POST-OPERATIVE INFECTIVE ENDOPHTHALMITIS AUDIT

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POST-OPERATIVE INFECTIVE ENDOPHTHALMITIS AUDIT
Dr G Papanikolaou Mr G. Zohdy Mr J
Roberts-Harry DEPARTMENT OF OPHTHALMOLOGY WEST
WALES GENERAL HOSPITAL CARMARTHEN
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BACKGROUND
Acute onset endophthalmitis post catact
surgery Frequency 7-8/10,000 lt 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
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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.
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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 PPHAVH 903
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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
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RESULTS II CONSULTANT IN CHARGE 6
DJ 3JRH SURGEON 6/9 identified 3 no record 4
Consultant 2 Middle grade
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RESULTS III AGE Mean 83.7y ( only 1
lt80) SEX F 8, M 1 TYPE OF CARE DC 8, IP
1 EYE 1st 5, 2nd 4
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RESULTS IV PRE-OP VA 1 no data 5 lt 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
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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)
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RESULTS VI
MICROORGANISM 66,6 Str. Pneu 3 Staph aureus
1 Str. Viridans 1 G () 1
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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)
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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
suturesIP, 1ECCE (planned), 1 IP
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RCOPHTH TREATMENT GUIDELINES
EVS STUDY (VA) gtLP 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
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PREVENTION STANDARD BETTER THAN TREATMENT Pre-op
selection of patients (blepharitis, mucocoele,
conjuctivitis treated pre-op) PREASSESMENT Povidon
e Iodine 5 pre and post op (5 min) Antibiotics
on irrigating solutions condemned No vancomycin
if I/C antibiotics Post-op Maxitrol/ other
combination
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PROPHYLACTIC MEASURES INSTITUTED

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

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HIGH RISK PATIENTS

1. gt80
2. Immunosuppresssed
3. DM
4. Colostomies
5. Complicated surgery
6. Pressure sores/ leg ulcers
7. KC, atopy, psoriasis
8. Residential homes

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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 (steroidsantibioticsat
  ropine)
• Tab Ciprofloxacin 750mg bd