Divya, Alex (2015) Clinical Study on Endophthalmitis. Masters thesis, Madras Medical College, Chennai.
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Abstract
AIM OF THE STUDY: 1. To evaluate the clinical presentations and assess visual outcomes of Endophthalmitis. 2. To evaluate the various etiological factors and predisposing factors leading on to endophthalmitis. 3. To assess the clinical presentation in different types of endophthalmitis. 4. Whether the treatment is controlling or eradicating the infection and giving symptomatic relief to the patient. 5. Whether the treatment is preventing secondary complications such as panophthalmitis. 6. To assess efficacy and visual outcome after medical and surgical intervention (including intravitreal antibiotics and PPV). MATERIALS AND METHODS: For all 50 patients included in the study, a detailed history was taken with special emphasis on the mode of insult including intraocular surgeries, trauma, focal sepsis and systemic diseases. All patients included in the study were evaluated first by measuring the visual acuity using Snellen’s chart. Anterior segment was thoroughly examined by slit lamp biomicroscopy. Posterior segment was examined with indirect ophthalmoscope. Vitritis grading was done for all the patients. Ultrasound (B scan) was done for all patients to confirm the diagnosis, to rule out intra ocular foreign body and to rule out associated choroidal or retinal detachment. All basic necessary investigations such as random blood sugar, blood pressure, complete hemogram, X-ray orbit was done. General examination with special emphasis to rule out septic foci such as dental caries, dacryocystitis were also done. Vitreous tap was taken from all the patients and was subjected for grams stain, KOH stain and culture and sensitivity. METHODOLOGY: PATIENT SELECTION: All cases (including referred cases from outside) attending the ophthal department with typical signs and symptoms of endophthalmitis during the study period October 2013 to August 2014 were registered, evaluated, managed and followed up. INCLUSION CRITERIA: A series of 50 patients with typical symptoms and signs of endophthalmitis such as loss of vision, anterior segment and posterior segment findings which was confirmed with an Ultrasound report (B Scan). Both genders were included. Age was not as a part of this study. EXCLUSION CRITERIA: 1. Patients who were unwilling to undergo interventional therapy. 2. Patients who lost for follow up. SUMMARY: Out of the 50 cases of endophthalmitis included in our study, 24 cases were from our institution. 26 cases were referred from other hospitals. Four different entity of endophthalmitis were included in the study namely post-operative, post traumatic, perforated corneal ulcer (with no history of ocular trauma) and endogenous endophthalmitis. Post-operative endophthalmitis was more common after small incision cataract surgery. (50%) were postoperative, (44%) were post traumatic, (4%) were secondary to perforated corneal ulcer and (2%) was endogenous endophthalmitis. Post-operative endophthalmitis was more common after small incision cataract surgery (44%) followed by phacoemulsification cataract surgery (20%). PC Rent with vitreous loss was documented in 32% of the cases which is a strong risk factor for the development of endophthalmitis. 3 out of 5 Phaco surgeries were associated with clear corneal sutureless incision. The same is a risk factor for the development of endophthalmitis. 44% of the cases were secondary to post trauma. Majority of the cases were associated with injury in a contaminated environment such as road traffic accident. There was a slight preponderance in the incidence of endophthalmitis in males. 58% as compared to females (42%). 48% of the cases had acute onset endophthalmitis. 10% intermediate onset and 32% presented with delayed onset endophthalmitis. All postop endophthalmitis cases secondary to Anti glaucoma surgery, Penetrating Keratoplasty, internal RD surgery (other than cataract surgery) had delayed onset endophthalmitis. 62% of the post traumatic cases presented with acute onset endophthalmitis. The incidence of post-traumatic endophthalmitis was most common in age group less than 40 years. Maximum incidence of post-operative endophthalmitis was between 51 and 70 years, which is the most common age group undergoing cataract surgery. There was an increased incidence of endophthalmitis in association with systemic diseases as diabetes mellitus. 20% had diabetes. 12 % of the cases were associated with focal sepsis. 34% of the cases were culture positive. The most common organism isolated was gram positive cocci Staphylococcus Epidermidis (coagulase negative staphylococci). 4 cases were associated with Aspergillus species (2 cases Post-Operative and 2 cases Post Traumatic of which 1 patient had retained intraocular foreign body). All the cases were highly resistant to treatment. Vitreous culture and sensitivity was found to be more specific and sensitive compared to vitreous smear positivity. Culture positivity was associated with poor treatment outcome and poor visual recovery. Ultrasound (Bscan) confirmed the diagnosis in all cases. B scan also aided in ruling out associated pathologies such as choroidal detachment. Retained intra ocular foreign body was picked up in2 cases. 4 patients underwent evisceration was associated with highly virulent organisms such as pseudomonas and aspergillus. Patients who had better visual acuity at the time of presentation, final visual acuity was also better. Patients who presented relatively late (more than 1 week) of having the symptoms had poor visual outcome. The patients who had dense vitritis of grade 1V or V had poor visual outcome. Systemic steroids were found to give symptomatic improvement in the patients. Intravitreal antibiotics helped in containment of the infection to a limit even though the visual recovery was highly unpredictable. 8 patients underwent core vitrectomy. Of which 5 patients had poor visual recovery, 2 had satisfactory and 1 had good visual recovery. Visual recovery is highly variable in cases of endophthalmitis. 24% of the total cases had satisfactory visual recovery and 8% of cases had good visual recovery. Post-operative endophthalmitis patients had better prognosis than other categories of endophthalmitis. The more the duration between the onset of symptoms and the initiation of the treatment, poorer the visual outcome. CONCLUSION: Even in this era of recent advances and technologies, endophthalmitis still remain as a devastating complication of intraocular surgeries and ocular trauma. Post-operative endophthalmitis remains the most common followed by post traumatic endophthalmitis. Incidence of endogenous endophthalmitis have considerably decreased. Gram positive organisms are the most common isolate in culture. The incidence of fungal endophthalmitis have slightly increased and are found to be more resistant to treatment. Patients who had better visual acuity at the time of presentation, final visual acuity was also better. Patients who presented relatively late (more than 1 week) of having the symptoms had poor visual outcome. The patients who had dense vitritis is associated with poor visual recovery. Those patients with positive culture and infection with highly virulent organisms had poor visual outcome. Post-operative endophthalmitis patients had better prognosis than other categories of endophthalmitis. The more the duration between the onset of symptoms and the initiation of the treatment, poorer the visual outcome.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Endophthalmitis : Clinical study. |
| Subjects: | MEDICAL > Ophthalmology |
| Depositing User: | Devi S |
| Date Deposited: | 06 Oct 2018 14:53 |
| Last Modified: | 06 Oct 2018 14:53 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/9683 |
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