 So the last presenter for this morning is our third and final 2B chief resident next year, and that's Reese Feist And he's going to be speaking on oral steroids for bacterial endophthalmitis And we also want to congratulate him because he's getting married in a month So I'll try to go pretty quick so y'all can get lunch So my project it I'm a little bit bummed out So I was going to look at oral steroids and endophthalmitis my IRV is still under review So I don't have any new data that we've been able to pull I'll blame dr. Shakur for that one, but he He and dr. Vitaly are the two providers that really routinely put patients on oral steroids after they've gotten In bacterial endophthalmitis so kind of most of the provider all the proper providers here They'll start with a tap and inject and then they'll do vincomitis and septasitim and then intravitural dexamethasone But then kind of in addition to that some of them will do oral steroids So we're planning to do a retrospective chart review of bacterial endophthalmitis cases that we've seen here So they don't all originate here, but we get a lot of referrals from outside as well Herb and evaluate the frequency of the infections organism type and then the response to treatment between those given oral steroid and those without So hopefully pretty soon we'll get that approved But just kind of as a justification for the study I was just going to review a little bit of the other literature first The endophthalmitis retract me study look was looking at 420 patients with endophthalmitis after primary cataract or secondary IOL plays They essentially randomize into four groups. So they did initial vitrectomy with or without antibiotics So there were two groups and then tap and inject with or without IV antibiotics So for the vitrectomy they're getting 20 gauge aiming to remove about 50% of the gel and eyes with no vitreous separation So try to a fairly minimalistic approach and this was followed by Intravidual amicacin and vancomycin as well as a subconjunction of vancomycin seftaz and dexamethasone They also put patients on topical antibiotics with vancomycin and amicacin which was used up to q1 hour Alternating if there is any evidence of a wound leak or wound infection and then q4 hours otherwise For the IV therapy they had seftaz and amicacin the amicacin was hydrated to serum concentrations, but then kind of one one point years that they did do oral steroids So they're using oral brightness on 30 milligrams twice a day for between five to ten days And their results at at their one-year Point they had 53% of patients who had actually done quite well getting 20 40 vision or better 74% were 2100 or better Their culture data so 47% of cultures were quag quag negative grand positive So staff that be those sort of things and then 16% were other grand positive bugs They found no benefit from IV antibiotics and then they ended up Recommending vitrectomy only for light perception patients that increased the chance of achieving 20 40 vision or better by by three times So about 33% of patients with white perception vision or worse that had vitrectomy ended up 20 40 or better versus 11% so After that and starting even a little bit before that there's been a move to kind of move away from the oral Oral steroids and towards Intraviturals so kind of in that it really in the 1970s was when most of literature Started coming about using intraviturals dexamethasone And Kind of the justification for that was you know lower lower Systemic toxicity and those sorts of things In one rabbit study with the pneumococcal endopthamitis They they were looking at intravitural vancomycin levels and found that the antibiotic level was significantly higher in those eyes Treated with intravitural dexamethasone at the same time So there's been kind of varying studies just mainly in anim in Ravis and those sorts of things looking at the outcomes with the intravitural mode of treatment the largest human study was I think about 250 patients they Unfortunately should know no significant difference in the portion of patients achieving a final best corrected visual acuity of 20 40 or better Actually not too long ago they open there was a Cochran review from From February of this year that was looking actually at it Outcomes of those treated with or without Intravitural steroids so they had found three studies with a total of about 95 patients perspective studies and They then all of the patients in these trials for their European Were treated with intravitural dexamethasone and then a combination of two intravitural steroids There was a trend a trend toward better Outcomes in the the intravitural dex patients, but no statistical no statistical significant difference between the two groups In terms of just the safety of this it does seem to be safe a dose of intravitural dex is it's eliminated from the vitreous cavity after about two days So it doesn't get you through the entire inflammatory stage of the infection But it does offer you some protection. It's found to be safe at doses of 400 micrograms and less Over that dose. It's thought that the Mueller cells are the primary site of toxicity. So similar to the to the Aminoglycosides and the response to those Oral steroids like I said have fallen out of routine use for many providers in the treatment of endophthalitis And as such there's been no studies looking at the outcomes of oral steroids on the treatment of endophthalitis The potential justification would be that by treating for a full course of five to ten days You can kind of get the patient through that entire time of the inflammatory process and not just the two days It takes to wash out But you know this being said it is still it's still fairly controversial There was a poll in 2004 and ASRS So only about 47% of retina providers at that time were routinely using any type of antibiotic in their endophthalitis patients Whether it was oral or intravitural so it's kind of people practice patterns are all over the place Kind of transitioning to that We do have an interesting endophthalitis case that I was going to present and kind of tags on to actually what Julia was talking About earlier with some of the kind of scleral fixated IOLs But this was a guy that kind of came in quite a while ago He had decreased vision in his right eye He was trying to have a chronic macular off retinal detachment as well as a dislocated intraocular winds So in January he had a combined scleral buckle 20 gauge of a trichomy of silicone oil, and then he had his IOL explained to him was initially left a fake egg His subretinal fluid resolved, but he developed chronic macular edema following this He came in about 2250 2200 somewhere in that range and Kind of the best he did post-operative was about 2125 He had no response to pred-14 nevinac at 10 weeks And so he eventually underwent a combined of a trichomy of silicone oil removal membrane peel And then a scleral fixated IOL on April of 2012 So he had this lens implanted with an adiogortex suture So July of 2012 he saw a persistent macular edema with count fingers vision He started on nevinac, but his macular edema persisted. So September Fred Forte was added to his regimen And April it still had minimal improvement in the CME despite a membrane peel despite And two agents so he was given the Nasrdex and had an retinal anatomic success, but still poor vision But then he started getting corneal decompensation These were actually some pictures taken from that time So there had been just these kind of little whispers in the chart of some kind of conge inflammation You can see these sites here. You can't see it as well nasally, but really really well out here Some kind of inflammation over the site of his Gore-Tex suture and that was back in April So his cornea started decompensating and then he had a DSEC procedure At the time of the procedure is noted to have nasal and temporal areas of the exposed Gore-Tex He underwent conjunctival revision with 80 and 90 vicaral Kind of otherwise in the short-term curse of course did require that his graph be refloated on post-op day number six And then in July 2013 the Gore-Tex suture again eroded through and then just over the Over the numerous visits are just these recurrent notes of suture erosion waxing and waning inflammation of the conjunctiva in July he was seen on call and noted to have a micro hyphen with vitreous hemorrhage on his B scan He was seen by one of the older retina fellows at that time as well So There was concern for ugg syndrome at that time because his hemorrhage eventually did clear fairly quickly This was July. So kind of similar similar appearance temporally and then kind of just this this whitish material over the the nasal site so Notes kind of changed a little bit and these were kind of eventually called Gore-Tex granuloma is unfortunately in January 2015 he came into triage clinic and had four plus ac cell and then again wide inflammatory tissue over the sutures had a tap and inject at that time with Vank seftas and then also dexamethasone the cultures, you know even at two years I checked and there's still no growth for bacteria or fungus Kind of given the clinical course thereafter this was Eventually and some of the notes that are attributed to a graft rejection He was treated with kind of varying modes of topical steroids. So maxitrol pred forte those sort of things in December of 2015 so, you know not quite a year later. He came back with again four plus ac cell wide Inflammatory white inflammatory tissue over the sutures and then was also noted this was when Jim Bell first saw him So noted have severe con scleral thinning over the over the line the or with overlying conjunctiva Had a repeat tap and inject again vein can seftas dex and then they also gave him voriconazole To Jim was concerned this could have a fungal component that just been kind of very very mildly festering And this got kind of cut off But his cultures again returned no growth for bacteria and fungi and they also sent off Vitria sample for a pan PCR at the University of Washington, which also negative totally negative So these were pictures from December 2015 so you start to see again more kind of Pigmentary changes in those sites so Kind of get the suspicion for some thinning under the conch there More kind of a suspicion for thinning under the conch Closer up, but then these are actually some Some retro trains a little bit some Illuminated view so you can see right here how thin that is and also kind of at the other site Just superior to that it's not showing up super well. Thank you, Dr. Betty Can't really see it quite as well up there, but there is also some Transillumination defect up there superiorly And then just here's another view of it as well so you can make it out a little bit better on this shot So in February of 2015 after the inflammation settled down from the tapin and jack He went ended up going back to the OR. He had Gore-Tex suture removal at that time They're able to actually refixate the IOL to the iris with Nine-O-Prolene suture The temporal conjunctiva was closed with amniotic membrane grafts and then the nasal with just sliding conjunctival flap with tenons And he did initially have a wound leak which was successfully treated with a bandage contact The Gore-Tex suture is actually dropped into a culture at tube and then sent for culture and finally finally got something back He ended up growing steratia, and then it was fortunately pretty almost pan sensitive. They're not typically sensitive to the Amoxicillin or ampicillin, but he'd been getting seph Sephthazim which it was sensitive to which was good So 20 and July of 2016 was his last visit. He had stable vision overall He'd been kind of at about 2400 following this this second procedure There's no further thinning notice throughout these visits, but unfortunately in August the patient was deceased So I haven't been able to follow up with him anymore since that time so just Just kind of in terms of this it was kind of interesting to me because the seracea is a rare cause of bacterial endoplamitis and in some of Various studies looking at that kind of the epidemiology of these it's it's you know probably less than 1% and at the most There was a review of 10 cases which was showing all were sensitive of sephthaz But they do horribly horribly poor with this infection It's there was I think one case in there that ended up 2020 But the rest were basically like no light perception Final visual acutus 20 or 2400 better and only 4 of 10 eyes and 4 of 10 also required evisceration Just the infection was just so horrible And so sclerophyxated IOLs have been reported as a risk factor for endoplamitis based on the presence of permanent tracks going through the sclero There's been numerous reports of late failure of polypropylene suture. Dr. Manlis can talk a little bit about this too It's a monofilament monofilament polymer of propene. It's not absorbent But biodegradation has been found in highly metabolic tissues So they recommend kind of placement far away from the lumbus and other sites of kind of actively dividing cells or high blood flow Gortex on the other hand, it's a it's a not absorbable polytetrafluoroethylene monofilament. It's got greater tensile strength So there's numerous kind of prospective benefits to using this over proline It's most commonly used now for heart valve and vascular procedures to cordyte tendinide procedures There was actually not too long ago a recent one-year follow-up of 84 sclerophyxated IOLs with Gore-Tex They had no super erosions and then low rate of other complications kind of that And they've published kind of two series of these one with just the sclerophyxated IOLs and then another in conjunction with the tractomy so kind of that the outcomes were kind of similar to what you'd expect with With corneal corneal edema vitreous hemorrhage those sort of things, but no other serious complications So Brian And these they were very yeah, and those series they were very I'm not sure I you know those patients very so Jim is like I said that the notes were kind of a Little bit light on detail But Yeah, Jim noted some what he calls to true tales And So just kind of in terms of the Gore-Tex, so it's it's been awesome for most people But just if you actually go on the website they they have a specific contraindication against ophthalmic surgery I'm not sure And they don't want to Yeah, and it's been it's been if you get it approved by the FDA and you haven't tested in the eye And you don't say that you can't get it approved. So that that's it's a it's a It's a foregone conclusion that if they don't study that way And then you know kind of that being said like when you Google Gore-Tex sutures So the first thing that comes up is their website and then right after that sclerophyxated IOL And then an American Academy of Ophthalmology It's just a little ironic but So that was kind of what I had you know, hopefully next year I'll have some some actual fresh data that we can use but Keep my fingers crossed with the IRB so Maserated We call them granuloma sutures Point is made very valid The minute you see a granuloma at the site of the suture Sometimes you know You have to have to have to do the suture Miniaturial the suture Everything's up with that So in retrospect putting information on topical You're treating the surface basically so as a matter of principle it doesn't serve you The minute you see granuloma anywhere after the surgery You just remove the suture That thing's up about you know Prevent the flavor of spice the face is concerned Here your sclerophyll will have stopped And we all might have sclerophyll So you get proxies and you can release the pain So so this isolated area where we have some type of prosthesis That just doesn't make sense and I knew you're going to get a bacteria I had a cordial transplant that I just could not suppress inflammation It was like that it just kept rejecting we replaced it several times and this is the third time around And I just looked and I just thought it looked very strange What was happening in the capsular bag And so I pulled the lens in the capsular bag and everything just left the patient a fake egg to see And it's Nick here Nick I think we got a seracea out of that one That was also a seracea So seracea is famous for just sitting there and just smoldering Smoldering sitting and causing this chronic inflammation and difficulty And until you get rid of the sight of it You can't eradicate it Even though it shows it's sensitive this is typical There's no other way So also a good thing that when you consider that Likely you've got that P-acne is another one that can fully elect this Just sit around forever until you finally get rid of it We had a case like that when I was lost After eye muscle surgery With long term smoldering infection I believe it was also seracea So it's a bad It's the pink and red stuff in your shower When you forget to clean it for a while There was a bad outbreak actually in Alabama When I was in med school it got into some TPN That they had mixed up for one of the private hospitals down the road Had a lot of people die from that one actually But it's on the faucets They were using faucet water That cheery note was a type of punch