WELCOME

SYMPOSIUM OF

BSCRS

What happens?

ENDOPHTHALMITIS

POST OPERATIVE

STOP ITNO

DIAGNOSIS &PROPHYLAXIS OF

POST OPERATIVE ENDOPHTHALMITIS

Prof.A.S.M.Kamal Uddin

DIAGNOSIS

•Clinical examination•Conj.swab•AC tap/Vit tap

ESCRS meta analysis

CNS (coagulase-negative staphylococci)

33 - 77 %

BHS (ß-haemolytic streptococci), S. pneumoniae, ∂-haemolytic streptococci including S. mitis and S. salivarius

9 - 19 %

Staphylococcus aureus 10 - 21 %

Gram-negative bacteria including Ps. aeruginosa (occurs rarely)

6 - 22 %

(Candida sp., Aspergillus sp., Fusarium sp.)

8 %

SUMMARY

29%- 43% intraocular contamination occurs with facultative pathogenic bacteria Sherwood, D. R., Rich, W. J., Jacobs, J. S., Hart, R. J., Fairchild, Y. L.: Bacterial

contamination of intraocular and extraocularfluids during extracapsular cataract extraction. Eye 3, 1989, 308 - 312

Only 0.3-0.015% Post operative endophthalmitis

Significant % of apparent endoph cases Culture -VE

SUMMARY

75%-95% of reported cases Gm +ve Ophthalmology 1999;106:1869-77

Causative organisms after cataract Sx-Usually genetically Identical to Pt’s own floraArch Ophthalmol1997; 115:357-361

8% Fungus

BANGLADESH (IIEH)

Organism 2012No organism 140Gm +ve cocci 02Gm+ve bacilli 19fungus 15Total 180

ENDOPHTHALMITIS

HOST RESISTANC

E

MICROBIAL POPULATION

VIRULANCE

29 – 43%

0.3-.015%

INCIDENCES ( phaco era) escrs 2007

PE SCENARIO ESCRS meta analysis

1910 10.001970- 1990 0.12 (Europe)

0.072 (USA)2000 - 0.3 – 0.015

INCIDENCES (BANGLADESH)Month 2011 2012 2013January 17 3 39February 4 1 13March 3 1 18April 1 1 25May 5 0 27June 0 0 13July 4 0 28August 1 10  September 1 20  October 17 48  November 22 68  December 13 39    88 191 155

RISK FACTORSSwedish National Cataract Register collected from 2002-2004 & 2005-2010

History 2002 -2004

2005-2010

Patient age (yrs)0–84 _>85

76/187 797 (0.040%)32/37 673 (0.085%)

104/393 298 (0.026)31/71 483 (0.043)

Type of surgeryPhaco with IOLOther than phaco with IOL†

101/220 658 (0.046%)6/4107 (0.146%)

128/459 640 (0.028)7/5221 (0.13)

Incision typeSclerocorneal Clear corneal

27/74 087 (0.036%)80/151 182 (0.053%)

Intracameral cefuroximeGiven Not given

100/223 156 (0.045%)8/2315 (0.350%)

123/461 951 (0.027)11/2804 (0.39)

Communication with vitreousAbsent Present

93/219 655 (0.042%)14/5790 (0.242%)

127/456 973 (0.028)8/7888 (0.1)

RISK FACTORS

Older age of patientPreoperative topical antibioticsPovidone IodineMore time more manipulationVitreous face breakdownPhaco vs SICSCCI vs scleral incision Intra cameral injectionSubconj inj. Of Antibiotics.

FLOW CHART – PROPHYLAXIS GUIDELINES(Based on the results of ESCRS multi-centre study as well as Healy et al.)

1• Topical

antibiotics 24 or 48 hours prior to surgery

2• Apply topical

antibiotic 1 hour and half-hour prior to surgery

3• Povidone iodine

minimum of three minutes

4• Apply 10 per cent

povidone iodine to the peri-orbital area

5 • Surgeon washes hands properly

6 • Gloves and gowning properly

7• Apply surgical drapes

properly

8• Perform

phacoemulsification surgery.

• Use foldable IOLs with sterile injector

9 •Apply inj cefuroxime (0.9 per cent) by intra-cameral injection at the end of surgery.

10• Antibiotics in the

irrigation fluid not encouraged

11• Re-apply topical

antibiotics at the end of surgery

12

• Use of subconjunctival antibiotic is not thought to offer effective prophylaxis

PITFALLS

OR protocolPatient relatedOT personal related OT assistant

OR PROTOCOL

operating room (OR) layout and disinfection

sterile surgical protocolsterilisation of instruments

Operating Room (OR) Layout and Disinfection Protocol

a)The outer zone b)The clean zone c)The aseptic

zone d)The disposal

zone

Ventilation

The current United States Public Health Service minimum requirements:

Temperature between 18-24°C, Humidity 55-80%, and 25

changes per hourBacterial count of air should not

exceed l/ft3(35.5/m3).

STERILE SURGICAL PROTOCOL

Air flow /AC ,Fan OT sterilization Oversrowding

STERILE SURGICAL INSTRUMENTS

PATIENT RELATED

• Select appropriate pt.

• Antibiotics prophylaxis

• Proper cleaning• Povidone iodine

OT PERSONAL

•Cap masking

GowningGloving

OT ASSISTANT

Disposables undraping

OT ASSISTANT

Fluid soaked trolly

OT ASSISTANT

Draping

MODE OF INCIDENCE

ClusterEndemi

c Isolated

Weakness of the

protocol

Disposables (liquid)

Sterilization failure

INCIDENCES (BANGLADESH)Month 2011 2012 2013January 17 3 39February 4 1 13March 3 1 18April 1 1 25May 5 0 27June 0 0 13July 4 0 28August 1 10  September 1 20  October 17 48  November 22 68  December 13 39    88 191 155

WHAT BSCRS CAN DO?

Task force – to trace out evidence

Information – through SMS/website etc

Microbial study of each lot of disposables

ETO sterilization plantEndophthalmitis study

THANK YOU

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