84 Year Old with Rosacea

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Griselda Mills
6 years ago
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84 Year Old with Rosacea S/p tap and injection of intravitreal vancomycin, ceftazidime, dexamethasone Post-injection day#1 Va HM IOP 14 mmhg Post-injection

1 84 Year Old with Rosacea S/p tap and injection of intravitreal vancomycin, ceftazidime, dexamethasone Post-injection day#1 Va HM IOP 14 mmhg Post-injection week#3 BCVA 20/20-3 (plano x 180) IOP 23 mmhg Cx results: Staphylococcus epidermidis Resistant to PCN/Sensitive to Vancomycin and 4 th generation FQs

2 Acute-Onset Endophthalmitis Following Cataract Surgery Clear cornea phacoemulsification 7 of 14,729 (0.05%) All other cataract surgery methods 1 of 4904 (0.02%) [p=0.692] BPEI Study

3 Prevention

4 Acute-Onset Endophthalmitis Following Cataract Surgery Risk factors for endophthalmitis Systemic immunosuppression (DM, PR) Intraoperative complications (vitreous loss) Perioperative factors (surface bacteria) Wound construction (wound leak; inferior wound placement) Chronic blepharitis BPEI Study

5 Endophthalmitis treatment in the setting of clear corneal incision Seidel test for potential wound leak Use peribulbar anesthesia for either vitreous tap or vitrectomy Obtain intraocular specimen 30-gauge needle for AC-tap (optional) 25 or 23-gauge needle for vitreous tap Intravitreal antibiotics

6 Isolates vs Visual Acuity Outcomes Percent 20/40 Isolates EVS BPEI Coag. neg. Staphylococcus 58.4% 59.1% Staphylococcus aureus 36.7% 17.0% Streptococcus species 13.0% 0.0% Enterococcus species 0.0% 0.0% Gram negative species 38.9% 0.0%

7 Endophthalmitis Caused by Staphylococcus epidermidis Methicillin Resistant 4 th Generation FQ Resistant Vitreous Tap/IOAB Vancomycin Sensitive VA HM VA 20/30

8 Acute-Onset Postoperative Endophthalmitis After Cataract Surgery Drug Vancomycin Ceftazidime or Amikacin Dose 1 mg in 0.1 ml 2.25 mg in 0.1 ml 0.4mg in 0.1 ml Dexamethasone 0.4 mg in 0.1 ml Intravitreal Therapy (Optional)

9 Macular Infarction after Intravitreal Amikacin 0.4mg Staphylococcus epidermidis

10 ESCRS study of prophylaxis of postoperative endophthalmitis Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW; ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg Mar;32(3):

11 Cataract Surgery Complications Retinal Detachment Endophthalmitis Retained Lens Fragments Cystoid Macular Edema Dislocated IOL

12 Retained Lens Fragments after Cataract Surgery

13 Retained Lens Fragments after Cataract Surgery Very hard nucleus Pseudoexfoliation Prior vitreous surgery Surgeon learning curve Patient movement

14 Retained Lens Fragments after Cataract Surgery Corneal edema Capsular rupture Poor vision Pain High Intraocular pressure TELL THE TREATING RETINA SPECIALIST!!

15 IOP 46 IOP 15 VA 20/400 VA 20/20

17 IOP 41 IOP 12 VA 20/40 VA 20/25

18 IOP 14 IOP 12 VA 20/60 VA 20/20

19 Retained Lens Fragments Primary Causes of Decreased Final Visual Acuity <20/ (44%) <20/ (20%) Cystoid macular edema 41 (29%) 16 (25%) Pre-existing ocular disease 34 (24%) 19 (29%) Corneal edema 22 (15%) 9 (14%) History of retinal detachment 19 (13%) 10 (15%) Epiretinal membrane 6 (4%) 2 (3%) Other (AMD, glaucoma, etc.) 21 (15%) 9 (14%)

20 Lens Fragments & CME Acute CME 25% of eyes Recurrent & Chronic CME common Average onset 4 months after surgery

21 Lens Fragments & CME Lens Framgents Total 167 Follow-up < 6 Months 55 Macular Disease 21 Study Eyes 91 No CME 68 (75%) CME 23 (25%) Acute 12 Recurrent 6 Chronic 5

22 Lens Fragments & CME Clinical CME ECCE Lens Frag Lens Frag PCIOL Lens Frag ACIOL

23 Cataract Surgery Complications Retinal Detachment Endophthalmitis Retained Lens Fragments Cystoid Macular Edema Dislocated IOL

24 Cystoid Macular Edema Clinical 2%, Agiographic 24%, OCT may be 50% Presentation 2 weeks 10 weeks Decrease vision, metamorphopsia Rarely uveitis DDx diabetic edema, pucker, AMD!

25 Cystoid Macular Edema

26 Cystoid Macular Edema

27 Cystoid Macular Edema Prophylaxis Do not use expensive newer drug for the routine prophylaxis Less-expensive NSAIDs or corticosteroids may be worth the cost for prophylaxis in higher risk patients Treatment First: Combination of topical NSAID (less-expensive variety) and topical corticosteroid Second: After 4 weeks to 6 weeks, we consider the use of a more expensive topical NSAID. Third: If no response is seen, then intravitreal corticosteroid should be considered. SHELSTA HN, JAMPOL LM, PHARMACOLOGIC THERAPY OF PSEUDOPHAKIC CYSTOID MACULAR EDEMA, 2010 Update, RETINA 31:4 12, 2011

28 Drug Quanity Price NSAID Acular LS 5 ML $200 Acuvail 60 Vials $424 Ketorolac 0.4% 5 ML $20 Ketorolac 0.5% 10 ML $40 Prolensa 3 ML $212 Bromfenac 0.09% 5 ML $212 Bromday 1.7 ML $144 Nevenac 3 ML $195 Steroidal 5 ML $45 Prednisolone 1% 10 ML $86 15 ML $125 Lotemax Suspension 15 ML $554 Lotemax Gel 5 ML $154 Durazol 5 ML $144 tes.com/ Prices September 2014, St. Petersburg, Florida

38 Cystoid Macular Edema New Developments New topical NSAIDS Intraocular Kenalog at time of ECCE Intraocular Avastin at time of ECCE Value of treating sub-clinical CME

39 Cataract Surgery Complications Retinal Detachment Endophthalmitis Retained Lens Fragments Cystoid Macular Edema Dislocated IOL

40 Dislocated IOL Symptoms - Risks Immediate or late complication Vision loss: gradual or abrupt Capsular tear Pseudoexfoliation Prior vitrectomy Trauma

41 Dislocated IOL Considerations Lens type In-the-bag Haptic vs. plate IOL Is lens visible to patient Status of eye Vitrectomized Iris integrity

42 Dislocated IOL Management Options Lens is not visible to patient Contact lens Secondary IOL without removal Lens is not stable or visible Exchange AC IOL or PC IOL Suture fixation - VIDEOS Scleral tunnel fixation

43 An expert is a man who has made all the mistakes which can be made, in a narrow field. Neils Bohr

44 Retinal Complications of Cataract Extraction: Retinal Detachment Endophthalmitis Retained Lens Fragments Cystoid Macular Edema Dislocated IOL Steven M. Cohen, MD St. Petersburg Clearwater Clinical Professor of Ophthalmology

Optometric Postoperative Cataract Surgery Management

Financial Disclosures Optometric Postoperative Cataract Surgery Management David Dinh, OD Oak Cliff Eye Clinic Dallas Eye Consultants March 10, 2015 Comanagement Joint cooperation between two or more specialists