Dr. Sreedurga Kiranmayi Vinti,
V17724, Dr. Naresh Babu K, Dr. Kim Ramasamy
Endophthalmitis, defined as inflammation of one or more coats of the eye and adjacent cavities, is an uncommon potentially sight-threatening condition that varies geographically in incidence and in cause.
Postoperative endophthalmitis after cataract surgery is damaging, because it can lead to permanent vision loss . Cluster endophthalmitis can be defined as five or more cases of endophthalmitis occurring on a particular day in a single operating room in one centre.
AIM :
To study treatment outcomes for post cataract endophthalmitis caused by Pseudomonas aeruginosa managed in a tertiary eye care centre.
METHODS :
Analysis of 6 eyes of 6 patients referred with acute postoperative endophthalmitis. The interval between surgery(SICS+IOL) and onset of symptoms was 3 days.
Diagnosis of endophthalmitis was made on the basis of symptoms of ocular pain, redness and
decreased visual acuity, and signs of hypopyon and/ or vitreous exudates on slit lamp bio-microscopy. Intraocular pressure (IOP) was also recorded. Ultrasonography of the eye was done in all cases to assess the extent and location of vitreous involvement and rule out retinal detachment and choroidal detachment. On ultrasonography, all of the eyes had echo dense opacities in the
anterior and mid vitreous.
All patients underwent an emergency core vitrectomy with intravitreal injection of 1mg/0.1ml of Vancomycin ; 2.25mg/0.1ml of Ceftazidime and 0.4mg/0.1mlDexamethasone. Silicon oil injection was done in one case. In addition, the vitreous aspirate was sent for microbiological examination and culture. Microbiological examination of the vitreous specimen obtained from the vitrectomy revealed Pseudomonas aeruginosa sensitive to piperacillin.
The postoperative regimens included topical administration of Piperacillin 2% and Fortified Ceftazidime 5% every hour , topical predacetate 1% every 6 hours; oral prednisolone 40mg for 7 days ; intravenous injection of Piperacillin – Tazobactum 12g every 8 hours and Cefotaxime 500mg every 12 hours.
Subsequently repeat vitrectomy and intravitreal piperacillin- tazobactum(225µg/0.1ml) & ceftazidime(2.25mg/0.1ml) was done for 2 patients depending upon the clinical response.
RESULTS :
Of the 6 eyes in the study , 4 eyes were left eye (66.66%) and 2 (33.33%) were right.The average age was 58.33yrs (range 50 -65 years). Initial vision was PL only in 5/6 eyes (83.33%) and HM in 1/6 eyes (16.66%) Final visual acuity was 6/18 in 1 eye , 6/24 in 1 eye, 6/60 in 1 eye, 4/60 in 1 eye, 1/60 in 1 eye and PL only in 1 eye. 3 of 6 eyes (50%) had 6/60 or better vision. The patient with silicon oil injection at the time of core vitrectomy showed the best recovery in visual acuity. The 2 eyes with poor visual outcome had severe corneal involvement.
DISCUSSION :
Pseudomonas aeruginosa is a common pathogen causing post cataract endopthalmitis. Generally the visual prognosis is poor in Pseudomonas endophthalmitis despite of the treatment with intravitreal antibiotics even in cases in which the isolates were sensitive or partially sensitive. In our series of 6 patients, 50% patients could regain 6/60 or better vision and 33.33% had moderate visual outcome.
CONCLUSION :
Post cataract endophthalmitis due to Pseudomonas aeruginosa can have good outcome, provided aggressive treatment with vitrectomy and multiple antibiotic injections could be performed. Severe corneal involvement at presentation had poor outcome.
To conclude intravitreal injection of piperacillin and tazobactam could be effective in the management of multi-drug-resistant endophthalmitis caused by gram-negative bacteria