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First Author: J.Ruiz Valadez MEXICO
Co Author(s): D. Jiménez Rosas L. Tapia López
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To establish the prophylactic measures in phacoemulsification surgery in order to diminish the incidence of endophthalmitis in patients with atopic dermatitis.
Asociación para Evitar la Ceguera en México I.A.P. Hospital "Dr. Luis Sánchez Bulnes". Ocular complications of atopic dermatitis can be blepharitis, keratoconjunctivitis, keratoconus, uveitis and subcapsular cataracts. Twenty five to fifty percent of adults with atopic dermatitis form cataracts. This case is presented to remark the importance of the inactivity of the atopic dermatitis by a multidisciplinary management in order to decrease the risk of endophthalmitis in this kind of patients who undergo cataract surgery.
A 23 years old woman with severe atopic dermatitis, allergic to iodopovidone, with chronic allergic conjunctivitis, with bilateral corneal graft due to keratoconus, presented an active severe atopic dermatitis and total intumescent cataracts. Phacoemulsification with intraocular lens implantation of the OS was performed on December 23rd, 2010. Soap was used for antisepsis. Six days later she presented sudden VA decrease, sever ocular pain, red eye, photophobia and tearing. A single dose of transseptal dexamethasone was injected and oral levofloxacin was started. On December 30th, 2010 CDVA was light perception and the ecography showed vitreous condensations. Intravitreal antibiotics were started and aqueous humor samples were taken. The cultures were negative for bacteria and for Candida spp. A central vitrectomy was performed and intravitreal antibiotics were injected on January 1st 2011. Four days later VA was 20/200 and IOP 15mmHg. Six weeks later OS VA decreased, IOP was 30mmHg, and posterior synechiae were seen. Closed angle secondary glaucoma was diagnosed and an Ahmed-valve implantation with iridectomy was necessary. The measures before the second eye surgery were a strict dermatologic control, allergen diet restriction, hospitalization, systemic antibiotics and steroids, local antibiotic prophylaxis, a corneoscleral incision, exhaustive cortical rests aspiration and ocular patch.
The left eye (OS) VA before the surgery was hand movement. The first day after the surgery the OS CDVA was 3/10, presenting six days later visual acuity decrease. After intravitreal antibiotics and central vitrectomy the visual acuity fourteen days after the surgery was 20/200. The patient developed close angle secondary glaucoma requiring filtering surgery and iridectomy getting a CDVA of 20/100. In the other hand, the right eye (OD), that had a visual acuity of hand movement, underwent phacoemulsification having pre and post surgical control of the disease and of the risks factors for intraocular infections, reaching a final VA of 20/40 without any of the problems that the other eye had to face.
Its important to achieve the control of the systemic disease in atopic dermatitis before undergoing cataract surgery, and also its useful to have an allergen diet restriction. Asepsis and antisepsis are essential prophylactic measures in every patient, and 5% iodopovidone is one of the main pillars to diminish the number of the colony forming units. In iodopovidone allergic patients the face can be subjected to surgical cleaning with surgical soap, but a few drops of iodopovidone have to be instilled into inferior conjunctival fornix. A corneoscleral incision reduces the risk of infections compared to a corneal wound that is more likely to allow the entrance of pathologic microorganisms to the eye. Hospitalization, systemic antibiotics and steroids, and local antibiotic therapy for three days are necessary in order to decrease the risk of endophthalmitis in patients with atopic dermatitis.