. Pars plana vitrectomy is recommended for patients with a more severe infection and an initial visual acuity of light perception only. Despite the recommended initial management, many patients when first seen at our centre either present with advanced disease or appear to have not received adequate treatment. This study looks at the first contact management profile of cases with postoperative endophthalmitis in northern India in this post-EVS era.
| Materials and methods|| |
A retrospective analysis was conducted of 37 consecutive referred patients presenting at our tertiary care centre from North India with presumed acute bacterial postoperative infective endophthalmitis, between November, 1999 and May 2000. The signs and symptoms used to diagnose endophthalmitis included pain, gross diminution of vision, redness, lid swelling, corneal oedema/infiltration, increased anterior chamber reaction, vitreous cells and poor or absent red reflex. Medical records were reviewed with particular reference to the predisposing event and the first contact management. At our institute, patients were managed with IOAB alone or with pars plana vitrectomy and IOAB. The IOAB consisted of vancomycin (1 mg in 0.1 ml) and ceftazidime (2.25 mg in 0.1 ml) administered sequentially and slowly into the mid-vitreous cavity using a 26 G needle. Vitreous obtained by vitreous tap or biopsy during pars plana vitrectomy was cultured and sensitivity tested according to the guidelines laid down by EVS.1 The data were analysed using the Pearson's correlation test.
| Results|| |
Twenty-three of 37 patients included in the study, (62.16%) were male and in 48.65% (18/37) patients the right eye was involved. The mean age was 60.51±10.72 years (range 30-80 years). The most common predisposing event was extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation, in 62.16% (23/37) patients. Intracapsular cataract extraction (ICCE) (10.81%), phacoemulsification with IOL implantation (10.81%), trabeculectomy (10.81%) and penetrating keratoplasty (5.4%) were the other predisposing surgical events.
In 78.3% (29/37) patients, independent practitioners were first contacted. The remaining 21.7% (8/37) patients, independent practitioners were referred from multi-specialty private hospitals and medical colleges. The mean duration from the onset of symptoms to the first contact was 5.23 days (range 1-14). The mean interval between the first contact and presentation to our hospital was 11.46 days. The chief complaint of presentation at our center was diminution of vision in 83.7% (31/37) patients, with absence of light perception in 6 patients. As recorded by the referring physician the initial visual acuity was light perception in 19 (67.5%) patients.
Only 27% (10/37) of patients had received IOAB. The remaining 73% (27/37) had received a combination of topical and parenteral antibiotics. Patients who had received only parenteral antibiotics had a significantly higher incidence of loss of light perception (5/27) compared to those who had received IOAB (1/10) (P<0.05).
Of the 31 patients (excluding the six who had no light perception), 70.9% (22/31) received vitrectomy and IOAB while 29.1% (9/31) patients received IOAB only at our centre. Of the nine patients who had received IOAB at first contact (excluding one patient who had no perception of light), 66.6% (6/9) achieved a final visual acuity of ž 6/60. Of the 22 patients who had received systemic antibiotics only at first contact (excluding five patients who had no perception of light), only 31.8%
(7/22) achieved a final visual acuity of ž 6/60 (P<0.05).
| Discussion|| |
The guidelines for the management of post-cataract surgery endophthalmitis have been well established by the EVS. It has been recommended that patients with post-cataract/post-secondary IOL endophthalmitis with an initial visual acuity of hand movements receive IOAB, and vitrectomy should be offered to those with a presenting visual acuity of light perception or less. The present analysis shows that the first contact management of patients with postoperative endophthalmitis in Northern India is inadequate. Only 27% (10/37) patients in the present analysis had received an IOAB prior to referral. Delay in institution of adequate treatment is known to adversely affect the outcome. This explains in why more patients in the latter group had no light perception on presentation.
Systemic and topical antibiotics are advocated as an adjuvant therapy in the management of exogenous endophthalmitis. Though the EVS showed no significant benefit with adjuvant systemic antibiotic therapy, there has been a debate regarding the choice of antibiotics used in the study. At present, systemic and periocular antibiotics may be considered at best to have an adjunctive role.
In the EVS, visual acuity of 6/60 or better was achieved in 77.7% of patients in whom the presenting visual acuity was hand motions or more. In our study, the presenting visual acuity at first contact was not always known. However, in the final analysis a statistically significant number of those patients who regained a final visual acuity of ž 6/60 had received IOAB as a primary therapy (66.6%), compared to those who had not (31.8%). Despite the inherent weakness of a retrospective study, our results demonstrate that the first contact care of patients with postoperative endophthalmitis is grossly lacking. This retrospective anlysis reemphasises the need to administer an intravitreal antibiotic as soon as the diagnosis of postoperative endophthalmitis is made and if not, the patient should be referred to a proper centre without further delay.
| References|| |
Endophthalmitis Vitrectomy Study Group. A randomized trail of immediate vitrectomy and of intravenous antibiotics for the management of postoperative endophthalmitis. Arch Ophthalmol
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Experimental aspects and their application. Ophthalmol
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Haimann MH, Weiss H, Miller J. Endophthalmitis Vitrectomy Study (Comment). Arch Ophthalmol