Post-cataract Endophthalmitis Research Articles

Post-intravitreal injection and post-cataract extraction endophthalmitis visual outcomes by organism: A systematic review and meta-analysis

Purpose: To compare visual outcomes of endophthalmitis following intravitreal injections (IVI) and cataract extraction (CE) by causative organism. Methods: Searches in Cochrane Central Register of Controlled Trials, MEDLINE, and Embase identified articles reporting visual outcome by causative organism in post-IVI and CE endophthalmitis cases from January 2010-February 2022. A random-effects meta-analysis compared visual improvement amongst endophthalmitis cases by causative organism. Results: 85 out of 3317 retrieved studies were included. The highest degree of VA improvement in both post-IVI and post-CE endophthalmitis was seen in cases caused by coagulase-negative staphylococci (CONS), followed by gram-negative organisms, and other gram-positive organisms such as streptococci and enterococci. Culture negative cases showed more VA improvement than culture positive cases in post-IVI endophthalmitis. These results remained consistent when accounting for endophthalmitis treatment, IVI type, condition requiring IVI treatment, follow-up period and initial pre-procedural VA. Conclusion: CONS and gram-negative organisms show the most VA improvement in both post-IVI and post-CE endophthalmitis. Other gram-positive organisms such as streptococci and enterococci are associated with less visual improvement. This updated systematic review and meta-analysis reveals that the results of the Endophthalmitis Vitrectomy Study are consistent decades later despite advancements to surgical practices and evolution of microorganisms over time.

Visual outcome of 25 Gauge vitrectomy for acute post operative infectious endophthalmitis.

The correlation between the change in foveal thickness measured using optical coherence tomography (OCT) following surgery for infectious endophthalmitis and preoperative and postoperative visual acuity is uncertain, and there are few pertinent studies on this topic. We explored the variations in macular thickness using OCT after emergency vitrectomy for post-cataract infectious endophthalmitis and the relationship between macular thickness with changes in visual function. We included 10 cases of post-cataract infectious endophthalmitis. Each patient underwent 25-G vitrectomy. The infection in all 10 patients was under control and visual function improved. Postoperative vitreous humor culture was positive in 8 patients, including 7 cases of coagulase-negative Staphylococcus epidermidis and 1 case of Lactobacillus acidophilus. The average age of these 10 patients was 71.60 ± 8.71 years (P< 0.05, two-tailed). There was no significant correlation between time 2 (the time of onset after cataract surgery) and visual prognosis. The average time 1 (the time of the vitrification surgery caused by the onset of the disease) was 1.45 ± 0.76 days (P< 0.05, two-tailed). The postoperative 3dVA ranged from 0.20 to 3.00, with an average visual acuity of 1.87 ± 1.12, which was superior to the preoperative value (P< 0.01, two-tailed). The correlation between the post3dVA and post 1mVA was significant. The post 1mVA ranged from 0.05 to 2.20, with an average visual acuity of 0.94 ± 0.74 (P< 0.05, two-tailed). The correlation between post 1mVA and post3mVA was significant. Also, paired t-tests comparing preoperative and postoperative visual acuity revealed a significant correlation (P< 0.05, two-tailed). The post3mVA was 0-1.00 with an average visual acuity of 0.44 ± 0.41. The postoperative foveal thickness ranged from 176.00 to 514.00 μm, with an average thickness of 281.10 ± 113.12 μm. Emergency 25-G minimally invasive vitrectomy can improve visual acuity and decrease the reoperation rate for patients who have acquired post-cataract infectious endophthalmitis. There were significant correlations between age, disease onset to operation time, preoperative and postoperative visual acuity, and postoperative macular thickness.

Bacterial and fungal flora of conjunctiva of patients presenting with cataract and their seasonal variation in Northern India

Objectives: The objective of this study was to study the microbial flora (bacterial and fungal) of the conjunctival sac of patients presenting with cataracts at a tertiary care hospital in North India. Materials and Methods: This observational cross-sectional study included 320 eyes from 238 patients presenting with cataracts. Three conjunctival swabs were collected from each eye and analyzed for the presence of aerobes, anaerobes, and fungal growth. Statistical Analysis: The data were analyzed using R statistical environment 4.0 software, along with the R Commander plugin “EZR.” Kruskal–Wallis rank sum test. In addition, the Fisher exact test was conducted, considering P &lt; 0.05 as statistically significant. Results: A total of 75.63% (242) of conjunctival sacs were culture-positive, with a predominance of bacterial growth. On the other hand, 24.37% (78) of conjunctival sacs were sterile. Common commensals isolated included Staphylococcus epidermidis (34.06%), Staphylococcus aureus (10.0%), Propionibacterium spp. (7.5%), and Corynebacterium spp. (5.31%). There were 23 (10%) Gram-negative cultures, whereas three fungi were isolated, all of which were Candida spp. The highest total growths were observed in age group 2 (51–65 years); however, no statistically significant correlation existed between age groups and growths. Season 1, characterized by temperatures between 10° and 15°, exhibited maximum growths. The most growths were coagulase-negative staphylococci (CONS). Conclusions: Our study of North Indian eyes revealed that 75.63% of healthy conjunctival sacs showed positive cultures, mainly CONS, with no seasonal trend. Given CONS’s prevalence in post-cataract endophthalmitis, routine pre-operative conjunctival swabs could guide prophylaxis and lower rates of post-operative endophthalmitis.

Antibiotic susceptibility in Endophthalmitis Management Study and intravitreal antibiotic practice trend in India-EMS Report #5.

Analyze antibiotic susceptibility in the Endophthalmitis Management Study (EMS) and compare it with the current intravitreal antibiotic practice trend of members of the Vitreoretinal Society of India (VRSI) practicing in India. The microbiology work-up of undiluted vitreous included microscopy, culture-susceptibility, polymerase chain reaction (PCR), and next-generation sequencing (NGS). VRSI members were invited to the survey. The EMS conventional culture-susceptibility (PCR and NGS excluded) results were compared vis-a-vis gram-positive cocci (GPC), gram-negative bacilli (GNB), and less commonly used antibiotics with the current recommended intravitreal antibiotics. p < 0.05 was considered significant. Culture and positivity (culture + PCR/NGS) positivity was 28.8% and 56.1%, respectively. GPC was most susceptible to cefazolin, linezolid, and vancomycin; GNB was most susceptible to amikacin, ceftazidime, colistin, and imipenem. There was no susceptibility difference between cefazolin and vancomycin (p = 0.999) and between ceftazidime and imipenem (p = 1.0). Colistin was superior to ceftazidime (p = 0.047) against GNB. The GNB resistant to amikacin (n = 14) were equally susceptible to ceftazidime and colistin; resistant to ceftazidime (n = 16) were susceptible to colistin; and resistant to colistin (n = 7) were susceptible to ceftazidime. The preference of VRSI members (n = 231) practicing in India was a vancomycin-ceftazidime combination (82%), vancomycin for GPC (94%), ceftazidime for GNB (61%), and voriconazole for fungi (74%). In EMS, GPC had good susceptibility to vancomycin; GNB had good susceptibility to ceftazidime and colistin. Given the lower resistance of colistin, a vancomycin-colistin combination could be an alternative empiric treatment in post-cataract endophthalmitis in India.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of Cataract Surgery: Report 13, monitoring post-cataract surgery endophthalmitis rates-the rule of X.

Cataract surgical safety has improved over recent decades, with endophthalmitis rates before 2006 typically 0.13-0.15% compared with the most recent UK national estimate of 0.02%. There remains, however, substantial variation in reported rates from different centres. Due to the low event rate, this disparity may not be noticed and opportunities to improve therefore be missed. We propose a method of monitoring post-cataract endophthalmitis rates that would help centres with higher rates identify this. A statistical tool, available to download or use online, permits comparison of local endophthalmitis rate with the estimated UK rate of 0.02%. Centres are encouraged to maintain a register of endophthalmitis cases, and when the number reaches a threshold (X cases), either in a certain time period or in a fixed number of procedures, then the centre can consider itself as an outlier and trigger local investigations to improve infection control. Example outputs are offered, such as for a unit doing 5000 cataracts annually, a value of X is suggested such that the third case of endophthalmitis (X = 3) in a 12-month period would give 85% confidence, the fourth case 90% confidence and the fifth case 95% confidence that the true endophthalmitis rate for that unit was higher than the national average. This statistical tool provides a basis for units to set a threshold number of cases of endophthalmitis within a given period that would trigger local processes, thus helping inform local monitoring processes for this rare but potentially catastrophic complication of cataract surgery.

Clinical Factors, Treatment Selection, and Outcomes in Postcataract Fungal Endophthalmitis from Contaminated Viscoelastics

To investigate the factors associated with treatment outcomes of postcataract surgery fungal endophthalmitis outbreaks related to contaminated viscoelastics. Retrospective analysis of clinical data from multiple institutions. This study included 228 eyes of 210 patients who were diagnosed with postcataract surgery fungal endophthalmitis related to the use of viscoelastic material (Unial, Unimed Pharmaceutical Inc); they were followed up for 6 months after the diagnosis. Clinical features and causative species were identified and treatment outcomes were analyzed in patients who underwent 6 months of follow-up. Propensity score matching was conducted to elucidate the impact of vitrectomy timing and intraocular lens (IOL) removal on treatment outcomes. Clinical factors and selection of treatment modalities associated with treatment outcomes at 6 months. Baseline visual acuity (P < 0.01), age (P= 0.05), and the presence of corneal edema (P < 0.01) were closely associated with poor best-corrected visual acuity (BCVA) at 6 months. Patients who underwent immediate vitrectomy after diagnosis showed significantly better BCVA at 6 months (mean logarithm of minimum angle of resolution 0.26 ± 0.43 vs. 0.52 ± 0.52, P= 0.03) and greater degree of visual improvement (mean-0.17 ± 0.37 improvement vs. 0.10 ± 0.57 deterioration, P= 0.03) than those who underwent deferred vitrectomy. Patients who underwent IOL removal during vitrectomy required a lower number of intravitreal antifungal agent injections (mean 8.9 ± 9.1 vs. 16.7 ± 12.2, P < 0.01) and showed a lower incidence of repeated vitrectomy (20% vs. 82%, P<0.01) than in those without IOL removal. In postcataract fungal endophthalmitis, prompt vitrectomy at the time of diagnosis resulted in better treatment outcomes, and IOL removal reduced the treatment burden. Prompt and aggressive surgicalintervention should be considered for postcataract fungal endophthalmitis. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Role of Prophylactic Oral Antibiotics in the Prevention of Post-cataract Surgery Acute Infective Endophthalmitis.

Purpose To evaluate the role of perioperative oral antibiotics in the prevention of acute infective endophthalmitis (IE) after cataract surgery. Methods A prospective cohort study of patients older than 18 years of age undergoing uncomplicated phacoemulsification was conducted. Group A was given post-op oral ciprofloxacin for three days, whereas Group B was not. Both groups received 5% povidone-iodine (PVI) preparation for five minutes in the conjunctival cul-de-sac, and intracameral (IC) 0.5% moxifloxacin was administered at the end of the procedure as prophylaxis. The minimum post-opfollow-up period was six weeks. Results Out of 2161 patients, 859 (39.8%) were included in Group A, and 1302 (60.2%) were included in Group B. No significant difference in anterior chamber (AC) reaction was found on day 1 (p = 0.67), day 14 (p = 0.03), or day 45(p = 0.1). One patient developed acute post-op IE (0.04%)and two patients developed toxic anterior segment syndrome (TASS) from Group A. The non-oral antibiotic group had no serious complications. Conclusion Perioperative oral antibiotic use in routine clinical practice is not recommended for the prevention of acute post-op IE. Pre-op conjunctival PVI 5% for five minutes and IC moxifloxacin at the end of surgery were proven to be effective prophylactic measures in our study.

Intravitreal triple therapy with vancomycin, ceftazidime, and moxifloxacin for bacterial endophthalmitis: A Twelve-year experience.

Increasing rates of antibiotic resistance in endophthalmitis have been reported. This study examines outcomes of triple therapy with intravitreal vancomycin, ceftazidime, and moxifloxacin for endophthalmitis. Retrospective, consecutive series of all patients treated with abovementioned intravitreal antibiotics from January 2009 to June 2021. Percentages of eyes attaining greater than or equal to 20/200 and 20/50 Snellen visual acuities and adverse events were evaluated. 112 eyes met inclusion criteria. 63 of 112 eyes (56%) achieved a visual acuity of 20/200 during follow-up, with 39 (35%) returning to at least 20/50. In subgroup analysis, 23 of 24 (96%) eyes with post-cataract endophthalmitis obtained ≥ 20/200 acuity and 21 of 24 (88%) obtained ≥ 20/50 acuity during follow-up. There were no cases of macular infarction. Intravitreal moxifloxacin (160µg/0.1mL) was well tolerated as an adjunct to vancomycin and ceftazidime for bacterial endophthalmitis. Use of this novel combination offers several theoretical advantages compared to standard therapy with two antibiotics, including expanded gram-negative coverage and potential synergy, and may be particularly valuable in geographies where the local antibiogram supports empiric use. Further study is merited to verify the safety and efficacy profile.

Early Vitrectomy: An Effective Treatment for Acute Postcataract Surgery Endophthalmitis.

Endophthalmitis is a rare but a high morbid complication after cataract surgery, and a gold standard treatment is not recommended yet. In this study, we aim to evaluate the effect of early vitrectomy on the visual acuity of patients with postcataract endophthalmitis. This study was a single-arm clinical trial on 27 patients with postcataract surgery endophthalmitis. Early vitrectomy was the intervention. Visual acuity as the primary outcome was evaluated and compared at baseline, at discharge, and 1 and 3 months after the intervention. From 27 patients who included in our study, six patients gain favorable visual acuity of 5/10 and above (success rate = 22%), and four of them have no improvement in their visual acuity. Retinal detachment was reported as a complication in just one case. Negative culture was a predictor for success in terms of visual acuity after the surgery. All patients who gain favorable results, presented in the first 15 days after the cataract surgery. The result of our study showed that, considering complete, early vitrectomy for the treatment of postcataract surgery endophthalmitis, especially for those who presented in the first 15 days of cataract surgery and for those who have negative culture is promising.

Gallium-Based Nanoplatform for Combating Multidrug-Resistant Pseudomonas aeruginosa and Postoperative Inflammation in Endophthalmitis Secondary to Cataract Surgery.

Postcataract endophthalmitis (PCE), a devastating complication following cataract surgeries, is one of the most crucial diseases causing irreversible eye blindness. Pseudomonas aeruginosa (PA), a multiple-drug-resistance (MDR) pathogen, always leads to uncontrolled infection and severe inflammation in PCE that can be difficult to treat by antibiotics. Therefore, it is urgent to develop new feasible strategies composed of both antibacterial and anti-inflammatory capabilities. Here, we report a multifunctional non-antibiotic nanoplatform (Ga-mSiO2-BFN) comprised of clinically approved gallium, mesoporous silica, and bromfenac (BFN) as a co-modified release system to simultaneously eradicate MDR-PA infection and cure inflammation for PCE. The released gallium ions can disrupt bacterial iron metabolism. Meanwhile, the simultaneously released BFN can suppresses the inflammation both postoperation and postinfection of PCE. In the PCE rabbit model, the slit-lamp dispersion and retro-illumination micrograph, ophthalmic clinical grading, and etiological histopathology analysis demonstrated that Ga-mSiO2-BFN could eradicate the MDR infection and alleviate the secondary inflammation from MDR-PA infection. Moreover, both cellular biocompatibility and in vivo animal model application verified the biocompatibility. A potential antibacterial mechanism implicated in the antibacterial action was demonstrated by comprehensive assays of iron antagonism evolutionary curve, colony autofluorescence, polymerase chain reaction, and electron microscopy, showing a repressing siderophore peptide pyoverdine, pyoverdine synthetase D, and interfering with bacterial DNA synthesis. All composites of our nanoplatform were FDA approved, making the Ga-mSiO2-BFN as a potentially promising therapeutic approach for treating MDR-PA in PCE accompanying satisfactory prognosis and prospects for clinical translations.

Seasonal and environmental variations in endophthalmitis after intravitreal anti-vascular endothelial growth factor injection: a six-year review

Purpose/Aim To evaluate seasonal and environmental variations on the incidence and outcomes of post-injection endophthalmitis. Materials and Methods A single-center, retrospective cohort study was conducted including all patients diagnosed with post-injection endophthalmitis between 2013-2018. Associations between climate variables and endophthalmitis incidence were evaluated. Results Of 423,297 injections administered, seasonal distribution in spring, summer, autumn, and winter was 26%, 27%, 25%, and 22%, respectively. Of 171 cases of endophthalmitis identified, seasonal distribution over the spring, summer, autumn, and fall was 25%, 23%, 26%, and 26%, respectively. Endophthalmitis incidence was not correlated with monthly precipitation (p = 0.45), monthly snowfall (p = 0.49), or monthly temperature (p = 0.65). Worse visual outcomes at initial endophthalmitis presentation were correlated with increased precipitation level (p = 0.025), but were not correlated with snowfall level (p = 0.228) or mean monthly temperature (p = 0.132). Although there were no seasonal variations of visual acuity at endophthalmitis presentation (p = 0.894), odds of final visual acuity returning to within two lines of pre-endophthalmitis visual acuity were worse among patients with endophthalmitis diagnosed in the spring (OR, 0.041; p = 0.016). Conclusion In contrast to previous work on post-cataract endophthalmitis, seasonal and weather factors were not associated with post-injection endophthalmitis risk or bacterial species isolated. Visual outcomes at initial endophthalmitis presentation were correlated with precipitation, and worse visual outcomes were seen in patients who developed endophthalmitis in the spring.

Intracameral Bacteriophage Injection as Postoperative Prophylaxis for Enterococcus faecalis-Induced Endophthalmitis After Cataract Surgery in Rabbits.

PurposePost–cataract surgery bacterial endophthalmitis is a serious postoperative complication, and Enterococcus spp.–induced endophthalmitis reportedly has a particularly poor visual prognosis. This study aimed to demonstrate the prophylactic effect of postoperative intracameral phage administration in Enterococcus faecalis–induced endophthalmitis after cataract surgery in rabbits.MethodsEndophthalmitis was induced in rabbits by injecting E. faecalis into the anterior chamber just after lensectomy while simultaneously administering either phage phiEF24C-P2 or vehicle. Retinal function was evaluated using electroretinography. The number of viable bacteria and myeloperoxidase (MPO) activity in the eye and histopathologic examinations were analyzed 48 hours after infection.ResultsIn the vehicle-treated group, retinal function at 24 hours after infection was impaired, and the number of viable bacteria and MPO activity in the eye increased 48 hours later. In the phage-administered group, retinal function was maintained; the number of viable bacteria and MPO activity were significantly suppressed. Histopathologic examinations showed disruption of the retinal layers and the presence of numerous E. faecalis in the lens capsule and vitreous cavity in vehicle-treated eyes. In contrast, retinal structures were intact, and no E. faecalis staining was observed in phage-treated eyes. No retinal dysfunction was observed in the group that received phage only without lensectomy; almost no phage was detected in the eyes after 14 days of treatment.ConclusionsPhage administration in the anterior chamber did not cause retinal dysfunction and suppressed postoperative endophthalmitis in rabbits.Translational RelevanceIn vivo results of intracameral phage administration suggest that phages are a promising prophylactic candidate for postoperative endophthalmitis.

Postoperative Endophthalmitis After Cataract Surgery: An Update.

Postoperative endophthalmitis is a serious complication that can happen after cataract surgery. It occurs mainly due to invasion of the globe by microbial flora, bacteria, or fungi from the adnexa and environment during the time of surgery. All patients undergoing cataract surgery should be evaluated for any potential risk factors that can enhance the development of postoperative endophthalmitis; managing the intraoperative risk and prophylaxis protocols should be considered in order to reduce the risk of endophthalmitis. Early follow-up after cataract surgery is highly recommended to detect any sign of endophthalmitis so as to treat it immediately and ensure patient compliance on post-surgery medication and precautions to reduce the serious complications caused by late diagnosis and treatment of post-cataract endophthalmitis.

Commentary: Dexamethasone and dilemma

Postoperative endophthalmitis has always been a nightmare for the patients and surgeons alike. Around 90% of patients having post trabeculectomy endophthalmitis and 40% of patients having postcataract surgery endophthalmitis would end up having final visual acuity worse than 20/200.[1] The economic burden of endophthalmitis is also significant as stated by Schmier et al.;[2] the average adjusted ophthalmic reimbursements were 156% greater for cases that developed endophthalmitis than for subjects having uncomplicated cataract surgery. The psychological impact on quality of life is also significant leading to poorer psychological well-being and ability to maintain a role in daily life.[3] Even after decades of publishing, the endophthalmitis vitrectomy study (EVS)[4] still holds key role in the endophthalmitis management algorithms. Ho et al.[5] in their study suggested that early vitrectomy may be beneficial for all cases and not just the ones with light perception or worse visual acuity as stated in EVS.[4] Few other studies also favor early vitrectomy.[67] The notable fact that EVS includes only postcataract surgery cases makes its significance diluted in cases post procedures other than cataract surgery specially in current era of variety of intravitreal injections, newer and more advanced surgical techniques, and newer drugs. Additionally, the postcataract endophthalmitis was proven to have better visual outcome than post trabeculectomy, postintravitreal injection, and endogenous endophthalmitis.[5] In treating endophthalmitis, antibiotics are the mainstay. Their augmentation with steroids remains controversial as ever. Many studies have reported that steroids do not add additional benefit to the final visual acuity of the patients.[8] The time of starting of steroids remains in the uncertainty. Concerns have been expressed regarding their safety and long-term outcomes. Shah et al.[9] reported worse visual outcome with the use of intravitreal steroids. In contrary to these reports, multiple studies have reported favorable outcomes with the use of intravitreal steroids and some reported that with the use of steroids even though the visual acuity did not have benefit, the intraocular inflammation and the overall morbidity related to the condition were helped.[101112] Albrecht et al.[11] in their study analyzed groups of “postcataract surgery,” “bleb related,” and “other” endophthalmitis, and they found a clinical trend of better visual acuity in the subgroup of postcataract surgery endophthalmitis patients who received steroids. Gan et al.[12] found out in their prospective placebo-controlled study that there was a trend toward better visual outcome in patients with suspected bacterial endophthalmitis when treatment with intravitreal antibiotics was combined with intravitreal dexamethasone. Multiple animal studies have also found out intraocular steroids to be beneficial in endophthalmitis.[81314] The authors in their practice have also noticed that during vitrectomy, immediate KOH mount assessment in a standard lab to rule out fungal infection and adjuvant intravitreal dexamethasone has helped their patients with faster recovery and less inflammation. The current metaanalysis does not show any clear visual benefit from use of adjuvant intravitreal dexamethasone in bacterial endophthalmitis.[15] Prospective randomized controlled trials for the treatment of postprocedure endophthalmitis with multicenter involvement are needed to clarify the gray areas around the usage of steroids and formulating preferred practice patterns for the new era.

Commentary: Rule out lacrimal duct obstruction before every intraocular procedure.

The age of presentation often overlaps for a person with acquired cataracts and acquired nasolacrimal duct obstruction (NLDO). Hence, there is more probability of having an asymptomatic NLDO and a cataract in the same person. Ipsilateral NLDO is considered an important risk factor for postoperative endophthalmitis in an intraocular procedure. Therefore, it becomes mandatory to rule out ipsilateral NLDO in all patients planned for cataract surgery.[1] Overall, the reported incidence of NLDO is 3–6.6%, with a mean age range of 48–59.5 years.[12] The ophthalmic evaluation of cataract surgery focuses on the factors affecting the visual acuity outcomes, like the health of tear-film, cornea, and anterior and posterior segments. Similarly, the ocular investigations are also targeted mainly at calculating and computing the refractive indices directly involved in the outcome of cataract surgery. Regurgitation on pressing lacrimal sac (ROPLaS) and lacrimal irrigation are generally not included in the routine examination of most ophthalmic cases. Hence, an asymptomatic lacrimal patient with a cataract tends to get his/her NLDO missed. ROPLaS and/or lacrimal irrigation must be included in the preoperative workup of a cataract patient to avoid the chance of postoperative endophthalmitis.[3] Lacrimal irrigation is an invasive diagnostic procedure requiring the desired skill-set to avoid any iatrogenic injury to the delicate lacrimal drainage system and interpret the results. Moreover, the patient and examiner must be in specific positions for lacrimal irrigation rather than sitting on an examination chair and slit lamp. Each step requires patient co-operation, like topical anesthesia, gaze positioning of the patient, punctum dilatation (preferably superior), lacrimal cannula insertion in horizontal canaliculus, and perception of gently forced injection of fluid in nose or throat. A significant part of lacrimal irrigation is dependent on the patient’s co-operation and systemic condition. ROPLaS, on the other hand, is a simple test that can be easily performed in the sitting position (any position) of the patient without consuming much time in the workup period. All those beneficial parameters are vital in high-volume centers and screening camps in remote areas. The examiner desires no special instrumentation or patient co-operation. In a survey involving members of the Oculoplastics Association of India, ROPLaS (59.6%) was opted as the preferred modality compared to lacrimal irrigation/syringing (32.6%), for checking NLDO before cataract surgery.[3] The sensitivity and specificity of ROPLaS have been reported to be 93.2% and 99.3%, respectively.[1] They recommended preoperative lacrimal irrigation to be unnecessary in case of a negative ROPLaS test. A recent retrospective, single-center study from India, including a large sample size (87,144 eyes), compared postcataract surgery endophthalmitis rates among eyes undergoing syringing (48,071 eyes) or ROPLAS (39,073 eyes) test before cataract surgery.[4] They found that the rates of post-cataract endophthalmitis (PCE) were comparable among the eyes undergoing either syringing test or ROPLAS before cataract surgery. This study was performed to avoid lacrimal irrigation, an aerosol-generating procedure, during COVID-19 times. However, when the safety of a vision-restoring surgical procedure (elective cataract surgery) is in question, more details in the ophthalmic examination will add to the safety value. As per the current study by Kim et al.,[5] the ROPLaS and lacrimal irrigation are both recommended to be performed in the preoperative workup of a cataract patient.[5] In their study, the ROPLaS was performed by an ophthalmologist, while a trained ophthalmic technician performed the lacrimal irrigation. We want to emphasize that ophthalmologists should first train the technician adequately before performing an invasive procedure (lacrimal irrigation) on a patient. This would ensure the desired outcomes from the lacrimal irrigation procedure without iatrogenic trauma to the lacrimal punctum and canaliculus. Additionally, a history of significant epiphora ± discharge goes a long way in suspecting lacrimal obstructions. Slit-lamp examination of the tear film and inferior conjunctival fornix is a must to rule out any debris/discharge. The fluorescein dye staining provides basic information about the health of corneal epithelium, and the simultaneous observation of the fluorescein dye disappearance test can provide an additional dimension in ruling out lacrimal duct obstruction. We believe that if a patient has a positive ROPLaS test, lacrimal irrigation is not necessary. However, in a patient with negative ROPLaS, lacrimal irrigation should be performed before any intraocular procedure to avoid the most-dreaded complication of endophthalmitis due to a treatable cause - NLDO.

Endophthalmitis following Intravitreal Injection, Cataract Surgery, and Vitrectomy: Clinical Features and Visual Outcomes.

Purpose To describe and compare the clinical features and visual outcomes of endophthalmitis following intravitreal injections (IVI), cataract surgery, and pars plana vitrectomy (PPV). Methods This is a single-centre, retrospective study. All included patients had acute postoperative endophthalmitis secondary to one of these three procedures. Visual acuity (VA), comorbidities, time to presentation, and treatment were assessed. The primary outcome was visual outcome. A poor outcome was considered if final VA was worse than or equal to counting fingers (CF) and a good outcome was classified as VA better than CF. Results Over 12 years, a total of 61 patients were included. Twenty-seven cases were post-cataract endophthalmitis; twenty-five were post-IVI and nine post-PPV. Endophthalmitis post-PPV had a worse visual outcome (88.9% of patients with VA worse than or equal to CF 95% CI 51.3 to 100.0%) than endophthalmitis following cataract surgery (25.9% of patients with VA worse than or equal to CF 95% CI 11.0 to 39.9%) and the IVI subgroup (44.0% of VA worse than or equal to CF 95% CI 24.0 to 67.0%) (p=0.001 and p=0.047). There were no significant differences in the proportion of patients with a poor visual outcome between endophthalmitis following cataract surgery and IVI (p=0.171). Conclusions The number of patients with poor visual outcomes following acute endophthalmitis was similar in endophthalmitis following IVI and cataract surgery, but better than endophthalmitis following vitrectomy.

Subconjunctival antibiotics: an alternative to intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery

Background: There has been an increase in the use of routine intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery. However, this can be associated with serious adverse events. Previously, subconjunctival antibiotics were the preferred route but there is minimal literature directly comparing the two. Hence, the safest and most efficacious route of prophylactic antibiotic administration remains controversial. Purpose: To evaluate the efficacy and safety of subconjunctival with intracameral antibiotics for postoperative endophthalmitis (POE) prophylaxis in patients undergoing uncomplicated cataract surgery. Methods: A literature review was conducted in Cochrane and PubMed for studies that compared the efficacy of prophylactic subconjunctival and intracameral antibiotics for post-cataract endophthalmitis. Searches were not limited to English or study design. Results: Three observational studies showed that subconjunctival and intracameral antibiotics both reduced POE rates. Intracameral antibiotics demonstrated a high efficacy (OR = 0.25, 95% CI 0.13-0.46, p < 0.0001) but was also associated with increased potential complications. All studies were conducted in a sequential nature during which cataract surgery techniques and instrumentation have improved in recent years. Conclusion: In institutions with a high incidence of endophthalmitis, routine intracameral antibiotic use would be more appropriate. However, in facilities with lower rates of POE, the subconjunctival route of delivery can be an alternative due to its better safety profile.

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.

Streptococcus pneumoniae endophthalmitis: clinical settings, antibiotic susceptibility, and visual outcomes

Streptococcus pneumoniae endophthalmitis is clinically more severe, more difficult to treat, and carry a higher risk of vision loss, evisceration, or enucleation. This study is to investigate the clinical settings, antibiotic susceptibility, and visual outcomes of S. pneumoniae endophthalmitis at a tertiary referral center in Taiwan. S. pneumoniae endophthalmitis was diagnosed in 38 eyes of 38 patients. The main clinical features were postcataract endophthalmitis (n = 13, 34%) and endophthalmitis associated with corneal ulcer (n = 12, 32%), trauma (n = 6, 16%), endogenous etiology (n = 4, 11%), trabeculectomy (n = 2, 5%), and pterygium excision-related scleral ulcer (n = 1, 3%). Presenting visual acuity ranged from counting fingers to no light perception. Pars plana vitrectomy with intravitreal antibiotics was performed in 17 eyes (39%) in primary or secondary treatments. S. pneumoniae isolates were susceptible to vancomycin (38/38, 100%), penicillin (37/38, 97%), ceftriaxone (37/38, 97%), cefuroxime (12/15, 80%), levofloxacin (13/15 ,87%), and moxifloxacin (15/17, 88%). Final visual acuity was better than 20/400 in 3 of 38 eyes (8%), 5/200 to hand motions in 3 eyes (8%), and light perception to no light perception in 32 eyes (84%). Ten eyes (26%) underwent evisceration or enucleation. Although S. pneumoniae isolates were susceptible to vancomycin, S. pneumoniae endophthalmitis had a very poor visual prognosis.

Surveillance of post-cataract endophthalmitis at a tertiary referral center: a 10-year critical evaluation

BackgroundAcute post-cataract endophthalmitis (APE) is a rare complication potentially causing irreversible visual loss. A 10-year study of APE was conducted to determine its incidence, microbiological spectra and antibiotic resistance profile of APE-related pathogens at a major tertiary referral center in Brazil.MethodsAPE cases reported between January 2010 and December 2019 were included. Phacoemulsification and extracapsular cataract techniques were eligible; combined procedures, traumatic and congenital cataract were excluded. Vitreous samples were cultured and antimicrobial resistance was compared for the periods of 2010–2014 and 2015–2019. The results were analyzed with Fisher’s exact test.ResultsOur sample consisted of 40,491 cataract surgeries and 51 (0.126%) APE cases. Culture was positive in 35 cases (71.4%), of which 31 (88.6%) Gram-positive, 3 (8.6%) Gram-negative, and 1 (2.9%) fungal. The most frequently isolated organism was Staphylococcus epidermidis (n = 17/35, 48.6%), followed by Staphylococcus aureus (n = 4/35, 11.4%). From 2010–2014 to 2015–2019, antimicrobial resistance increased against moxifloxacin (11.1–54.5%, p = 0.07), ciprofloxacin (54.5–72.7%, p = 0.659) and oxacillin (66.7–93.3%, p = 0.13).ConclusionsThe observed incidence and microbial spectra were compatible with previous studies. A trend towards growing moxifloxacin and ciprofloxacin resistance was observed. Surveillance remains crucial to prevent treatment failure from antimicrobial resistance.