Acute Postcataract Endophthalmitis Research Articles

Complete and early vitrectomy for endophthalmitis

We recently co-authored a report on the ten-year (2007-2017) results achieved at our center (Retina Specialists of Alabama) in the treatment of Acute Post-Cataract Endophthalmitis (APCE). Of all eyes, 77.4% were initially treated with Complete and Early Vitrectomy for Endophthalmitis (CEVE). Visual acuity of ≥ 20/40 was restored in 79% of all eyes versus 53% of eyes reported in the Endophthalmitis Vitrectomy Study. We believe that CEVE is the initial treatment of choice whenever the fundus is obscured by endophthalmitis vitreous opacity.

Complete and Early Vitrectomy for Endophthalmitis After Cataract Surgery: An Alternative Treatment Paradigm.

PurposeIn this study, we report the treatment outcomes of complete and early vitrectomy for endophthalmitis (CEVE) after cataract surgery as the predominate initial treatment, accompanied by systemic antibiotics and retreatment of persistent or recurrent purulence (CEVE+).Patients and MethodsClinical features and microbiological factors were retrospectively reviewed in 62 eyes of 62 patients who were treated for acute postcataract endophthalmitis (APCE) occurring within three weeks of cataract surgery at Retina Specialists of Alabama, between 2007 and 2017.ResultsVisual acuity on presentation included light perception (LP) in 18 eyes (29%) and hand motion (HM) in 23 eyes (37%). Initial treatment was maximum possible vitrectomy in 48 eyes (77%) and tap-and-inject in 14 eyes (23%), with 38 eyes (61%) receiving two or more treatments. Cultures for the first intervention were positive in 49 eyes (79%) and virulent in 18 eyes (29%). At a median follow-up time of five months, final visual acuity was ≥20/40 in 49 eyes (79%), between 20/50 and 5/200 in seven eyes (11%), and <5/200 in six eyes (10%). Virulence was the strongest predictor of poor visual outcome. Retinal detachment occurred in four eyes (6%), likely from necrotic retinal defects in each case.ConclusionComplete and early vitrectomy is a safe and effective initial treatment for APCE. When accompanied by systemic antibiotics and retreatment (CEVE+) of recurrent media opacification, it improves recovery of 20/40 or better visual acuity by approximately 50% compared to a predominantly tap-and-inject treatment paradigm. We recommend CEVE for fundus-obscuring APCE (~75% of all cases) whenever the view is inadequate to rule out macular distress.

Visual Outcome in Pars Plana Vitrectomy for Acute Postoperative Endophthalmitis after Cataract Surgery

Purpose: To determine the visual outcomes in patients undergoing pars plana-vitrectomy (PPV) for acute postoperative endophthalmitis after cataract surgery.Study Design: Quasi experimental study.Place and Duration of Study: Al- Ibrahim Eye Hospital, Malir, Karachi for a period of 2 years.Material and Methods: Thirty-three patients were selected using non-probability convenient sampling technique.Patients with acute postoperative endophthalmitis after cataract surgery diagnosed clinically and on B-scan, withvisual acuity of only perception of light were included while patients with better visual acuity and any other typesof endophthalmitis were excluded. PPV was performed in all cases and the patients were examined postoperativelyon 1st day, 3rd day, 1, 2 and 3 weeks after surgery. During these follow ups, visual acuity wasrecorded, detailed slit lamp and fundus examination was performed. Using SPSS version 20.0, chi-square testwas applied to test for significance keeping p-value of &lt; 0.05 as significant.Results: Out of 33 patients 19 (57.6%) were males and 14 (42.4%) were females. Mean age of the patients was54.50 ± 14.14 years. On 1st post-operative day 8 patients (24.2%) showed improvement of visual acuity fromperception of light to finger counting while 02 (6.1%) patients reported visual acuity of 6/60. On final visit at 3rdweek postoperatively, 19 patients (57.6%) had visual acuity of finger counting, 08 patients (24.2%) had handmovement and 06 (18.2%) patients reported a visual acuity of 6/60.Conclusion: PPV for acute post-cataract endophthalmitis results in favourable outcomes in terms of visual acuity.

Genetic and Phenotypic Traits of Staphylococcus Epidermidis Strains Causing Postcataract Endophthalmitis Compared to Commensal Conjunctival Flora

The aim of this study was to compare the virulence and antibiotic resistance traits of Staphylococcus epidermidis strains causing acute postcataract endophthalmitis to those isolated from the conjunctiva of uninfected control patients. Case-control study. We isolated an S epidermidis strain from each of the 22 endophthalmitis patients, and from 43 of the 72 controls. Species identification was confirmed using both Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry and tuf gene amplification and sequencing. Antibiotic susceptibilities were evaluated using the AST-P631 card and the Vitek II automated system. The S epidermidis strains were tested for the presence of 7 virulence genes (icaA, icaB, icaC, icaD, atlE, aap, and capA), the insertion sequence IS256, and the mecA gene. The S epidermidis strains from the endophthalmitis patients displayed higher prevalence rates for aap, atlE, and mecA gene carriage compared to those of the control group (77% vs 42%, P= .007; 100% vs 79%, P= .02; and 54% vs 11%, P < .001, respectively). They also harbored the combination of the mecA and icaA genes more frequently compared to the control group (13% vs 2%, P= .01). They were significantly more resistant than control strains to methicillin, fluoroquinolones, and the aminoglycosides. A higher capacity of adhesion to the intraocular lens and formation of biofilms as well as greater resistance to antibiotics were found in S epidermidis strains causing postcataract endophthalmitis. The usefulness of such virulence and antibiotic resistance markers warrants further evaluation for prevention, treatment, and prognostic evaluation of S epidermidis endophthalmitis.

Acute postcataract endophthalmitis at a referral center in northern Taiwan: Causative organisms, clinical features, and visual acuity outcomes after treatment: A retrospective cohort study.

Acute-onset endophthalmitis after cataract surgery is a rare but serious complication. In this study, we identified the clinical profile of acute-onset endophthalmitis after cataract surgery using a retrospective review between January 1, 2009 and December 31, 2015 at a referral center in northern Taiwan. Twenty-five eyes of 25 patients with endophthalmitis were included; 60% were male. The mean age at diagnosis was 70.44 ± 1.66 years. The right eye was affected in 44% of patients. The mean time of cataract surgery to hospital was 12.76 ± 1.88 days. The mean time from the onset of endophthalmitis to hospital was 3.72 ± 0.78 days. Furthermore, 56% of patients received the immediate treatment of an intracameral or intravitreal injection of antibiotics at a clinic before referral. The mean initial visual acuity was 1.97 ± 0.15 logarithm of the minimum angle of resolution. The initial examination found corneal edema in 84% of patients, hypopyon in 48%, and vitritis in 88%. A total of 76% of patients underwent an initial treatment of pars plana vitrectomy and intraocular antibiotic injection (IOAI); 24% received an IOAI. The culture results of 52% (13/25) of patients were positive; 4 isolates were gram-positive, 8 were nontuberculosis Mycobacterium abscessus, and 1 was fungal. Thirteen of 25 patients had hypertension; 2 of 25 had diabetes mellitus. The mean follow-up time was 61.64 ± 8.27 days. Multiple factors influenced the final visual outcome of acute-onset endophthalmitis after cataract surgery. This study found that early referral for treatment could improve the final outcome. In addition, postcataract endophthalmitis caused by M abscessus recurs easily and has a worse visual outcome despite appropriate treatment.

Longitudinal study of retinal status using optical coherence tomography after acute onset endophthalmitis following cataract surgery

PurposeTo analyse the macula imaged with optical coherence tomography (OCT) in patients treated for acute postcataract endophthalmitis.MethodsPatients presenting with acute postcataract endophthalmitis were included in this observational and multicentre study...

Occurrence and risk factors for retinal detachment after pars plana vitrectomy in acute postcataract bacterial endophthalmitis

Background/aimsTo report the incidence, risk factors and prognosis of retinal detachment (RD) in patients who had vitrectomy for acute bacterial endophthalmitis after cataract surgery.Methods123 patients with acute postcataract endophthalmitis, consecutively...

Correlation between clinical data and antibiotic resistance in coagulase-negative Staphylococcus species isolated from 68 patients with acute post-cataract endophthalmitis

Coagulase-negative staphylococci (CNS) cause the majority of post-cataract endophthalmitis, which can lead to anatomical and/or functional loss of the eye. This study reports the antibiotic susceptibilities of CNS isolates associated with acute post-cataract endophthalmitis cases and correlates antibiotic resistance with severity and outcome of infection in these patients. Clinical data (initial ocular examination, final prognosis, antibiotic treatment) and the antibiotic susceptibilities of the isolated CNS strains were obtained from 68 patients with post-surgical endophthalmitis recruited during a 7-year period by the FRench Institutional ENDophthalmitis Study (FRIENDS) group. The CNS strains displayed 100% susceptibility to vancomycin, 70% to fluoroquinolones, 83% to fosfomycin, 46% to imipenem and 18% to piperacillin. The most effective antibiotic combinations were fosfomycin plus a fluoroquinolone and imipenem plus a fluoroquinolone, which were considered adequate in 80% and 58% of patients, respectively. Methicillin resistance was significantly associated with older age (p 0.001), diabetes mellitus (p 0.004), absence of fundus visibility (p 0.06), and poor visual prognosis (p 0.03). Resistance to fluoroquinolones was significantly associated with absence of fundus visibility (p 0.05) and diabetes mellitus (p 0.02). This large prospective study demonstrates that methicillin resistance and, to a lesser extent, fluoroquinolone resistance in CNS strains causing postoperative endophthalmitis are both prevalent in France and associated with a poorer visual prognosis. These results emphasize the need for an effective surveillance of this antibiotic resistance and the development of new diagnostic tools for rapid detection for early optimization of antibiotic therapy in endophthalmitis patients.

Anatomical and visual outcome after pars plana vitrectomy in acute postcataract endophthalmitis

AbstractPurpose To report visual and anatomical outcome of patients vitrectomized for acute post bacterial endophthalmitisMethods 123 patients with acute postcataract endophthalmitis and consecutively treated by pars plana vitrectomy (PPV) were included in four academic hospitals (French Institutional Endophthalmitis Study (FRIENDS) group).Results At 6 month follow‐up, 49 patients (40%) had a visual acuity (VA) greater than or equal to 20/40, and 83 patients (68%) had VA greater than or equal to 20/200. Baseline factors associated with final VA ≥20/40 were a younger age (Odds ratio, OR= 1.05 (1.05‐1.09), p=0.006), presence of fundus visibility (OR=7 (1,4‐34,6),p=0.007), and absence of cataract surgery complications (OR=15.3 (1.9‐32), p=0.001), corneal edema (OR= 2.3 (1.1‐4.9), p= 0.02), hypopion (OR= 2.6 (1.1‐6.6), p=0.04), or of virulent bacteria (OR=3.1 (1.4‐6.7), p=0.005). At the time of PPV, absence of vasculitis at the posterior pole at the time of PPV (OR= 7 (1.4‐34.6), p=0.02) and a lower duration of PPV (OR=1.02 (1.01‐1.04), p=0.02) were significantly associated with final VA ≥20/40. Risk factors of RD were diabetes (OR = 4.7 (1.4‐15.4), p=0.01), and visualization of retinal vasculitis on the posterior pole (OR = 3.8 (1.1‐13.9), p= 0.03) at the time of PPV.Conclusion PPV allowed to be beneficial in a majority of the patients. Baseline inflammatory signs and bacterial virulence are the main prognostic visual factors. RD remains the major complication but final anatomical and visual outcome is still poor, despite updated vitreoretinal techniques

Baseline predictive factors of visual prognosis in acute bacterial postcataract endophthalmitis

AbstractPurpose To identify baseline clinical factors of visual prognosis in patients with acute endophthalmitis following cataract surgery.Methods 99 patients of four academic hospitals (FRIENDS group). Factors were analyzed based on the final visual outcome, defined as poor (&lt;20/100) or good (≥20/40) using univariate and multivariate analysisResults Multiple logistic regression analysis showed that high bacterial virulence was the only independent factor (odds ratio [OR]= 14, 95% confidence interval [CI]: 2.7–71, p=0.001) for poor visual outcome. On the other hand, low bacterial virulence (OR=0.1 95%CI: 0.03–0.6, p=0.01) and the absence of complications (OR=0.07, 95%CI: 0.01–0.4, p=0.003) during cataract surgery were independent factors for good VA.Conclusion Visual outcome factors in acute postcataract endophthalmitis identified in this prospective study (2004–2007) were similar to those reported by the EVS 10 years ago. The bacterial virulence level was the main predictive factor of final visual prognosis. This emphasizes the need for rapid bacterial identification and characterization using new biomolecular tools.

Management of postoperative endophthalmitis

AbstractPostoperative endophthalmitis remains a devastating condition both for the patient and the surgeon. Even with careful prophylaxis such an ocular infection may occur. The EVS (Endophthalmitis Vitrectomy Study) has shed light and provided robust guidelines for the management of acute postcataract endophthalmitis. However since the publication of the EVS in 1995 we may wonder whether the findings of this major trial are still valid in 2012. Vitrectomy techniques have improved, the choice of the systemic antibiotics used in the EVS was not optimal and the widespread use of local antibioprophylaxis may have changed the presentation and prognosis of postoperative endophthalmitis. Others questions are not fully answered; what about the use of intravitreal corticosteroids, how do the EVS data apply to other endophthalmitis presentations (traumatic, glaucoma or chronic endophthalmitis?). In this presentation we will give some very practical and useful clinical tips for postoperative endophthalmitis management, mainly based on the FRIENDS group (FRench Institutional ENDophthalmitis Study) which has gathered about 100 cases of endophthalmitis.

RELATIONSHIP BETWEEN BASELINE CLINICAL DATA AND MICROBIOLOGIC SPECTRUM IN 100 PATIENTS WITH ACUTE POSTCATARACT ENDOPHTHALMITIS

To correlate the initial ocular presentation with bacterial identification in 100 patients with acute postcataract endophthalmitis. This was a prospective multicenter study. Demographic data, medical history, and the initial eye examination data were recorded on a standardized form. The relationship between bacterial identification and clinical factors at baseline was studied using univariate and multivariate analyses. One hundred patients were admitted to the hospital with a median delay of 6 days after cataract surgery. The main symptoms were loss of vision (94.9%) and pain (75.5%). Major clinical signs were hypopyon (72%), pupillary fibrin membrane (77.5%), and loss of fundus visibility (90%). Baseline factors significantly associated with microbiologic identification were as follows: diabetes mellitus, a shorter delay of onset, initial visual acuity limited to light perception, higher intraocular pressure, chemosis, pupillary fibrin membrane, loss of the red reflex, and reduced fundus visibility. As compared with other bacteria, the identification of Streptococcus species (n = 19) was more frequently associated with male gender, diabetes mellitus, initial visual acuity limited to light perception, and pain. The Staphylococcus aureus and Staphylococcus lugdunensis group (n = 14) differed from other coagulase-negative Staphylococcus groups (n = 33) in that those patients had greater hypopyon height. The baseline features of acute endophthalmitis after cataract surgery in the era of phacoemulsification are similar to those reported in the Endophthalmitis Vitrectomy Study 15 years ago and differ according to the bacterial species. The association between the clinical signs and the microbiologic identification suggests that initial characteristics other than visual acuity may be useful in identifying patients presumed to be infected with a virulent species.

Analysis of Diluted Vitreous Samples from Vitrectomy Is Useful in Eyes with Severe Acute Postoperative Endophthalmitis

This study was designed to compare the diagnostic yield of microbiological analysis performed on diluted and undiluted vitreous samples from pars plana vitrectomy (PPV) in patients with acute postcataract endophthalmitis. Cohort study, evaluation of diagnostic test or technology. Patients with acute postcataract endophthalmitis (<6 weeks). Undiluted and diluted vitreous samples were taken from 34 consecutive patients at the beginning of PPV as part of the multicenter prospective study of the French Institutional Endophthalmitis Study (FRIENDS) group. Vitrectomy was performed after 1 (n = 12) or 2 (n = 22) intravitreous antibiotic injections. McNemar's nonparametric test was used to compare culture and polymerase chain reaction (PCR) results between diluted and undiluted samples. Rate of positivity of conventional culture (brain heart infusion broth) and eubacterial PCR tests from undiluted and diluted vitreous samples. The microbiological analysis of both undiluted and diluted vitreous samples detected and identified a bacterial pathogen in 26 out of 34 cases (76.4%). The analysis of undiluted and diluted vitreous at the time of PPV, using eubacterial PCR and conventional culture, gave similar results (P = 0.99; McNemar test). However, eubacterial PCR was more sensitive than culture in detecting bacteria in vitreous at the time of PPV (76% vs 6%; P = 0.001; McNemar test). The difference in sensitivity between the 2 techniques was primarily associated with false-negative culture results for undiluted samples (2/3 of cases), mainly for coagulase-negative staphylococci. The microbiological results obtained combining PCR and culture techniques were similar for diluted vitreous and undiluted vitreous analysis. When eubacterial PCR is available, sampling diluted vitreous, an easier procedure, may replace sampling undiluted vitreous.

Predictive factors of visual outcome in acute post‐cataract endophthalmitis

Abstract Purpose To study potential clinical and microbiological predictive factors of visual outcome in patients with acute endophthalmitis following cataract surgery. Methods A prospective study included 100 patients in 4 University hospital.Factors related to the cataract surgery, the initial clinical presentation and the microbiological identification were analyzed according to the final visual outcome using univariate and multivariate (logistic regression) analysis. Results 46% out of the patients had a final visual acuity less than or equal to 0.3 logMar (good visual outcome) at 6 months while 10% had only light perceptions. Patients with good visual outcome differed for the duration of cataract surgery, initial visual acuity, the visibility of fundus and the identification of a coagulase negative staphylococcus. In contrast, patients with a poor visual outcome were older, had more cornea oedema and a more important hypopion at the admission, more complications at the time of cataract surgery. Furthermore a bacterium was more frequently identified in this latter group. Multivariate analysis showed that age, complications at the time of cataract surgery, microbiological identification, pars plana vitrectomy were independent predictive factors. Conclusion Factors of visual outcome in acute postcataract endophthalmitis identified in this prospective study were similar to that reported during the Endophthalmitis Vitrectomy Study 10 years ago. As part of the treatment, pars plana vitrectomy is associated with predictive factors of poor visual outcome. Identification of these predictive factors at presentation should allow a better management of patients needed an aggressive treatment.

Eubacterial PCR for Bacterial Detection and Identification in 100 Acute Postcataract Surgery Endophthalmitis

To evaluate eubacterial PCR compared with conventional cultures for detection and identification of bacterial agents in ocular samples from patients with acute postcataract endophthalmitis. Broad-range eubacterial PCR amplification was used, followed by direct DNA sequencing in ocular samples (aqueous humor, vitreous samples from tap or vitrectomy) from 100 consecutive patients presenting with acute postcataract endophthalmitis. Bacterial cultures were performed on the same ocular samples by using traditional methods (brain-heart infusion broth). At the time of admission, the detection rate was not significantly different between cultures and PCR (38.2% for cultures versus 34.6% for PCR in aqueous humor samples; 54% versus 57% in vitreous from a vitreous tap). In contrast, in the vitreous obtained from vitrectomy, after intravitreous injection of antibiotics, PCR detected bacteria in 70% of the cases, compared with 9% in cultures. By combining PCR and cultures, bacterial identification was obtained in 47% of aqueous humor samples at admission, in 68% of vitreous samples from a vitreous tap at admission, and in 72% of vitreous samples from pars plana vitrectomy. Gram-positive bacteria predominated (94.3%). The concordance between cultures and PCR was 100%. The contamination rate was 2%. Cultures and eubacterial PCR are complementary techniques for bacterial identification in eyes with acute postcataract endophthalmitis. PCR technique was needed for identification of the involved microbial pathogen in 25% of all the cases. Eubacterial PCR is more effective than cultures in detecting bacteria in vitreous samples from patients with previous intravitreous administration of antibiotics.

Subconjunctival antibiotics for acute postcataract extraction endophthalmitis—is it necessary?

PurposeTo evaluate the efficacy of adjunctive subconjunctival antibiotic injection in the treatment of acute postcataract extraction endophthalmitis. DesignRetrospective cohort study. MethodsPatients who presented with hand motions or better vision and received subconjunctival antibiotics (SC+ group) were compared with those who did not (SC− group) in the treatment of acute postoperative endophthalmitis. ResultsThe rate of obtaining a final vision of 20/40 or better was 60% in the SC+ group (n = 25) compared with 72% in the SC− group (n = 18) (P = .69), and the mean change in logMAR was –1.36 (improvement) versus –1.34 (P = .93). Based on a linear regression model controlling for presenting vision, there was no statistical difference in the mean logMAR change between the two groups (P = .73). ConclusionSubconjunctival antibiotic injection as an adjunct to intravitreal antibiotics was unassociated with treatment benefit in patients with acute postoperative endophthalmitis presenting with vision of hand motions or better.