 Hi, my name is Bala Ambadi. I'm an ophthalmologist at the University of Utah, and today I'd like to spend a few minutes with you discussing endophthalmitis, or infection inside the eye after cataract surgery. The main risk factors for endophthalmitis are elderly age, more than 80, immunocompromise, such as HIV or other immune deficiency disorders, severe bluffritis, or poor lid hygiene, if there's a lot of matter and crud on the eyelashes and eyelid margins. If there's a poor construction of the wound, if the wound at the end of cataract surgery is leaky or doesn't seal well, that's a huge risk factor for infection inside the eye. And then very importantly, if there's any intraoperative complications, such as posterior capsule tear or vitreous loss. This is what endophthalmitis can look like. As you can see on the left picture, there's a hypopian at the bottom of the anterior chamber, as well as fibrin within the anterior chamber, resulting in an irregular pupil due to synechia formation. There's also loss of the red reflex, indicating vitreosopacification. B-scan ultrasound can show these vitreosopacifications and fluid collections or abscess formation within the eye. And if you don't have a good view of the back of the eye, a B-scan is mandatory to look for endophthalmitis in any patient who you suspect of it. The signs and symptoms that lead you to suspect endophthalmitis are pain that is unresolved with topical anesthetic or redness of the eye, especially around the limbus, which is called ciliary flush. If there's in severe injection or ciliary flush that's not resolved with dilating drops, that can also be a clue that there's endophthalmitis. Of course, decreased vision, loss of the red reflex, and everything I showed you on those slides before, fibrin formation in the anterior chamber, hypopian, vitreosopacities, all of those can point you towards a diagnosis of endophthalmitis. The main causes of postoperative endophthalmitis are skin flora such as staph aureus or staph epidermidis. Streptococcal infections can also occur such as strep pyogenes or strep agilactae. Pneumococcus tends to occur in the context of cataract surgery in patients who have had previous glaucoma surgery such as blebs with trabeculectomy or tube shunts. Bacillus can infect a traumatized eye and Bacillus is typically found in endophthalmitis after some sort of penetrating trauma that's not surgical. Why is endophthalmitis important? Well, you can lose vision permanently or you can lose your eye. This is a very serious devastating complication of cataract surgery. It's very feared by cataract surgeons and patients and so it should be made clear to the patient that anytime you do surgery there is a risk for infection that you could even lose your eye with. It's a very low risk but it's not zero. Even if you save the eye there can be complications inside the eye such as scar tissue formation on the retina or other intraocular structures, retinal detachment or long-term glaucoma. How can we prevent and reduce the risk of endophthalmitis after cataract surgery or other intraocular surgeries? First, treat the patient's eyelids and skin. If they don't have good hygiene, talk with them about what you want them to do to optimize their eyelids and facial hygiene before surgery and phrase it in a context of not accusing the patient. Don't say your face is dirty. Tell them to reduce the risk for infection after surgery. You want them to do X, Y and Z and so that will go into the conversation of blufferitis management, facial hygiene and so on. Make sure they have an access to clean water in this discussion. Then during surgery, of course avoid hitting the posterior capsule. Avoid losing vitreous but if you do have those complications, if you do encounter vitreous make sure you have a clean vitrectomy so that you don't leave vitreous adherent to the wound. Adherent vitreous strands can cause CME but they can also be a wick for bacteria to get into the posterior segment of the eye. About two years ago, I switched to using intracameral antibiotics on all of my cataract surgery and this has been very helpful. I use intracameral moxifloxacin on every single feco emulsification procedure that I perform. Alternatives to moxifloxacin include intracameral suffuroxium and intracameral vancomycin. The reason I prefer moxifloxacin more than the others even though it's a bit more expensive is that at least in the United States context there is no suffuroxium formulation available and even if you do compounded suffuroxium there's a risk of TASS or toxic anterior segment syndrome. In Europe and perhaps in the countries that you're in there might be an intracameral suffuroxium formulation called aprochem but I believe that is very expensive. The reason I don't use vancomycin is that there is a rare but devastating risk of something called hemorrhagic occlusive retinal vasculitis, HORV, H-O-R-V. And anytime you have the word retina with occlusion or vasculitis that's a bad thing, right? We don't want to go there. As cataract surgeons we want a normal retina that's not bothered. Moxifloxacin which we get straight from the Vigamox bottle and you can divide it into probably 15 injections from a 3cc bottle of Vigamox is a little bit more expensive but doesn't have any of those other potential side effects or complications. For patients who have surgical complications where there's vitreous loss in addition to doing intracameral antibiotics I will give them oral moxifloxacin 400 milligrams a day for one week, maybe 10 days, as well as considering doing subconjunctival antibiotics including vancomycin and septazidine into the subconjunctival space not into the eye. If a patient gets end opthaminus after surgery this is something you have to jump on. If you have a cataract post op who's calling you at 2 in the morning with severe pain don't wait till the following morning. Go in and see that patient at 2 in the morning because every hour that the patient is not treated you can lose retinal cells. If the patient's vision is hand motion or better usually intracameral antibiotics are sufficient again vancomycin or septazidine. If the patient's vision is light perception or worse then they need a vitrectomy. That person doing the vitrectomy should be a retina surgeon somebody who's skilled at doing a parisplina vitrectomy and taking care of the retina. Together with the vitrectomy doing intracameral antibiotics is a good idea. Post-operatively I would give oral moxifloxacin for probably two weeks. Make sure whether you do the intracameral injection or vitrectomy surgery that you get a vitreous culture. You want to send that to the lab for microbiologic evaluation because you might have a fungal infection. You might have a rare bacterial infection and either of those situations you might need different drugs than what I've just discussed with you. Thank you very much. Again my name is Bala Ambadi and it's been my privilege to share some time with you discussing end ophthalmitis. Thank you.