Cases Of Postoperative Endophthalmitis Research Articles

The Safety and Efficacy of Routine Administration of Intracameral Vancomycin during Cataract Surgery.

Purpose. To evaluate the safety and efficacy of intracameral vancomycin during cataract surgery using a standardized dosage and delivery technique. Methods. The charts of 20,719 consecutive eyes that underwent phacoemulsification with intraocular lens implantation in a single ambulatory surgery center were retrospectively reviewed over a 5-year period. Results. The first 11,333 consecutive cases did not receive intracameral vancomycin, whereas the next 9,386 consecutive cases all received intracameral vancomycin. There were no significant differences in the baseline characteristics between the cohort of subjects who received intracameral vancomycin and the cohort of subjects that did not. There were a total of 11 subjects (0.97 cases per 1,000) that developed postoperative endophthalmitis in the group that did not receive intracameral vancomycin, whereas there were no cases of postoperative endophthalmitis in the group that received intracameral vancomycin (p = 0.0015). The overall rate of intraoperative and postoperative complications and the final postoperative visual acuities were similar among cohorts. There were no cases of toxic anterior segment syndrome occurring in either group during the study period. Conclusions. Routine administration of intracameral vancomycin during cataract surgery significantly decreased the incidence of postoperative endophthalmitis and was not associated with an increased incidence of postoperative adverse events.

Quality Assessment of Cataract Surgery in Denmark

Background: To assess the quality of cataract surgery in Denmark by studying the epidemiology of cataract surgery in Denmark during the last decade and by examining the risks of pseudophakic retinal detachment (PRD) and postoperative endophthalmitis (PE). Methods: A ph.d. thesis based on four register- and chart based studies. Results: It was found that over a 10 year calendar period a cataract operation increased the risk of PRD by a factor 4.2. Age and sex were statistically significant risk factors for retinal detachment but the effect of cataract surgery on the risk of retinal detachment per se was not statistically significantly modified by age and sex. The risk of PE at public eye departments was about 4 per 10000 registered cataract operations. A few private clinics had a statistically significantly higher risk of PE following registered cataract surgery compared to public eye departments. Out of 121 cases of PE, a complication after surgical intervention for PE occurred in 27% of all cases. Overall, a vitreous tap was not associated with a statistically significantly higher risk of surgical complications compared to a pars plana vitrectomy. Patients who underwent cataract surgery in private clinics were operated at an increasingly younger age and were healthier compared to patients who underwent cataract surgery in public hospitals. In general, there was a lack of registration of cataract surgery by the private clinics. Conclusions: The risks of PRD and PE can be used as quantitative indicators of the quality of cataract surgery in Denmark, but the lack of registration of cataract surgery by private clinics limits the quality of the Danish cataract registries. A more complete registration of cataract surgery in Denmark will make it easier to assess and monitor the quality of cataract surgery in the future.

A cluster of endophthalmitis caused by Mycobacterium abscessus after cataract surgery

We report two cases of postoperative endophthalmitis after cataract surgery caused by the same strain of Mycobacterium abscessus confirmed by arbitrarily primed polymerase chain reaction, sequencing of the erythromycin ribosome methyltransferase gene and pulsed-field gel electrophoresis. The outcomes were poor despite aggressive treatments. This is the first report of nontuberculous mycobacteria as a causative pathogen for a cluster of endophthalmitis.

Surgical outcomes of 23-gauge vitrectomy for the management of lens fragments dropped into the vitreous cavity during cataract surgery

PurposeTo assess the clinical features and surgical outcomes of 23-Gauge (G) vitrectomy for lens fragments dropped into the vitreous during cataract surgery. MethodsA retrospective, non-comparative, interventional case series at a single medical center. The medical records of 45 eyes from 45 consecutive patients who were referred to our hospital for surgical retrieval of phacoemulsification dropped lens fragments and who underwent 23-G vitrectomy were retrospectively reviewed. Data pertaining to patient demographics, pre- and post-operative Snellen visual acuity, and postoperative complications were recorded. Factors associated with dropped lens fragments were also examined. ResultsMean patient age was 68.18±11.47years. The preoperative and postoperative mean logarithm of minimum angle of resolution (logMAR) visual acuity was 1.91±0.59 (Snellen equivalent 0.06±0.15) and 0.42±0.51 (Snellen equivalent 0.54±0.31), respectively. Forty-two eyes (93.3%) had dislocated lens fragments <50% of the total lens size. Two eyes (4.4%) had a large and hard lens nucleus, which necessitated the use of a 20-G fragmatome to efficiently and completely remove the lens material. At the final examination, 30 eyes (66.6%) had a visual acuity better than 20/40. Post-vitrectomy complications included elevated IOP for at least 3months (n=5 eyes, 11.1%), intraocular lens dislocation (n=2 eyes, 4.4%), and cystoid macular edema (n=1 eye, 2.2%). No cases of postoperative endophthalmitis or retinal detachment were observed. ConclusionsA 23-G vitrectomy is safe and efficient for the surgical management of dropped lens fragments following cataract surgery.

Impact of Changes in Antibiotic Prophylaxis on Postoperative Endophthalmitis in a Spanish Hospital

Objective: This study aims to assess whether changes in antibiotic prophylaxis used in cataract surgery in the La Mancha Centro General Hospital, Spain, were associated with a reduced incidence of postoperative endophthalmitis (POE).Methods: The hospital employed two different antibiotic prophylaxis regimens during two clearly differentiated periods. In the first period (January 2000 to April 2003), subconjunctival injections of gentamicin were used while in the second (May 2003 to December 2008), vancomycin and gentamicin were added to the irrigating solution. During both periods, povidone iodine was used at the site of surgery and aminoglycoside eye drops were administered postoperatively. A Poisson regression model was used to evaluate the relationship between the incidence rate of endophthalmitis and variables such as time trends, seasonality, and change in antibiotic prophylaxis regimen.Results: During the period between 2000 and 2008, 26 cases of POE were detected after 14,285 operations for an incidence rate (IR) of 1.8 cases per 1000 procedures (95% confidence interval 1.2–2.7 cases out of 1000 procedures). In the period prior to the change in prophylaxis, 23 cases were detected (IR 4.5 cases/1000 procedures) while only three cases were observed in the period after the change (IR 0.3 cases/1000 procedures). A total of 84% of the microorganisms isolated were gram-positive, and all were sensitive to vancomycin.Conclusions: The change in antibiotic prophylaxis regimen for cataract surgery was associated with a relevant and significant decrease in the incidence of POE.

Biofilm: The Haven for Staphylococcus epidermidis in Post-operative Endophthalmitis

Background: Staphylococcus epidermidis, in spite of being a commensal of the eye, is regarded as one of the common etiological agents of bacterial endophthalmitis. The purpose of the study was to determine the pathogenic potential of this commensal organism in post-operative endophthalmitis. Methods: A total of 63 S epidermidids isolates, comprising of 47 from vitreous samples of post-operative endophthalmitis cases and 16 controls from the healthy conjunctivae, were studied. Biofilm producing ability was determined by quantitative adherence test and AB Polymerase Chain Reaction (PCR) assay. Bacteria adhering onto the lens surfaces were enumerated by standard protocol. Scanning electron microscopy (SEM) was employed to visualize the biofilms on the lenses. Results: Of the 47 isolates, 23 (48.9%) were adherent and 24 (51.0%) were nonadherent. PCR showed that 16 (34.0%) isolates possessed the ica locus whereas 31 (65.9%) did not possess this gene. All 16 (100%) ica positive organisms and only 7 (22.58%) of the 31 ica negative organisms adhered to artificial surfaces (p<0.001). SEM revealed that isolates carrying ica gene had formed intimate biofilms on intra ocular lenses. Clinical isolates showed significantly higher number of attaching bacteria onto the lens material as compared to the commensals. Conclusions: This study documented that bacteria carrying ica gene were found to be adherent and biofilm producers. Biofilm could be incriminated as a virulence marker for S epidermidis causing post-operative endophthalmitis. PCR was a sensitive and rapid tool to detect biofilm forming ability.

Treatment of Postoperative Endophthalmitis

Endophthalmitis is a feared complication of trauma, surgical procedures, and septicemia. The rates of postoperative endophthalmitis have been low for many years, but recent reports suggest that this type of ocular infection may be on the rise. Fluctuations in the number of cases appear to correlate with the type of intraocular surgery performed. Postoperative endophthalmitis has been reported as a consequence of nearly every type of ocular surgery, but is most common following cataract surgery. Numerous reports have demonstrated that Gram-positive bacteria cause the vast majority of postoperative endophthalmitis cases. Coagulase-negative staphylococcal isolates are the most common. Most intraocular infections resulting from infection with coagulase-negative staphylococci can be treated with antibiotic and anti-inflammatory agents, resulting in restoration of partial or complete vision. However, the more virulent the bacterial strain, the more devastating the visual outcome. Intraocular infections withStaphyloccus aureus, enterococci,Bacillus, or Gram-negative strains are often intractable, and blindness or loss of the eye itself is not uncommon. The therapeutic success of treating postoperative endophthalmitis depends largely on accurate and prompt diagnosis. Antibiotic therapy can be topical, sub conjunctival, systemic, or intravitreal. Vitrectomy must be reserved for patients who present with initial visual acuity of light perception. Only in these cases has vitrectomy been shown to be more advantageous in terms of the intravitreal antibiotic injection.

Postcataract Surgery Endophthalmitis after Introduction of the ESCRS Protocol: A 5-year Study

To present the results of a retrospective comparative unicentric institutional study of the incidence of postcataract surgery endophthalmitis before and after the introduction of the European Society of Cataract and Refractive Surgeons (ESCRS) protocol in 2007 in our department. This study included 15,689 eyes of patients undergoing cataract surgery between 2005 and 2011. Surgeries were performed by 9 different surgeons. After June 2007, the ESCRS protocol was introduced, and all patients underwent intracameral injection of 1 mg of cefuroxime (10 mg/mL) at the end of cataract surgery. Cefuroxime was prepared prior to surgery in the operating room. All patients were observed between 6 weeks and 3 months after surgery. Between January 2005 and June 2007, before the introduction of the ESCRS protocol in our department, 2299 patients underwent cataract surgery and there were 6 cases of postoperative endophthalmitis (0.26%). After the introduction of the protocol, 13,390 surgeries were performed and there were no cases of endophthalmitis. Postoperative endophthalmitis is one of the most devastating cataract surgery complications. Our results provide strong evidence of the utility of cefuroxime as prophylaxis of endophthalmitis after cataract surgery.

Outsourced cataract surgery and postoperative endophthalmitis

To compare the risk of postoperative endophthalmitis (PE) after cataract surgery at eye departments in public hospitals and private hospitals/eye clinics and to evaluate if the Danish National Patient Registry (NPR) is a reliable database to monitor the PE risk. Postoperative endophthalmitis cases were retrospectively identified via the NPR and chart review in order to confirm PE cases that had cataract surgery in the calendar period 2002-2010. We identified 39 cases of PE after 107 701 registered public cataract operations; PE risk = 0.36 [corrected] per 1000 operations and 27 cases of PE after 36 760 registered private operations; PE risk = 0.73 [corrected] per 1000 operations. There was homogeneity in the PE risk among the eye departments in public hospitals (p = 0.6), but heterogeneity in the PE risk among the private hospitals/eye clinics (p = 0.0001). Six private hospitals/eye clinics had a statistically significantly higher PE risk compared with the eye departments in public hospitals. In all, 98% of public cataract surgery was registered in the NPR compared with 38% of private cataract surgery. The private hospitals/eye clinics with the highest PE risk after registered cataract surgery had many cases of PE where the causative cataract operation was not registered with the NPR. A few private hospitals/eye clinics had a statistically significantly higher PE risk than the PE risk at the eye departments in public hospitals. The lack of registration with the NPR by the private hospitals/eye clinics suggests that better monitoring of cataract surgery is needed in Denmark to reduce risk and to improve quality.

Response to Nestel

Sir, We thank Dr Nestel1 for his interest in our study.2 We found some associations between the pathogenic conjunctival bacteria and the systemic co-morbidities of patients undergoing cataract surgery, which was the main purpose of the study. Among these associations, we found that enterococci prevalence is associated with age and diabetes. Owing to the current wide use of intracameral cefuroxime for the cataract surgery prophylaxis,3, 4 we introduced the example of the postoperative endophthalmitis (PE) caused by enterococci for illustrating the implications of our findings in the management of patients carrying conjunctival bacteria resistant to a particular prophylaxis, such as the enterococci to cefuroxime, as Dr Nestel pointed. The systemic co-morbidities associations with other bacteria (for instance multi-resistant Staphylococcus) could also help in choosing a prophylaxis. The answers to other comments are as follows: In the study design, polymyxin B plus trimethoprim eye drops is an empirical prophylaxis for all patients, except those having conjunctival pathogen bacteria resistant to these antibiotics, such as enterococci. We try not to increase the resistance to first-line antibiotic treatments. The occurrence of four PE cases in the first year of the study period2 was before using intracameral cefuroxime. This fact could point to streptococci as the most likely cause, as there was no case of Streptococci-PE in the ESCRS groups treated with cefuroxime,5 and no others prophylactic measures had changed in our study. The oral antibiotic for patients with conjunctival enterococci was chosen in accordance with their susceptibility tests;6 quinolones being the first choice, if possible. Finally, the ‘potential' risk of intraocular contamination by enterococci, in patients over 85 years, was calculated with respect to the conjunctival enterococci prevalence of patients younger than 86 years (Supplementary Table 3).2 This information is extended in Table 1. Table 1 Increasing potential risk of intraoperative contamination by enterococci according to age in patients operated on for cataract

Penetration of Prulifloxacin in human aqueous humour following oral administration

Editor, Endophthalmitis is one of the most serious sight-threatening complications secondary to intraocular procedures and penetrating intraocular trauma. Consequently, intraocular drug penetration capacity is warranted to prevent or treat this complication in the best way possible. Only a few drugs can penetrate in the eye after oral administration, and they rarely reach significant concentrations. Over the past 10 years, several studies have indicated that fluoroquinolone antibiotics achieve significant intraocular concentrations after oral administration, even in non-inflamed eyes (Cekic et al. 1999; Donnenfeld et al. 1997; Fiscella et al. 1999; Garcia-Saenz et al. 2001; Hariprasad et al.2003). We studied aqueous penetration after systemic administration of prulifloxacin (PFUX), a fourth-generation quinolone with a broad spectrum of activity. After systemic administration, PFUX is rapidly absorbed, reaches Tmax at 1 hr after being administered, has a long elimination half-life and is well distributed in tissues, often achieving concentrations that exceed serum concentrations. PFUX is generally administered in one 600-mg daily dose although a double dose can also be administered (a 600-mg tablet every 12 hr): it is rapidly metabolized into its active metabolite ulifloxacin (UFX). We studied forty patients selected among those referred for cataract surgery: they were randomly divided into two groups: the first group (20 patients) received a single oral dose of 600 mg PFUX at 7 a.m. on the day of surgery; the second group (20 patients) received two oral doses of 600 mg PFUX, the first one at 7 p.m. the day before surgery and the second at 7 a.m. on the day of surgery. Immediately before surgery, aqueous humour was aspirated by paracentesis using an insulin syringe, promptly transferred to a pretared Eppendorf vial and immediately stored at −20°C. As PFUX is rapidly metabolized into UFX, we determined its intraocular concentration through high-performance liquid chromatography (HPLC-UV) that uses a reversed-phase column as described previously (Pellegrino et al. 2008). Our study showed that PFUX penetrates into the aqueous humour after systemic administration: in the first group, mean UFX concentration was 0.03822 ± 0.022 μg/ml, and in the second group, it was 0.06255 ± 0.029 μm/ml. Moreover, UFX concentration increases linearly following the systemic dose, and it is constant without significant variations during the time of the examination (Fig. 1). Aqueous humour concentration of patients receiving a single and double oral dose of prulifloxacin. Our study showed that UFX reaches efficient therapeutic intraocular levels only for some pathogen infections: in fact, after a single dose, mean UFX concentration in the aqueous humour reaches MIC90 for Escherichia coli (0.025), Klebsiella oxytoca (0.025), Shigella sp. (0.025), Proteus mirabilis (0.025) and Morganella morganii (0.025), while after a double systemic dose of PFUX, mean UFX concentration reaches MIC90 also for Klebsiella pneumoniae (0.05) and Haemophilus influenzae (0.05). The Endophthalmitis Vitrectomy Study (EVS 1995) revealed that gram-positive bacteria cause 94.2% of cases of postoperative endophthalmitis, most commonly Staphylococcus epidermidis and Staphylococcus aureus. Gram-negative pathogens accounted for 5.9% of confirmed-growth isolates, and the most common pathogen involved is Proteus mirabilis (Han et al. 1996). Then, systemic administration of PFUX is efficient for only a limited number of intraocular postoperative infections, because it cannot reach clinically significant concentrations against the majority of gram-positive pathogens. However, the administration of 600 mg twice a day of PFUX ensured therapeutic aqueous concentrations against certain important pathogens, particularly Proteus mirabilis and Haemophilus influenzae, the major player in endophthalmitis after filtering surgery. We believe that because endophthalmitis is one of the most serious sight-threatening complications, this information is significant: it is useful to know the intraocular penetration capacity of each drug following systemic administration because it can potentially be used as a prophylaxis or as a therapy against infections.

Postcataract Surgery Endophthalmitis in the United States: Analysis of the Complete 2003 to 2004 Medicare Database of Cataract Surgeries

To estimate endophthalmitis incidence after cataract surgery nationally and at the state level in 2003 and 2004 and to explore risk factors. Analysis of Medicare beneficiary claims data. We evaluated billed claims for cataract surgery and endophthalmitis diagnosis and treatment for all Medicare fee-for-service beneficiaries in 2003-2004. Cataract surgeries were identified by procedure codes and merged with demographic information. Cataract annual surgical volume was calculated for all surgeons. Presumed postoperative endophthalmitis cases were identified by International Classification of Diseases-9 Clinical Modification Codes on claims within 42 days after surgery. Endophthalmitis rates and 95% confidence intervals (CI) were calculated at state and national levels. Logistic regression was used to investigate the association between developing endophthalmitis and surgery location and surgeon factors. Endophthalmitis incidence and risk factors. We included 4006 cases of presumed endophthalmitis, which occurred after 3 280 966 cataract surgeries. The national rate in 2003 was 1.33 per 1000 surgeries (95% CI, 1.27-1.38) and decreased to 1.11 per 1000 (95% CI, 1.06-1.16) in 2004. Males (relative risk [RR], 1.23; 95% CI, 1.15-1.31), older individuals (RR, 1.53; 95% CI, 1.38-1.69; ≥85 compared with 65-74 years), blacks (RR, 1.17; 95% CI, 1.03-1.33), and Native Americans (RR, 1.72; 95% CI, 1.07-2.77) had increased risk of disease. After adjustment, surgeries by surgeons with low annual volume (RR, 3.80; 95% CI, 3.13-4.61 for 1-50 compared with ≥1001 annual surgeries) and less experience (RR, 1.41; 95% CI, 1.25-1.59 for 1-10 compared with ≥30 years), and surgeries performed in 2003 (RR, 1.20; 95% CI, 1.13-1.28) had increased endophthalmitis risk. Endophthalmitis rates are lower than previous yearly US estimates, but remain higher than rates reported from a series of studies from Sweden; patient factors or methodologic differences may contribute to differences across countries. Patient age, gender, and race, and surgeon volume and years of experience are important risk factors.

Results at seven years after the use of intracamerular cefazolin as an endophthalmitis prophylaxis in cataract surgery

BackgroundTo evaluate results after seven years using prophylactic intracameral cefazolin for the prevention of endophthalmitis in cataract surgery.MethodsA prospective, observational study of all patients submitted to cataract surgery over the period January 1996 to December 2009. All cases of postoperative endophthalmitis over that period were reviewed. The patients were classified in two groups: Group 1 (11,696 patients) operated on between January 1996 and December 2002, Group 2 (13,305 patients) between January 2003 and December 2009 (in whom a 1 mg/0.1 bolus of intracameral cefazolin was instilled).ResultsDuring the study period, 76 cases of endophthalmitis were observed in Group 1, and seven in Group 2. The rate of postoperative endophthalmitis reduced from 0.63% to 0.05% with a cefazolin injection. The relative risk (RR) for endophthalmitis in Group 1 against group 2 was 11.45 [95% CI 5.72-22.84, p < 0.001].ConclusionsAn intracameral bolus injection of cefazolin (1 mg in 0.1 ml solution) at the conclusion of the cataract surgery significantly reduced the rate of postoperative endophthalmitis.

Treatment of Post-operative Endophthalmitis

The rates of post-operative endophthalmitis have been low for many years, but recent reports suggest that this type of ocular infection may be on the rise. Fluctuations in the number of cases appear to correlate with the type of intraocular surgery performed. Post-operative endophthalmitis has been reported as a consequence of nearly every type of ocular surgery, but is most common following cataract surgery. Numerous reports have demonstrated that Gram-positive bacteria cause the vast majority of post-operative endophthalmitis cases. Coagulase-negative staphylococcal isolates are the most common. Most intraocular infections resulting from infection with coagulase-negative staphylococci can be treated with antibiotic and anti-inflammatory agents, resulting in restoration of partial or complete vision. However, the more virulent the bacterial strain, the more devastating the visual outcome. Intraocular infections withstaphyloccus aureus,enterococci,Bacillusor Gram-negative strains are often intractable, and blindness or loss of the eye itself is not uncommon. The therapeutic success of treating post-operative endophthalmitis depends largely on accurate and prompt diagnosis. Antibiotic therapy can be topical, sub-conjunctival, systemic or intravitreal. Vitrectomy must be reserved for patients who present with initial visual acuity of light perception. Only in these cases has vitrectomy been shown to be more advantageous with respect to the intravitreal antibiotic injection.

Treatment of Post-operative Endophthalmitis

The rates of post-operative endophthalmitis have been low for many years, but recent reports suggest that this type of ocular infection may be on the rise. Fluctuations in the number of cases appear to correlate with the type of intraocular surgery performed. Post-operative endophthalmitis has been reported as a consequence of nearly every type of ocular surgery, but is most common following cataract surgery. Numerous reports have demonstrated that Gram-positive bacteria cause the vast majority of post-operative endophthalmitis cases. Coagulase-negative staphylococcal isolates are the most common. Most intraocular infections resulting from infection with coagulase-negative staphylococci can be treated with antibiotic and anti-inflammatory agents, resulting in restoration of partial or complete vision. However, the more virulent the bacterial strain, the more devastating the visual outcome. Intraocular infections withStaphyloccus aureus, enterococci,Bacillusor Gram-negative strains are often intractable, and blindness or loss of the eye itself is not uncommon. The therapeutic success of treating post-operative endophthalmitis depends largely on accurate and prompt diagnosis. Antibiotic therapy can be topical, sub-conjunctival, systemic or intravitreal. Vitrectomy must be reserved for patients who present with initial visual acuity of light perception. Only in these cases has vitrectomy been shown to be more advantageous with respect to the intravitreal antibiotic injection.

Endophthalmitis following cataract surgery: the role of prophylactic postoperative chloramphenicol eye drops

The main aim of the study was to assess whether omitting prophylactic postoperative topical antibiotics (chloramphenicol) influenced the risk of developing endophthalmitis after cataract surgery. We conducted a retrospective study including all patients who had cataract surgery at our outpatient cataract unit between 2004 and 2011. Postoperative topical antibiotics (chloramphenicol) were omitted from 2007 onwards, as was the first postoperative day review. Patients with a diagnosis of endophthalmitis after cataract surgery were extracted, and the rate of postoperative endophthalmitis (PE) before and after changing these routines was compared. The diagnosis of PE was defined as severe intraocular inflammation requiring prompt vitreous sampling for culture. Seven thousand one hundred and twenty-three and 8131 cataract surgeries were performed in the following periods: January 2004 through December 2006 (period 1) and January 2007 through December 2010 (period 2), respectively. Five cases of PE were identified in period 1 (0.070%) and four patients in period 2 (0.049%). The median time between cataract surgery and onset of symptoms was 6 days in period 1 and 4.5 days in period 2. Median time for intervention was 7 and 5 days postsurgery, respectively. We found no difference in the frequency of PE following cataract surgery when changing the postoperative topical medication from a mixture of corticosteroids and antibiotics to only corticosteroids.

Postoperative nosocomial endophthalmitis: is perioperative antibiotic prophylaxis advisable? A single centre’s experience

We report the endophthalmitis rate after cataract surgery in patients preoperatively given topical povidone-iodine and gentamicin-containing irrigation fluid as prophylaxis without intracameral cefuroxime or perioperative topical antibiotics. In a retrospective clinical study, we included patients undergoing cataract surgery over a 12-year period at one large university teaching hospital. Data from 26,566 cataract procedures were analysed. Cases of postoperative endophthalmitis were identified and diagnosed both clinically and microbiologically. A total of 26,566 cataract procedures were reviewed, and we identified 16 patients with postoperative endophthalmitis (rate: 0.6 per 1000 operations, or 0.06%; 95% confidence interval: 0.03-0.09%). A causative micro-organism was detected in 81.3% (13/16) of the cases. Most organisms were Gram-positive bacteria (10/13) with susceptibility to cefuroxime (9/10) and/or fluoroquinolones (4/8), and/or resistance to aminoglycosides (10/10). The three Gram-negative pathogens were susceptible to cefuroxime, aminoglycosides, and fluoroquinolones. Using our regimen of topical povidone-iodine and gentamicin irrigation, we observed a low postoperative endophthalmitis rate not differing from the infection rates recently reported in other large studies. We speculate that neither intracameral cefuroxime nor perioperative levofloxacin eye drops are necessary to minimise postoperative infectious complications following cataract surgery, and we suggest that the European Society of Cataract and Refractive Surgery guidelines (in which perioperative antibiotics are mandatory) therefore be revisited to permit alternative effective regimens for the prevention of postoperative infections following cataract surgery.

Clinical observations associated with proven and unproven cases in the ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery

To describe cases of postoperative endophthalmitis in the European Society of Cataract & Refractive Surgeons (ESCRS) study of the prophylaxis of endophthalmitis, compare characteristics of unproven cases and cases proven by culture or polymerase chain reaction, and compare the characteristics with those in other reported series. Twenty-four ophthalmology units in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom. Univariable and multivariable logistic regression models were used to analyze data for statistical association of signs and symptoms in cases with proven or unproven endophthalmitis. Specific data describing characteristics of the cases were compared between the 2 types of cases. Data from 29 endophthalmitis cases were analyzed. Swollen lids and pain were statistically associated with proven cases of endophthalmitis on univariable regression analysis. Multivariable analysis indicated that swollen lids and an opaque vitreous were associated with proven cases. Five cases of endophthalmitis occurred in the cefuroxime-treated groups. No case of streptococcal infection occurred in the cefuroxime-treated groups. However, cases of infection due to streptococci showed striking differences in visual acuity and were associated with earlier onset. Characteristics in the 29 cases parallel results in previous studies, such as the Endophthalmitis Vitrectomy Study, although the addition of a control group in the ESCRS study elicited additional findings. Swollen lids, pain, and an opaque vitreous were statistically associated with proven endophthalmitis cases in the ESCRS study.

Quality of life after postoperative endophthalmitis

The aim of this study is to determine if postoperative endophthalmitis adversely affects quality of life after cataract surgery. We compared quality of life in patients who developed endophthalmitis after cataract surgery between 1 January and 31 December 2003 with those who had uncomplicated surgery. The National Eye Institute VFQ-25 (VFQ-25) and EuroQol EQ-5D (EQ-5D) questionnaires and time trade-off utility scores were used to compare self-perceived general health and vision-related quality of life between groups. Linear regression was used to model differences between groups after adjusting for age, gender and visual acuity in the better eye. Nineteen postoperative endophthalmitis cases were compared with 30 who had uncomplicated cataract surgery. Following surgery the mean composite VFQ-25 score was 13.5% (95% confidence interval [CI]: 6.0-26.4, P < 0.01) lower in endophthalmitis cases. Endophthalmitis patients reported significantly lower (P < 0.05) general vision, near vision, peripheral vision, mental health and role difficulties subscales scores after adjusting for age, sex and visual acuity. No significant differences were found in other subscales. Mean time trade-off utility and all EQ-5D scores were similar except for mobility (95% CI: 0.04-0.68, P < 0.05). Endophthalmitis after cataract surgery negatively impacts on self-perceived vision-related quality of life, resulting in poorer psychological well-being and ability to maintain a role in daily life.

Treatment of two postoperative endophthalmitis cases due to Aspergillus flavus and Scopulariopsis spp. with local and systemic antifungal therapy

BackgroundEndophthalmitis is the inflammatory response to invasion of the eye with bacteria or fungi. The incidence of endophthalmitis after cataract surgery varies between 0.072–0.13 percent. Treatment of endophthalmitis with fungal etiology is difficult.Case PresentationCase 1: A 71-year old male diabetic patient developed postoperative endophthalmitis due to Aspergillus flavus. The patient was treated with topical amphotericin B ophthalmic solution, intravenous (IV) liposomal amphotericin-B and caspofungin following vitrectomy.Case 2: A 72-year old male cachectic patient developed postoperative endophthalmitis due to Scopulariopsis spp. The patient was treated with topical and IV voriconazole and caspofungin.ConclusionAspergillus spp. are responsible of postoperative fungal endophthalmitis. Endophthalmitis caused by Scopulariopsis spp. is a very rare condition. The two cases were successfully treated with local and systemic antifungal therapy.