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Endophthalmitis case presentation of ophthalmology..pptx
- 1. CASE PRESENTATION Dr. RahulGupta 2nd year Resident Department of ophthalmology 20th JUNE, 2025
- 2. • Name: ReshamBahadur Bhandari • Age : 71 years • Sex : Male • Occupation : Farmer • Address : Sindhupalchowk • Contact: 9808321406 • Mode of presentation: OPD • Date of Presentation : 2025/05/22
- 3. CHIEF COMPLAINS 1. Decreasedin vision in Right eye for 2 days 2. Redness in Right Eye for 2 days 3. Pain in right eye for 2 days
- 4. HISTORY OF PRESENTINGILLNESS • The patient was apparently well 2 days back when he developed marked decrease in vision his right eye, which was acute in onset, Severe in nature. • Associated with redness of same eye. • He also complained of Pain, which was acute in onset, Severe in nature, associated with right side headache • Patient underwent right eye SICS +PCIOL on 18th May, 2025 and 1st POD vision was RE-6/9, LE-6/24 and improving(Pre op VA; RE=5/60) • There was no complain of distorted vision, flashes or black shadows.
- 5. PAST HISTORY PAST OCULARHISTORY: • No similar ocular illness in the past. • No any ocular surgery in past. • No history of use of glasses. PAST SYSTEMIC HISTORY: • No any chronic illness like Diabetes, HTN, COPD • No any surgical history.
- 6. TREATMENT HISTORY • Gtt.Predacetate 1% 1 drop RE in tappering dose after cataract surgery • Gtt. Ofloxacin 0.3% 1 drop QID for 2 weeks • Oint. Ocupol-D LA HS RE for 2 weeks
- 7. PERSONAL HISTORY – NonVegetarian, – Non smoker – Non alcoholic – Regular bowel and bladder habit – Good appetite FAMILY HISTORY No similar history in the family SOCIO-ECONOMIC HISTORY low socio-econmic status
- 8. DRUG AND ALLERGYHISTORY: • No any known allergic history to drugs or food.
- 9.
- 10. GENERAL EXAMINATION Physical examination •conscious and oriented to time, place and person • Ill-looking, Average built, anxious Vitals Temp : Afebrile Pulse : 84/min Respiratory rate : 22/min Blood pressure : 130/90mm of Hg at right arm in sitting position Pallor/Icterus/Lymphadenopathy/Clubbing/Edema/ Cyanosis/dehydration : Absent
- 11. SYSTEMIC EXAMINATION Respiratory system– B/L vesicular breath sound Cardiovascular system - S1 & S2 audible; no murmur Nervous system: sensory and motor system intact Gastrointestinal system: Normal bowel sound, No organomegaly
- 12. Ocular Examination 1. Visualacuity (VA) 2. Near vision: Couldn’t be Performed 2. Refraction (NIG) Right eye Feature Left eye HM VA( unaided) 6/24 NI VA (with pinhole) 6/24 HM BCVA 6/24 0 0 0 0
- 13. External Ocular Examination HEADPOSTURE NO HEAD TILT, CHIN LIFT, OR FACE TURN, NO TORTICOLLIS FACIAL SYMETRY BILATERAL SYMMETRICAL Orbit No Proptosis/ enopthalmos
- 14. RIGHT EYE LEFTEYE FULL RANGE IN ALL THE DIRECTION OF GAZE EOM FULL RANGE IN ALL THE DIRECTION OF GAZE 10cm CONVERGENCE 10cm EOM- Full in all range No pain No restriction in all gazes No diplopia in any gazes
- 15.
- 16. RIGHT EYE LEFTEYE HIRSCHBERG TEST 0 0 COVER TEST NO ANY CORRECTIVE MOVEMENT NO ANY CORRECTIVE MOVEMENT UNCOVER TEST NO ANY CORRECTIVE MOVEMENT NO ANY CORRECTIVE MOVEMENT COVER/ UNCOVER TEST NO ANY CORRECTIVE MOVEMENT NO ANY CORRECTIVE MOVEMENT Impression: Orthophoria
- 17. OCULAR EXAMINATION EYEBROWS RIGHTEYE LEFT EYE SYMMETRY Symetrically placed, Curved and with convexity upward, Comma- shaped. Symetrically placed, Curved and with convexity upward, comma shaped. CILIA Evenly distributed brow hairs. Evenly distributed brow hairs. PAF HORIZONTAL 27mm 28mm VERTICAL 7mm 10mm LID CREASE HEIGHT 4mm 2mm
- 18. RIGHT EYE EYELIDSLEFT EYE UPPER LID-COVERS 2.5 MM OF CORNEA, SWELLING PRESENT LOWER LID- TOUCHES 2mm ABOVE LIMBUS POSITION UPPER LID-COVERS 2 MM OF CORNEA LOWER LID- TOUCHES THE LIMBUS Lateral Canthi is Acute, and medial canthus is rounded. CANTHI Lateral Canthi is Acute, and medial canthus is rounded. Upper lids follows the eyeball in downward movement. MOVEMENT IF LIDS Upper lids follows the eyeball in downward movement. 2mm flat, no inward or outward rolling. No swellings, pus point LID MARGIN 2mm flat, no inward or outward rolling. No swellings, pus point DERMATOCHALASIS (present) DERMATOCHALASIS (present) 3 rows upper lid around 2 rows in lower lid. No misdirected,graying, loss of lashes EYE LASHES 3 rows upper lid around 2 rows in lower lid. No misdirected, graying, loss of lashes
- 19. RIGHT EYE LEFTEYE • 0.2mm • 6.5mm FROM INNER CANTHUS • 6mm FROM INNER CNATHUS • NO SWELLING, ERYTHEMA • INDURATION,PUS POINTS or TENDERNESS • TEMPERATURE- NORMAL • Negative LACRIMAL APPARATUS LACRIMAL PUNCTA LOWER UPPER LACRIMAL SAC AREA ROPLAS TEST • 0.2mm • 6.5mm FROM INNER CANTHUS • 6mm FROM INNER CANTHUS • NO SWELLING, ERYTHEMA • INDURATION,PUS POINTS or TENDERNESS • TEMPERATURE- NORMAL • Negative
- 20. RIGHT EYE CONJUNCTIVALEFT EYE • congestion present (CCC), diffuse type • No cysts, blebs, nodules, FB • No papillae, concretions, FB, nodules, discharge • No follicles, concretions, nodules, FB, discharge BULBAR UPPER TARSAL LOWER TARSAL AND FORNIX • Lusturous • No congestion, Chemosis No cysts, blebs, nodules, FB • No papillae/ concretions/ FB/ nodules/ discharge • No follicles, concretions, congestion, nodules, FB, discharge
- 21. RIGHT EYE 2LEFT EYE Diffuse engorgement episclersal vessels SCLERA No dilated episclersal vessels SIZE: Horizontal -11.7mm, vertical- 11mm. SURFACE: Smoth Epithelium TRANSPARENCY: Decreased STROMA: Haze, DM fold present, EDOTHELIUM: RBC in endothelium CORNEA SIZE: Horizontal -11.7mm, vertical- 11mm. SURFACE: Uniformly Smooth and regular TRANSPARENCY: Clear with no scar Normal depth, White Fibrin cortex @11 o clock, RBC+, Exudates+, Grade IV cells+, Dispersed Hyphema+, Hypopyon(?) ANTERIOR CHAMBER QUIET, NORMAL DEPTH(Van Herick grade IV) • Hazy View IRIS • Brown In color with normal distribution of crypts and collarette • No Neovascularization.
- 22. RIGHT EYE LEFTEYE Fixed, Irregular, Posterior Synaeciae+, No break of Synechiae, Hazy View+ PUPIL ROUND REGULAR REACTIVE SINGLE NUMBER SINGLE • Hazy View LENS • Normal position, No subluxation or dislocation. • Nuclear sclerosis grade1 present • 21mmHg IOP • 19mmHg
- 23. RIGHT EYE POSTERIORSEGEMENT LEFT EYE • No visualization VITREOUS • Normal Transparent vitreous • No floating strands, cells, blood or membrane visualized. • No Visualization FUNDUS Optic disc: Pinkish color, well defined margin, circular shape, area of 1.5mm size, with cup disc ratio of : 0.3:1. AVR: 2:3 MACULA: Healthy FOVEAL REFLEX: Absent
- 24. DIFFERENTIAL DIAGNOSIS Based onHistory and Examination: • Acute Postoperative Endophthalmitis • Toxic Anterior Segment Syndrome (TASS) • Acute Angle Closure Glaucoma (Post-op)
- 25.
- 26. Final Diagnosis Right EyeAcute Post Op Endophthalmitis with 4th day S/P Right Eye Small Incision Cataract Surgery with Posterior Capsule IOL.
- 27. In the sameday Treatment: • Patient planned for Intravitreal injection. 1. Inj. Vancomycin(1mg/0.1ml) 2. Inj. Ceftazidime (2.25mg/0.1ml) • Intravitreal injection given 3.5mm in superotemporal quadrant of patient. • Patient councelling done was admitted to ward with following medications.
- 28. Medication 1.Tab. Ciprofloxacin 750mgPO BD for 7 days 2. Tab. Pantoprazole 40mg PO BD for 7 days 3. Tab. PCM 500mg PO SOS 4. Gtt. Predacetate 1% 1 drop RE 1 hourly 5. Gtt. Fort. Vancomycin 50mg/1ml 1 drop RE 1 hourly 6. Gtt. Moxifloxacin 0.5% 1 drop RE 1 hourly 7. Gtt. Atropine 1% 1 drop RE TDS 8. Oint. Ocupol-D LA RE HS
- 29. Investigation on 22ndMay 1.RBS = 99.0 mg/dl 2. CBC = all counts within normal limit 3. Blood C/S = No growth 4. Urine RME = within normal limit
- 30. During 1 DOAFollow up on 23th May, 2025 1. Complain: 1. Mild right side headache 2. Visual Acuity: Right eye Feature Left eye PL+ PR+all quadrant VA( unaid ed) 6/24 NI VA (with pinhole) 6/18P PL+ BCVA 6/18P 3. Refraction NO Improvement 0 0 0 0
- 31. History and Investigation Vitals: •BP=110/70mmHg • Pulse, Saturation, RR= Normal limit RE Examination: • Eyelid= swelling decreasing • Conjunctiva= SCH present, congestion present.
- 32. RIGHT EYE 2 Diffuseengorgement episclersal vessels SCLERA EPITHELIUM: F. Stain positive, SPKs Present, decrease tear film layer TRANSPARENCY: Decreased STROMA: Haze still present DM fold present, EDOTHELIUM: RBC in endothelium CORNEA Normal depth, White Fibrin cortex @11 o clock, RBC+, Exudates+, Grade IV cells+, Settling Hyphema(0.3mm), Hypopyon(?) ANTERIOR CHAMBER • Hazy View, No vascularization IRIS
- 33. RIGHT EYE 6mm dilated,Posterior Synaecia breakage, Hazy View+ PUPIL • Hazy View LENS • 21mmHg IOP • Hazy View VITREOUS • Hazy View FUNDUS ADVICE 1.Sub conjunctival Inj. Midriacaine given PLAN: 2. Sub conjunctival Inj. Dexamethasone tomorrow
- 34.
- 35. Patient send toward • Medication continued as prescribed day before. • Fort. Vancomycin changed after 24 hours • Patient adviced to rest with head elevation.
- 36. Regular followed updone in OPD till patient discharged 1. Complain: 1. Mild eye pain (due to drop fort. Vancomycin 2. relief on Drop CMC 2. Visual Acuity: Right eye Feature Left eye Gradual increased to CF at 2 feet VA( unaid ed) 6/24 VA (with pinhole) 6/18P CF at 2 feet BCVA 6/18P 3. Refraction NO Improvement 0 0 0 0
- 37. Examination 1. Anterior Segmentof RE: • Eyelid = Swelling of UL gradually decreased. • Conjunctiva = SCH dissolved, congestion resolving, surgical wound healthy • Cornea = SPK decreasing,Stromal haze resolved, DM fold resolved, mild Endothelial Dusting with RBC present • Anterior Chamber = Cells grade 2 present. Fibrin cortex, exudates, hyphema, hypopyon resolved. • Pupil = 5mm dilated, synechiae broken • Iris = normal collarette and crypts • Lens = Clear
- 38. 2. Posterior Segment •Fundus glow = Apreciated • Vitreous = Hazy view, Vitreous cell grade 4 present • Posterior pole = hazy view, vascular markings present 3. IOP = RE :11 mm hg, LE: 17mmhg 4. 2nd dose Intravitreal injection(Vancomycin+Ceftazidime) on 25th may with Gtt. Combigan 1 drop stat given. 5. Sub conjunctival Inj.Dexamethason given on 26th may and 2nd June. 6. Medication = Oral medication dose completed, Topical medication tappered and continued
- 39. At discharge • Patientvitals was stable. • his vision was gradually improving • adviced to continue medication as prescribed • avoid strenous work and rest • maintain ocular hygiene • follow up done after 5 days/SOS.
- 40. Medication tappered onpatient discharge 1. Tab. Fortiplex 1 tab PO OD continued 2. Gtt. Predacetate 1% 1 drop RE 2 hourly(tappered) 3. Gtt. Fort. Vancomycin 50mg/1ml 1 drop RE 4 hourly 4. Gtt. Moxifloxacin 0.5% 1 drop RE QID 5. Gtt. Atropine 1% 1 drop RE TDS 6. Gtt. CMC 0.5% 1 drop RE QID 6. Oint. Ocupol-D LA RE HS
- 41. 1st follow upafter patient discharged 1. Complain: 1. No frest complain 2. Visual Acuity: Right eye Feature Left eye Gradual increased to CF at 3-4 feet VA( unaid ed) 6/24 VA (with pinhole) 6/18P CF at 3-4 feet BCVA 6/18P 3. Refraction NO Improvement 0 0 0 0
- 42. On Examination 1. AnteriorSegment: • Conjunctiva : mild congestion, surgical site wound resolving • Cornea : Clear • AC = grade 2 cells • Pupil = 5mm dilated • Iris = Normal • Lens = clear 2. Posterior Segment: • Vitreous = haze present • Fundus = Disc visible with vesels apreciated.
- 43. IOP = withinNormal Limit Medication 1. Gtt. Predacetate 1% 1 drop RE 2 hourly for 2 weeks 2. Gtt. Moxifloxacin 0.5% 1 drop RE QID for 2 weeks 3. Gtt. Atropine1% 1 drop RE TID continue 4. Cap. Fortiplex 1 cap PO OD for 1 month 5. Gtt. CMC 0.5% 1 drop RE QID continue 5. Oint. Ocupol - D LA RE HS for 2 weeks Patient adviced to follow up in eye OPD after 2 weeks/SOS
Editor's Notes
- #3 Orbital cellulitis Orbital abscess
- #4 There was no any associating or aggravating factor.
- #5 No history of Tuberculosis, Diabetes.
- #10 96 drg fahrenheit
- #12 Visual acuity charts : Snellens Chart, Landolt C chart, Allens picture chaer. etc Near Chart: jaegers chart, Romans near vision chart Snellen’s Near vision chart.
- #13 Eye ball Examination: The two eyeballs are symmetrically placed in the orbits in such a way that line joining the central points of superior and inferior orbital margins just touches cornea. Head Posture: In paralytic squint head posture is abnormal. In complete ptosis chin is elevated to uncover pupil area. Head is turned in the direction of paralysed muscle to avoid diplopia. Forehead examination: Increased wrinkling due to overaction of frontalis muscle in patient of ptosis. Complete loss of wrinkling in one half forehead with lower motor neural palsy. Facial symetry may be affected in facial or bells palsy.
- #14 EOM EXAMINATION: Uniocular movement: aka duction, these are: there was full range of movement in adduction, abduction, supraduction and infraduction. Adduction: medial roation along vertical axis, Abduction: lateral rotation along vertical axis, Infraduction: downward movement(depression) along horizontal axis, Supraduction: upward movement(elevation) along horizontal axis, Incycloduction(Intorsion): rotatory movement along AP axis in which superior pole of cornea moces medially, Excycloduction(Extortion): rotatory movement along AP axis in which superior pole of cornea moves laterally. Binocular movement: Version aka conjugate movement of both eyes in same direction : On binocular versions examination, there was full range of movement in Levoversion, Levoelevation, Levodepression and Dextroversion, Dextro elevation, dextro depression. Dextroversion: movement of both eyes to right, Levoversion: movement of both eyes to left. Vergence aka disjugate movement are symmetric movement of eyes: On binocular vergence evaluation, Convergence: simultaneous inward movement of eyes. Divergence: simultaneous outward movement of eyes.
- #15 EOM EXAMINATION: Uniocular movement: aka duction, these are: there was full range of movement in adduction, abduction, supraduction and infraduction. Adduction: medial roation along vertical axis, Abduction: lateral rotation along vertical axis, Infraduction: downward movement(depression) along horizontal axis, Supraduction: upward movement(elevation) along horizontal axis, Incycloduction(Intorsion): rotatory movement along AP axis in which superior pole of cornea moces medially, Excycloduction(Extortion): rotatory movement along AP axis in which superior pole of cornea moves laterally. Binocular movement: Version aka conjugate movement of both eyes in same direction : On binocular versions examination, there was full range of movement in Levoversion, Levoelevation, Levodepression and Dextroversion, Dextro elevation, dextro depression. Dextroversion: movement of both eyes to right, Levoversion: movement of both eyes to left. Vergence aka disjugate movement are symmetric movement of eyes: On binocular vergence evaluation, Convergence: simultaneous inward movement of eyes. Divergence: simultaneous outward movement of eyes.
- #16 the Hirschberg test, also Hirschberg corneal reflex test, is a screening test that can be used to assess whether a person has strabismus (ocular misalignment). Cover and uncover is done for tropias altranate cover test done for phorias
- #17 Note: The two eyebrows are horizontaly placed over superciliary ridge of the frontal bone seperated by glabella. The Level of eyebrows may be changed in patient with ptosis due to overaction of frontalis muscle, where ptotic eye have raised eyebrow. Cilia of lateral 1/3 may be absent(madarosis) in pt. with leprosy or myxedema. In Brow ptosis there is downward pulling of eyebrows. Abnormality of PAH: 1. Ankyloblepharon is usually seen in adhesion of lids following burns, ulcerative blepharitis. 2. Blepharophimosis: congenital anamoly in which all around narrowing of Palpebral fissure.
- #18 IN primary position if gaze the upper eyelid covers around 2 mm and lower eye lid just touches the cornea. Canthus: In Both eyes the lateral canthus forms acute angle of 60 degrees (2mm above medial canthus) and medial canthus is rounded. the lateral canthus is slightly positioned upward compared to medial canthus. LID MARGIN : In both the eyes the opposing lid margins are nearly flat 2mm in width, the lacrimal papillae with lacrimal punta present. The lacrimal portion of lid margin is rounded and devoid of lashes. The ciliary portion consist of rounded ant. border and sharp border placed against globe. distance of punta ( upper punta is 6mm and lower punta is 6.5 mm from medial canthus). with presence of horizontal linear gray line. EYE LASHES: arrenged in 2-3 rows in upperlid, directed forward upward backward. In lower lid forward downward and backward In ptosis upper lid covers more than 1/6th (2mm) cornea. Upper limbus is visible due to lid retraction seen in thyrotoxicosis and sympathetic overactivity. Movement of lids: upper lid follows eyeball in downward movement but lags behind in case of TED. blinking is decreased in trigeminal anaesthesia and absent in 7th nerve palsy.
- #19 Lacrimal Apparatus: While Examination of lacrimal apparatus, On inspection and palpation of lacrimal sac region there was no redness, swelling of fistula. While examining lacrimal punta, there was no defect such as eversion, stenosis, abscence or discharge. ROPLAS: Regurgitation on pressure over lacrimal sac. positve in Dacrosystitis and NLDO.
- #21 Positions of Eye ball : Eye balls symetrically placed in orbit and the lines joining the central points superior and inferior orbital margin just touches the cornea. Visual axis of eyeball: both eyes are simultaneously directed at the same object which is maintained at all direction of gaze. deviation in visual axis is called squint. Conjunctiva: Bulbar conjucntiva was normal with a fine network of vessels is seen with no any sign of conjunctival or circumcilliary congestion or chemosis. On examining Palpebral conjunctiva, there was no discharge, discoloration, papillae or follicles present. Sclera: bluish discoloration seen in isolated anomaly or in osteitis deformans, Marfans syndrome, Pseudoxanthoma elasticum. Inflamation of sclera: Episcleritis: Superficial localised pink or purple circumscribed flat nodule. Scleritis: deep, dusky patch associated with marked inflammation and ciliary congestion. 5. Cornea: Ant. surface elliptical with horizontal diameter of 11.7mm and vertical diameter of 11mm. SURFACE smothness of cornea can be examined by use of Placido Keratoscopic disc(disc painted with alternating black and white circles). SHEEN= Normal cornea is a bright shining structure. Sheen of corneal surface is lost in dry eye conditions. While Examining Corneal Endothelium: Specular microscopy clear morphological study of endothelial cells including cell density of endothelium is around 3000 cells/mm2 in young adults, which decreases with advancing age.
- #22 PUPIL: Single pupil in left eye, around with 3 mm in size and round regular and reactive to light. On direct light reflex constriction of pupil of ipsilateral eye noted and swinging light reflexcould’nt be performed. There was no Synaeciae in LE. LENS : Position of lens normally positioned in the patellar fossa. Normal thickness 3-4 mm of lens.( IOL thickness around 1mm). Shape of lens= Normal lens is a biconvex structure, which is nicely demonstrated in an optical section of the lens on slit-lamp examination. COLOR: In nuclear cataract lens may look amber, brown or black in colour
- #24 other D/D: 1. Delayed Suprachoroidal Hemorrhage (DSCH): Usually occurs within the first week post-op, Presents with sudden severe pain and vision loss, AC shallowing and high IOP may be seen, Often associated with hyphema and corneal edema, Fundus may be obscured due to hemorrhage. ✅ Could be considered if IOP was high and there was significant shallowing of AC, but: IOP here is 21 mmHg (normal range), Redness and anterior reaction with exudates more favor infectious process 2.Phacoanaphylactic (Lens-Induced) Uveitis: May occur if lens matter remains post-phacoemulsification, Presents with granulomatous inflammation, AC reaction, possibly hypopyon, Typically subacute, and pain is less intense,Fundus may be visible unless there is secondary vitritis.
- #25 1.Dense Low to Medium Reflective Vitreous Opacities: vitreous cavity shows heterogeneous echogenicity, indicating the presence of vitreous exudates (cellular debris, inflammatory proteins, possible microorganisms). This is a hallmark feature of vitritis, which is characteristic of endophthalmitis. 2. Hazy Vitreous Without PVD Membrane or Vitreous Strands: No evident PVD or clear linear membranes; instead, the opacities are diffuse and amorphous, which is typical of dense inflammatory material rather than hemorrhage. Note: In vitreous hemorrhage, one often sees mobile, moderate-to-high reflective echoes, but in endophthalmitis, the echoes tend to be more granular, ill-defined, and dense. No Obvious Retinal Detachment or Choroidal Elevation
- #34 1.Dense Low to Medium Reflective Vitreous Opacities: vitreous cavity shows heterogeneous echogenicity, indicating the presence of vitreous exudates (cellular debris, inflammatory proteins, possible microorganisms). This is a hallmark feature of vitritis, which is characteristic of endophthalmitis. 2. Hazy Vitreous Without PVD Membrane or Vitreous Strands: No evident PVD or clear linear membranes; instead, the opacities are diffuse and amorphous, which is typical of dense inflammatory material rather than hemorrhage.
- #45 Do Treatment Patterns for Endophthalmitis after Cataract Surgery Follow the Endophthalmitis Vitrectomy Study Recommendations?" A retrospective cohort study analyzing treatment trends for postoperative endophthalmitis in the AAO (2014–2022) 2,425 cases of cataract-associated endophthalmitis within 42 days post-op assessed. Only 14% (345) underwent pars plana vitrectomy (PPV), while 86% (2,080) received tap-and‑inject (TAP) Among those presenting with light perception (LP) vision, 66% were treated with TAP rather than PPV, contrary to EVS recommendations, Factors positively associated with PPV: worse VA (LP: OR, CF/HM: Despite the 1995 EVS guidance favoring immediate PPV for LP presentation, most real-world cases opt for TAP—even when PPV may yield better visual outcomes. This highlights a gap between evidence and practice, suggesting potential underuse of vitrectomy in high-risk presentations. Observed variation based on race/ethnicity and geography points to possible healthcare disparities or differing practice patterns.