Acute-onset Postoperative Endophthalmitis Research Articles

An unusual case of endophthalmitis

Postoperative endophthalmitis is an uncommon yet devastating complication after cataract surgery. We report a case of acute-onset postoperative endophthalmitis secondary to a rare causative pathogen Chryseobacterium. Elderly male patient with chronic kidney disease on hemodialysis with acute-onset postoperative endophthalmitis was managed with systemic and local higher antibiotics, leading to the resolution of the infection.

Endophthalmitis following vitrectomy for malignant glaucoma: Multidrug-resistant Klebsiella pneumoniae

The purpose of this case report is to present a case of acute-onset postoperative endophthalmitis, caused by multidrug-resistant (MDR) Klebsiella pneumonia, following pars plana vitrectomy for malignant glaucoma. A 52-year-old male patient underwent elective phacoemulsification cataract surgery with intraocular lens implantation in the right eye. Two weeks later, the patient presented with a diminution of vision and clinical features suggestive of malignant glaucoma. With no response to conventional treatment, pars plana vitrectomy was done. Acute-onset postoperative endophthalmitis developed, with severe intraocular inflammation, caused by MDR Klebsiella pneumoniae. The isolates demonstrated sensitivity to polymyxins and tigecycline only. Intravitreal colistin (0.1 mg/0.1 mL) was administered. The response was satisfactory and the vision could be salvaged. At 2 months follow-up a visual acuity of 20/50 was recorded. This is a rare case report of acute-onset postoperative endophthalmitis due to MDR Klebsiella following pars plana vitrectomy. With timely intervention, the patient came out of two difficult situations of malignant glaucoma and MDR endophthalmitis with a reasonably good visual recovery.

Unilateral endophthalmitis after immediate sequential bilateral cataract surgery in a cognitively impaired patient: diagnosis and treatment

Introduction: Immediate sequential bilateral cataract surgery (ISBCS) is a reasonable approach for cataract surgery in patients needing general anesthesia, such as those with cognitive impairment. To our knowledge, this is the first reported case of unilateral acute-onset postoperative endophthalmitis in a patient with cognitive impairment after ISBCS, with emphasis on diagnostic and treatment challenges. Patient and Clinical Findings: A 64-year-old woman with a history of cognitive impairment, seizure disorder, and no prior ocular surgery presented with dense visually significant cataracts and visual acuity of fix and follows in both eyes. Diagnosis, Intervention, and Outcomes: Patient underwent ISBCS under general anesthesia and without intracameral antibiotics or corneal sutures. The patient returned with unilateral acute-onset endophthalmitis 2 weeks postoperatively. Because of the patient's limited ability to comply with treatment, and lack of emergency general anesthesia needed for vitreous cultures, intravitreal vancomycin injection (1 mg/0.1 mL) was empirically given, with clinical resolution of the infection and visual acuity of fix and follows. Conclusions: Acute-onset postoperative endophthalmitis in the setting of cognitive impairment is challenging because emergency general anesthesia may not be available, and the patient can tolerate only limited interventions. In this patient, empiric intravitreal vancomycin injection without cultures led to a satisfactory clinical outcome.

Acute-onset postoperative endophthalmitis after cataract surgery performed by resident and attending physicians at a university teaching hospital.

To evaluate acute-onset postoperative endophthalmitis following cataract surgery and to compare rates between resident and attending physician-performed cohorts. Bascom Palmer Eye Institute, Miami, Florida. Retrospective chart review. Records of patients diagnosed with endophthalmitis within 6 weeks of surgery performed by attending and resident physicians between January 1, 2015, and December 31, 2020, were reviewed. Total cataract volume was obtained from institutional records, and resident case totals were obtained from case logs. Endophthalmitis cases were obtained from billing records and confirmed with chart review. There were 22 cases of endophthalmitis among 32 505 cases (0.068%). Endophthalmitis occurred in 6 of 6447 (0.093%) resident cases and 16 of 26 058 (0.061%) attending cases ( P = .55). The most common bacterial isolates were coagulase-negative Staphylococcus (8/22, 36.3%) and Streptococcus species (3/22, 13.6%), with negative cultures in 10 (10/22, 45.5%). Initial treatment with vitreous tap and injection of intravitreal antibiotics was performed in 21 eyes (21/22, 95.4%) and vitrectomy with intravitreal antibiotic injection in one (1/22, 4.5%). Vitrectomy was performed secondarily in 9 patients (9/22, 40.9%). Corrected distance visual acuity (CDVA) at last follow-up was ≥20/40 in 13 eyes (13/22, 59%) and ≤hand motions in 3 eyes (3/22, 13.6%). CDVA (logMAR mean ± SD) was 1.22 ± 1.16 in resident and 0.49 ± 0.79 in attending cases ( P = .11). In the current study, acute-onset postoperative endophthalmitis developed infrequently following cataract surgery. The rates and visual outcomes of endophthalmitis were similar in resident and attending cases.

The Role of Systemic Antimicrobials in the Treatment of Endophthalmitis: A Review and an International Perspective.

BackgroundThe optimal management of patients with endophthalmitis is challenging and includes both intravitreal and, in some cases, systemic antimicrobials. Systemic antimicrobials may be administered either intravenously or orally. In this article we review systemic antimicrobial options currently available for the treatment of types of endophthalmitis and the role of systemic antimicrobials (antibiotics and antifungals) in these treatments.ReviewWhile systemic antimicrobials are not universally utilized in the management of endophthalmitis, they may be helpful in some circumstances. The blood–retinal barrier affects the penetration of systemic medications into the posterior segment of the eye differently; for example, moxifloxacin and imipenem cross the blood–retinal barrier relatively easily while vancomycin and amikacin do not. However, inflammation, including endophthalmitis, may disrupt the blood–retinal barrier, enhancing the penetration of systemic agents into the eye.ConclusionSystemic antimicrobials may be particularly beneficial in patients with certain types of endophthalmitis; as such, they are standard treatment in the management of endogenous endophthalmitis (fungal and bacterial) and also widely used for prophylaxis and treatment of open-globe injuries. Although systemic antimicrobials are used in some patients with acute-onset postoperative endophthalmitis following cataract surgery, the literature generally does not support this practice. It is noted that there are currently no randomized clinical trials demonstrating a benefit of systemic antibiotics for any category of endophthalmitis.

Endophthalmitis after Cataract Surgery in the United States: A Report from the Intelligent Research in Sight Registry, 2013–2017

To determine recent incidence and visual outcomes for acute-onset endophthalmitis after cataract surgery performed in the United States. Retrospective cohort study. United States cataract surgery patients, 2013-2017 (5 401 686 patients). Cases of acute-onset postoperative endophthalmitis occurring within 30 days after cataract surgery were identified using diagnosis codes in the American Academy of Ophthalmology IRIS (Intelligent Research in Sight) Registry database, drawn from electronic health records in ophthalmology practices across the nation. Annual and aggregate 5-year incidences were determined for all cataract surgeries andspecifically for standalone procedures versus those combined with other ophthalmic surgeries. Patientcharacteristics were compared. Mean and median visual acuity was determined at 1 month preoperative aswell as 1 week, 1 month, and 3 months postoperative among patients with and without endophthalmitis. Incidence of acute-onset postoperative endophthalmitis after cataract surgery. A total of 8 542 838 eyes underwent cataract surgery, 3629 of which developed acute-onset endophthalmitis (0.04%; 95% confidence interval, 0.04%-0.04%). Endophthalmitis incidence was highest among patients aged 0 to 17 years (0.37% over 5 years), followed by patients aged 18 to 44 years (0.18% over 5 years; P < 0.0001). Endophthalmitis occurred 4 times more often after combined cases (cataract with other ophthalmic procedures) than after standalone cataract surgeries (0.20% vs. 0.04% of cases), and occurred in 0.35% of patients receiving anterior vitrectomy. Mean 3-month postoperative visual acuity was 20/100 (median, 20/50) among endophthalmitis patients, versus a mean of approximately 20/40 (median, 20/30) among patients without endophthalmitis. However, 4% of endophthalmitis patients still achieved 20/20 or better visual acuity, and 44% achieved 20/40 or better visual acuity at 3 months. Acute-onset endophthalmitis occurred in 0.04% of 8 542 838 cataract surgeries performed in the United States between 2013 and 2017. Risk factors may include younger age, cataract surgery combined with other ophthalmic surgeries, and anterior vitrectomy. Visual acuity outcomes vary; however, patients can recover excellent vision after surgery. Big data from clinical registries like the IRIS Registry has great potential for evaluating rare conditions such as endophthalmitis, including developing benchmarks, longer-term time trend investigation, and comprehensive analysis of risk factors and prophylaxis.

Acute-onset postoperative endophthalmitis after cataract surgery and transzonular intravitreal triamcinolone–moxifloxacin

To report 4 cases of acute postoperative endophthalmitis (POE) after uneventful temporal clear corneal topical dropless cataract surgery involving intravitreal triamcinolone-moxifloxacin (TriMoxi). Private practice in Peoria, IL, USA. Retrospective noncomparative case series. Charts of patients presenting with POE after an uneventful temporal clear corneal phacoemulsification with in-the-bag implantation of a posterior chamber intraocular lens over a 15-month period were reviewed. Patients presented with typical signs and symptoms of acute POE 3 to 14days after cataract surgery. The POE resolved after 25-gauge pars plana vitrectomy and injection of intravitreal vancomycin, ceftazidime, and dexamethasone. Two of 4 eyes were culture-positive for coagulase-negative Staphylococcus. The corrected distance visual acuity at the last follow-up visit was 20/40 or better in 3 eyes, and 20/400 in 1 eye because of underlying atrophic age-related macular degeneration. Postoperative endophthalmitis can occur after dropless cataract surgery with intravitreal triamcinolone-moxifloxacin.

The rate of endophthalmitis after pars plana vitrectomy and its risk factors.

To study the incidence of endophthalmitis after pars plana vitrectomy, its causative organisms, and visual acuity outcomes. In this retrospective, comparative study, the medical records of patients with acute-onset postoperative endophthalmitis after pars plana vitrectomy at Farabi Eye Hospital, Tehran, Iran, during a 12-year period between January 2004 and November 2015 were reviewed. To compare the endophthalmitis patients with other cases who underwent pars plana vitrectomy at the same day and also the same operating room, a control group was developed by gathering the data from surgical records. In the present study, the incidence rate of pos- vitrectomy endophthalmitis was 0.04% (16/39783). The organisms identified in aqueous or vitreous cultures (culture positive 44%) included Streptococcus pneumoniae (two patients, 12.5%), Pseudomonas aeruginosa (two patients, 12.5%), fungi (two patients, 12.5%), and Streptococcus viridans (one patient, 6.25%). Visual acuity after treatment for endophthalmitis ranged from light perception (7 eyes) to hand motion (1 eye), and evisceration was performed in 8 eyes (50%). When comparing the cases (patients developing endophthalmitis) and controls (patients with no complications operated in the same day and place of operation with the case group), only not using tamponade showed a statistically significant relation with the occurrence of endophthalmitis (p = 0.034). Our results indicated low incidence of endophthalmitis after pars plana vitrectomy comparable to previous studies which resulted in poor visual acuity. It seems that not using tamponade might increase the risk of endophthalmitis among these patients.

Acute-Onset Postoperative Endophthalmitis in Silicone Oil–Filled Eyes Managed With Intravitreal Antibiotics Alone

Endophthalmitis in postoperative silicone oil–filled eyes is rare. The traditional management of these eyes is a return to the operating room for oil removal, instillation of intravitreal antibiotics, and reinjection of silicone oil. We describe 2 cases of endophthalmitis successfully treated with an office injection of intravitreal antibiotics. In both eyes, there was a prompt resolution of endophthalmitis with no apparent signs of retinal toxicity and with favorable visual outcomes. These are the first cases to be described of endophthalmitis in silicone oil–filled eyes successfully treated with intravitreal antibiotics alone.

Hot Topics in Perioperative Antibiotics for Cataract Surgery.

Acute-onset postoperative endophthalmitis is an uncommon but potentially serious complication of cataract surgery. Since there are relatively few randomized clinical trials comparing the timing and administration of prophylactic antibiotics, there are wide variations in prevention practices around the world. Literature review. Antibiotics may be used before surgery, during surgery, or after surgery in an attempt to decrease the rates of endophthalmitis. Antibiotics may be delivered by various routes, including topical, subconjunctival, in the irrigating solution, or by bolus intracameral injection. Polymerase chain reaction and other DNA identification techniques for bacterial isolates and their antibiotic sensitivity profiles will play an important role in future management strategies. There is no consensus regarding the precise use of antibiotics in the perioperative period. Because of increased multidrug-resistant bacteria, evolving strategies are needed to address these issues.

The occurrence rate of acute-onset postoperative endophthalmitis after cataract surgery in Chinese small- and medium-scale departments of ophthalmology

Endophthalmitis can be a devastating complication after cataract surgery. Therefore, this study sought to better understand the occurrence rate of acute-onset postoperative endophthalmitis after cataract surgery in Chinese small and medium-scale departments of ophthalmology, as well as identify its risk factors and assess the treatment options. This investigation revealed 52 postoperative endophthalmitis cases in 46,185 operations at 30 hospitals from 2011 to 2013, at an occurrence rate of 0.11%. A small cataract surgery volume of less than 500 cases per year (OR 2.21; p = 0.006), the absence of 0.5% povidone iodine (PVP-I) irrigation (OR 1.73; p = 0.046), and intraoperative posterior capsular rupture (PCR) with vitreous loss (OR 4.40; p = 0.034) showed statistically significant associations with endophthalmitis in the multivariate analysis. The rate of culture positivity was 44.2%, with Staphylococcus epidermidis being the most common organism isolated in China. More than 40% of the endophthalmitis cases were treated with a nonstandard antibiotics regimen, and only 32.7% of these had a visual acuity of better than 20/40. We concluded that the occurrence rate of acute-onset endophthalmitis following cataract surgery in Chinese small and medium-scale departments of ophthalmology lags behind the level of developed countries, as well as Chinese top eye centers. Overall, the use of 0.5% PVP-I irrigation seemed to be an effective measure to reduce the risk of the development of postoperative endophthalmitis.

Endophthalmitis Prophylaxis in Cataract Surgery: Overview of Current Practice Patterns Around the World.

Acute-onset postoperative endophthalmitis after cataract surgery remains a rare but important cause of visual loss. There is no global consensus regarding the optimal strategies for prophylaxis of endophthalmitis and practices vary substantially around the world, especially with respect to the use of intracameral antibiotics. The European Society of Cataract & Refractive Surgeons in a randomized clinical trial (2007) reported an approximately 5-fold reduction in endophthalmitis rates associated with the use of intracameral cefuroxime. Despite this report, the use of intracameral antibiotics has not been universally adopted. Various endophthalmitis prophylaxis patterns around the world (including the United States, Canada, Australia/New Zealand, Japan, China, India, Indonesia, South Africa, Argentina, Russia, Sweden and Mexico) are compared. Each contributing author was asked to provide similar information, including endophthalmitis rates based on published studies, current practice patterns, and in some cases original survey data. Various methods were used to obtain this information, including literature reviews, expert commentary, and some new survey data not previously published. Many different practice patterns were reported from around the world, specifically with respect to the use of intracameral antibiotics. There is no worldwide consensus regarding endophthalmitis prophylaxis with cataract surgery.

Clinical observations of acute-onset endophthalmitis after clear corneal phacoemulsification

To evaluate the incidence of acute-onset endophthalmitis after clear corneal phacoemulsification and to report its clinical features, microbiology, and therapeutic efficacy. It was a retrospective case series study. Medical records were reviewed for all patients diagnosed with acuteonset postoperative endophthalmitis from 2006 through 2013 associated with cataract surgery at Shandong Eye Institute of China. The 8-year frequency of acute-onset endophthalmitis after clear corneal phacoemulsification was 0.13%. The mean time between cataract extraction and endophthalmitis onset was 6 days (median, range 1 to 37 days). Endophthalmitis onset occurred within 7 days in 57.1%. The incidence was significantly higher in summer (0.25%) than in other seasons seasons (F=8.61, P=0.05). The incidence in diabetes was 0.06% , and in non-diabetic patients was 0.16% (F=1.51, P=0.23). There were no significantly difference (F=0.003, P=0.422, ) in the endophthalmitis rates between those with capsular rupture (0.24%)and those without (0.13%). Three of the 21 cases (14.3%) were cured by antibiotic agents only. Antibiotic irrigation of the capsular bag was taken in 8 patients (38.1%). Six patients (28.6%) had both antibiotic irrigation of the capsular bag and intravitreal injection of the antibiotics and the other 4 patients (19.0%) were cured by vitreous surgery. Cultures were positive in 33.3% of cases with aqueous humor samples and in 16.7% of cases with vitreous biopsy. The culture isolates showed Staphylococcus species in 2 eyes, while Pseudomonas paucimobilis, Corynebacterium xerose, Neisseria mucosa and Enterococcus faecalis in 1 eye respectively. Sixteen patients (76.2%) achieved a final visual acuity of 20/40 or better. Five (23.8%) had worse than 20/40 to better than 20/200. No eyes were eviscerated. Early recognition and appropriate treatment are the most important factors in the successful management of endophthalmitis.

Ocular Infection: Endophthalmitis.

Endophthalmitis is characterized by marked inflammation of intraocular fluids and tissues. Infective endophthalmitis may be categorized by the cause of the infection, which helps predict the underlying etiology and most likely causative organisms. The major category remains acute-onset postoperative endophthalmitis. Infective endophthalmitis is a clinical diagnosis but is confirmed by evaluation of intraocular fluid specimens. The Endophthalmitis Vitrectomy Study offered important guidelines for the initial management of endophthalmitis, and these guidelines remain relevant to this day. Prompt initiation of empiric broad-spectrum antimicrobial therapy is important in achieving best outcomes.

Reevaluating intracameral cefuroxime as a prophylaxis against endophthalmitis after cataract surgery in India

To determine whether an intracameral injection of cefuroxime sodium at the conclusion of cataract surgery lowers the incidence of acute-onset postoperative endophthalmitis. Tertiary eye care center, Bhubaneswar, India. Prospective comparative interventional cohort study. Under a uniform protocol, cataract surgery with posterior chamber intraocular lens (PC IOL) implantation was performed from September 27, 2006, to July 31, 2010 (Group 1). All eyes were evaluated 1 day, 7 days, and 5 weeks ± 1 (SD) postoperatively. Treatment of eyes suspected to have developed infectious endophthalmitis was managed by retina-vitreous surgeons. From August 1, 2010, to August 31, 2012, the same surgeons performed cataract surgery with PC IOL implantation in another group of eyes, in which they administered intracameral cefuroxime prophylaxis (Group 2). All other protocols of postoperative care and microbiological investigation of the vitreous samples were similar. The rate of clinical and culture-positive endophthalmitis was compared between the 2 study groups: eyes without intracameral cefuroxime (Group 1) and eyes with intracameral cefuroxime (Group 2). The incidence of clinical endophthalmitis in Group 1 (0.155% [12/7756 eyes]) and in Group 2 (0.108% [8/7366 eyes]) was not significantly different (P = .57). The culture positivity rate in Group 1 (0.09 % [7 eyes]) and in Group 2 (0.04% [3 eyes]) was also not significantly different (P = .38). In the treatment without intracameral cefuroxime, there was a minimal, statistically insignificant increase in postoperative acute endophthalmitis (odds ratio, 1.42; 95% confidence interval, 0.53-4.02; P = .506). There is not strong evidence to support use of intracameral cefuroxime to reduce the rate of acute endophthalmitis after cataract surgery; however, the marginal benefit might justify its use. No author has a financial or proprietary interest in any material or method mentioned.

Postoperative endophthalmitis due to Burkholderia cepacia complex from contaminated anaesthetic eye drops

ObjectiveTo report the clinical presentation and outcomes of cluster postcataract Burkholderia cepacia complex endophthalmitis, the source of infection and clonal relatedness of the isolates.MethodsThis was a retrospective study on 13...

Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital in China

A retrospective study of all intra-ocular operations performed at Zhongshan Ophthalmic Centre, China between 1 January 2000 and 30 December 2009 was conducted to gain further knowledge about nosocomial acute-onset postoperative endophthalmitis. In total, 147,244 intra-ocular operations were performed during this period. Acute-onset postoperative endophthalmitis was diagnosed in 29 cases, giving a frequency of 0.020%. The frequency remained low and did not increase over the 10-year period. The highest rate of endophthalmitis was found following secondary intra-ocular lens implantation (0.129%). Cataract surgery had a rate of 0.01%, which is on the lower end of estimates from other large-scale studies. Gram-positive bacteria were the most commonly isolated organisms (71%), with the majority being Staphylococcus epidermidis (64%). However, no S. epidermidis was identified in the cases following cataract extraction; these patients received intracameral vancomycin at the end of the procedure. Visual outcomes of patients with postoperative endophthalmitis were generally poor. Three (10%) patients had visual acuity (VA) ≥20/40 at the final follow-up visit (all had undergone cataract surgery) and 15 (52%) patients had VA ≤20/400 at the final follow-up visit (10 had undergone pars plana vitrectomy). Factors associated with poor visual outcomes included initial VA of hand motions or worse, and positive culture results. Theresults of this 10-year study may serve as a source of comparison for other centres and future studies.

A cluster of acute-onset postoperative endophthalmitis over a 1-month period: investigation of an outbreak caused by uncommon species

AimTo report the clinical course, treatment response and prognosis of eight cases which developed acute-onset postoperative endophthalmitis over a 1-month period.Methods8 patients who were operated on over a period of...

Nosocomial Acute-Onset Postoperative Endophthalmitis at a University Teaching Hospital (2002–2009)

To evaluate acute-onset postoperative endophthalmitis occurring at an academic medical center and to compare rates over the last 25 years at a single institution. Retrospective, consecutive case series. Medical records were reviewed for all patients diagnosed with acute-onset postoperative nosocomial endophthalmitis from 2002 through 2009 associated with surgery at Bascom Palmer Eye Institute. The 8-year frequency of acute-onset postoperative endophthalmitis was 0.025% (14 of 56 672 intraocular surgeries). The rate was 0.028% (8/28 568) for cataract surgery and 0.011% (2/18 492) for pars plana vitrectomy (PPV). Both PPV endophthalmitis cases followed 20-gauge surgery and no cases followed small-gauge, transconjunctival PPV (n = 2262). Three cases occurred following penetrating keratoplasty (3/2788, 0.108%). The most common bacterial isolate was Staphylococcus (n = 7, 50%). Initial treatment involved ocular paracentesis (n = 8, 57%) or vitrectomy (n = 5, 36%), in combination with injection of intraocular antibiotics (n = 14, 100%). Vancomycin and ceftazidime were used in 13 eyes (93%) and intraocular steroids were given initially to 9 eyes (64%). Final visual acuity was > or =20/200 in 9 eyes (64%) and 2 eyes (14%) were no light perception. At this institution since 1984, there has been a statistically significant trend for a decreasing rate of acute-onset postoperative endophthalmitis (1984-1994: 0.09%; 1995-2001: 0.05%; 2002-2009: 0.025%; P < .001). At a university teaching hospital involving resident, fellow, and faculty surgeons, the frequency of acute-onset postoperative nosocomial endophthalmitis is low, has not increased in the era of sutureless clear corneal cataract surgery, and has steadily decreased when compared to prior time periods from the same institution.

THE USE OF BLOOD CULTURE BOTTLES IN ENDOPHTHALMITIS

To study the use of blood culture bottles for culturing vitreous specimens in acute-onset postoperative infectious endophthalmitis cases. Forty-eight eyes of 48 patients with mean age of 66.4 +/- 14.7 years with postoperative endophthalmitis that occurred within 6 weeks after ocular surgery, presenting from June 2001 to January 2005, were retrospectively studied. Vitreous fluid specimens of these patients were cultured in blood culture bottles. The measured outcome is the yield of positive culture. Vitreous specimens yielded positive in 34 of 48 (70.8%) eyes with blood culture bottles. The most common organism isolated was Staphylococcus epidermidis in 17.6% (6/34) of cases. The direct inoculation of vitreous specimens into the blood culture bottles is easy to perform, with a high yield positive rate (70.8%). It may be an alternative to conventional culture media for culturing vitreous specimen in infectious endophthalmitis especially in clinics or hospitals that are unable to have adequate microbiology laboratory facilities.