Prevention Of Postoperative Endophthalmitis Research Articles

A novel gatifloxacin-loaded intraocular lens for prophylaxis of postoperative endophthalmitis.

Postoperative endophthalmitis (POE) has been the most threatening complication after cataract surgery, which perhaps can be solved by the antibiotic-loaded intraocular lens (IOL). However, most drug-loaded IOLs demonstrate insufficient drug quantity, short release time, increased implantation-related difficulties or other noticeable drawbacks. To prevent POE and to address these deficiencies, a drug-loaded copolymer IOL, prepared from poly (urethane acrylate) prepolymer, isobornyl methacrylate (IBOMA), N-vinyl-2-pyrrolidone (NVP), Irgacure 819, RUVA-93, and gatifloxacin (GAT), was rapidly fabricated via photocuring and by using a 3D-printed mold. This composite displayed an outstanding and controllable GAT release behavior in vitro, a high light transmittance, and a moderate refractive index. Also, it demonstrated improved strain stress and elongation compared with the reference commercial acrylic IOL material. In vivo tests demonstrated satisfying released drug concentration at the early treatment stage. In vitro and in vivo studies further confirmed the remarkable bacterial inhibition and prevention of POE by the proposed IOL, which also displayed good biocompatibility. These findings suggested that the GAT-loaded IOL could be a promising implant to prevent and cure POE, also the proposed methods could inspire more designs for various medical applications.

Prevention of postoperative endophthalmitis – some random thoughts

Prevention of postoperative endophthalmitis – some random thoughts

Acute Endophthalmitis after Cataract Surgery: Clinical Characteristics and the Role of Intracameral Antibiotic Prophylaxis

To evaluate the clinical characteristics and investigate the role of surgical antibiotic prophylaxis (SAP) in acute endophthalmitis cases after cataract surgery. Retrospective, consecutive case series. A total of 126 patients referred to a tertiary center from 2007 to 2015 for acute endophthalmitis after unilateral cataract surgery. All patients who underwent a vitreous biopsy were included. Clinical and microbiology data were reviewed, and associations with visual outcome were analyzed using multivariate logistic regression. Data regarding SAP via intracameral injection were also retrieved. Bacterial culture results and visual acuity outcome. Bacterial growth was observed in 92 of 126 cases (73%). Among these positive cultures, 49 (53.3%), 29 (31.5%), and 13 (14.1%) were coagulase-negative staphylococci, other gram-positive, and gram-negative bacteria, respectively. Among the 77 gram-positive strains tested, 76 (98.7%) were vancomycin-sensitive; among the 12 gram-negative strains tested, all 12 (100%) were ceftazidime-sensitive. Best achieved visual acuity outcome was ≥20/40 Snellen in 77 of 114 cases (67.5%). On multivariate analysis, we found an association between visual outcome of worse than 20/40 Snellen and a positive culture of more virulent bacteria (gram-negative and other gram-positive groups) and presentation with light perception or worse, with an odds ratio of 3.3 and 3.0, respectively. A subgroup of 25 cases (19.8%) developed endophthalmitis despite receiving a SAP by cefuroxime at the end of cataract surgery. Two-thirds of the patients in this endophthalmitis cohort experienced a visual outcome of ≥20/40 Snellen. Efficacy of primary treatment with vancomycin combined with ceftazidime is supported by this study. A subgroup treated prophylactically with cefuroxime demonstrated that SAP alone does not prevent endophthalmitis. This highlights the importance of surgical factors in the prevention of postoperative endophthalmitis.

Intracameral cefuroxime in the prevention of postoperative endophthalmitis: an experience from Hong Kong.

The purpose was to study the effect of introducing intracameral cefuroxime, which was compounded by a hospital pharmacy, on postoperative endophthalmitis in a tertiary eye centre in Hong Kong. All cases that underwent cataract surgeries over a 12-year period (January 2004 to December 2015) were included. The routine use of intracameral cefuroxime at the end of cataract surgery was introduced at our centre after April 2010. All cefuroxime aliquots were prepared by the hospital pharmacy using an aseptic compounding technique. The rates of postoperative endophthalmitis before April 2010 (Group 1, no intracameral cefuroxime) and after April 2010 (Group 2, routine use of intracameral cefuroxime) were compared. A total of 30,428 eyes (7,332 in Group 1 and 23,096 in Group 2) were studied. Eight cases developed postoperative endophthalmitis (1.09 in 1000; 0.11%) in Group 1 whereas no cases developed endophthalmitis (0%) in Group 2. The rate of reduction was statistically significant (p < 0.0001). Seven out of eight cases of endophthalmitis were confirmed by positive culture. Organisms identified were Group G Streptococcus (two cases), Group B Streptococcus, Staphylococcus aureus, Serratia marcescens, and coagulase-negative Staphylococcus (two cases). Antibiotic susceptibility testing results were available in six cases. Four out of six organisms were susceptible to the penicillin group. No adverse events related to the use of intracameral cefuroxime were encountered. The use of intracameral cefuroxime could significantly reduce the rate of postoperative endophthalmitis in a tertiary centre in Hong Kong. The use of aseptic compounding to prepare cefuroxime aliquots by hospital pharmacy appeared to be safe and efficacious.

The incidence of postoperative endophthalmitis after cataract surgery in China: a multicenter investigation of 2006–2011

AimsTo estimate the cumulative incidence of postoperative endophthalmitis, identify risk factors and determine clinical outcomes in China.MethodsMedical records were reviewed for all patients with acute-onset endophthalmitis after cataract surgery from...

Can Intraocular Lenses Deliver Antibiotics Intracamerally?

To determine the therapeutic concentrations of moxifloxacin achieved in an artificial anterior chamber by soaking the hydrophobic acrylic AcrySof™ SA60 (Alcon Inc.) intraocular lens (IOL) and the hydrophilic collamer Afinity™ CQ2015 (Staar Inc.) IOL in commercially available moxifloxacin 0.5% (Vigamox™; Alcon Inc.). Forty IOLs (20 Acrysof SA60 and 20 Afinity CQ2015) were soaked in 1 mL of commercially available moxifloxacin 0.5%: 10 of each IOL for 1 min, and another 10 of each IOL for 10 min. The IOLs were placed on absorbent pads for 10 s on each side to dry excess liquid, and then placed in vials of 10 mL balanced salt solution (BSS™) for 30 min. Five milliliters of the balanced salt solution was removed and analyzed by high-pressure liquid chromatography to determine antibiotic levels. The moxifloxacin levels achieved after soaking the hydrophobic SA60 lens were 0.238 and 0.342 μg/mL for 1 and 10-min soaks, respectively. The moxifloxacin levels achieved after soaking the hydrophilic CQ2015 lens were 0.283 and 0.717 μg/mL for 1 and 10-min soaks, respectively. Both lenses were capable of delivering clinically significant antibiotic levels after a 1-min soak. Moxifloxacin concentrations reached at both 1 and 10-min soak times exceed the MIC(90) of the most common pathogens responsible for postoperative endophthalmitis. The antibiotic-soaked IOL has potential to become a clinically significant technique in the prevention of postoperative endophthalmitis.

Measurement of AQCmax of Five Different Ophthalmic Solutions and Discussion of Its New Application

After measuring the pharmacokinetic parameters of five fluoroquinolone ophthalmic solutions, we utilized the obtained indices to try to predict the clinical effects of antimicrobial ophthalmic solutions and apply the characteristics to the index for inhibition of resistant bacteria. Each ophthalmic solution was instilled in white rabbit eyes 3 times every 15 min and the anterior chamber aqueous humor was collected 10, 30, 60, 120, and 240 min after instillation. Drug concentrations were measured by high-performance liquid chromatography (HPLC) to determine the maximum aqueous concentration (AQCmax) of each drug by using a 1-compartment model. Moxifloxacin (MFLX) had the highest AQCmax, 9.04 microg/mL, among the five drugs, followed by levofloxacin (LVFX, 2.65 microg/mL), gatifloxacin (GFLX, 1.26 microg/mL), ofloxacin (OFLX, 0.89 microg/mL), and tosufloxacin (TFLX, 0.42 microg/mL) in descending order of AQCmax. Furthermore, the AQCmax/MPC (mutant prevention concentration) against Staphylococcus aureus was 15.07 and 1.06 for MFLX and LVFX, respectively. The AQCmax/MPC against Streptococcus pneumoniae was 18.08 and 1.15 for MFLX and LVFX, respectively. From these results, we can expect that the MFLX ophthalmic solution will be a sufficiently effective therapeutic agent in the treatment of eye infection, prevention of postoperative endophthalmitis, and prevention of drug resistance.

Use of collagen shields for ocular-surface drug delivery

Collagen shields are contact lens-shaped, dissolvable protein matrixes placed on the cornea, primarily indicated for the promotion of epithelial wound healing. The shield can also serve to deliver ocular medications if soaked in a water-soluble antibiotic and/or steroid solution prior to their placement. Collagen shields have distinct advantages over other precorneal drug reservoirs, such as intensive topical therapy, which inconveniences both the patients and caregivers, and subconjunctival injections, which risks hemorrhaging and perforation. It has also been suggested that collagen shields can be used to augment ocular tissue concentrations of various medications over topical administration alone. Despite these potential advantages, the use of collagen shields in drug delivery has not become common practice. In this article, we summarize the evidence for and against the use of collagen shields in delivering and sustaining high levels of ocular therapeutics, with a special focus on the prevention of postoperative endophthalmitis.

Postoperative endophthalmitis: optimal management and the role and timing of vitrectomy surgery

To review the evolving role of pars plana vitrectomy, as well as other therapeutic modalities, in the treatment and prevention of postoperative endophthalmitis and its sequelae. Medline database searches and review of recent relevant literature on the prevention and treatment of postoperative endophthalmitis. Despite significant technologic advances in ophthalmic surgery and the ready availability of improved pharmacologic agents, the rates of postoperative endophthalmitis have dramatically increased over the last decade. New surgical procedures, interventions, and techniques have increased patient exposures to this serious surgical complication. Cause, presentation, and outcome vary significantly requiring a tailored approach to each case. Appropriate prophylaxis and good surgical technique remain the mainstays of prevention. Intravitreal antibiotics and pars plana vitrectomy remain the primary treatment options. Postoperative endophthalmitis is a complex and multifaceted entity with potentially grave visual consequences. It requires a multifaceted approach, including appropriate prevention and prophylaxis, rapid recognition, and aggressive management. Since publication of the Endophthalmitis Vitrectomy Study, improvements in pharmacologic agents and vitrectomy techniques have refocused debate on the role of early surgical intervention in this condition.

In vitro study of antibiotic effect on bacterial adherence to acrylic intraocular lenses

Implantation of artificial intraocular lenses into the eye during ophthalmic surgical procedures ensures an unliving surface on which bacterial pathogens may attach and form biofilms. Despite antibiotic treatment bacteria growing in biofilms might cause inflammation and serious complications. In this study the adhesive ability of 7 Staphylococcus aureus and 11 coagulase-negative Staphylococcus (CNS) strains to the surface of acrylic intraocular lenses had been examined by the ultrasonic method. In untreated cases adhesion of the S. aureus and CNS strains did not differ significantly. We could not demonstrate significant differences between the adhesive ability of the standard strains and the clinical isolates. In this study a single – 60 min long – antibiotic (ciprofloxacin and tobramycin) treatment had been applied, that correlate well with the single or intermittant antibiotic prophylaxis of patients. Ciprofloxacin administration was able to reduce significantly the number of attached cells on the surface of acrylic lenses both in the case of S. aureus and CNS strains. Dependence of the effect from concentration could also be demonstrated. Tobramycin treatment was able to inhibit significantly the attachment of S. aureus cells. Despite the debate on antibiotic prophylaxis we presented in our experiments that a single antibiotic administration can decrease the attachment of bacterial cells to the surface of acrylic intraocular lenses, and might be effective in the prevention of postoperative endophthalmitis, that is a rare but serious complication of ophthalmic surgery.

Endophthalmitis: incidence and prevention

To present current peer-reviewed articles related to the incidence and prevention of postoperative endophthalmitis. Recent literature indicates that the incidence of postoperative endophthalmitis may be on the rise. Although the preoperative use of antibiotics as prophylaxis is still controversial, it is becoming more common. The reports of endophthalmitis analyzed from peer-reviewed ophthalmic journals suggest that the incidence of endophthalmitis has increased, ranging from 0.1 to 0.18% in different countries. This may be related to factors associated with the incision. Although some resistance has been detected, fourth-generation fluoroquinolones seem to be a proper antibiotic for endophthalmitis prophylaxis because of their spectrum, mode of action, and penetration.

Flomoxef Sodium and Levofloxacin Concentrations in Aqueous Humor

Aims: We intravenously administered flomoxef sodium (FMOX) 120 minutes before cataract surgery, topically administered levofloxacin (LVFX) into the eyes four times at 30-minute intervals before surgery, and measured the aqueous humor concentrations of these agents to investigate their penetration into the aqueous humor and their efficacy in the prevention of postoperative endophthalmitis. Methods: Sixty-eight patients who underwent cataract surgery at the Department of Ophthalmology, Yokohama City University School of Medicine, or its affiliate, Kanazawa Hospital, Yokohama, were enrolled in this study. They received one or both of the following: 1.0 g FMOX via a 20-minute intravenous drip and LVFX ophthalmic solution applied four times at 30-minute intervals, both beginning two hours before the operation. Aqueous humor was aspirated from the anterior chamber and assayed for FMOX and LVFX concentrations using high-performance liquid chromatography (HPLC). Results: The mean intraoperative FMOX and LVFX concentrations in the patients' aqueous humor were 1.21 ± 0.63 μ g/ml and 0.69 ± 0.47 μ g/ml, respectively. These concentrations sufficiently exceeded the MIC90 values against Staphylococcus epidermidis, S. aureus, and Propionibacterium acnes. Conclusions: The FMOX and LVFX concentrations in the aqueous humor sampling were adequate to kill bacteria in vitro. These drugs may have efficacy in the prevention of postoperative endophthalmitis in patients undergoing cataract surgery.

Prevention of endophthalmitis

To report the incidence of postoperative endophthalmitis in a series of patients who had cataract surgery with intraocular lens (IOL) implantation and to apply guidelines toward the prevention of postoperative endophthalmitis. The Buzard Eye Institute for Corneal, Refractive and Cataract Surgery, Las Vegas, Nevada, USA. In this prospective institutional study, 5,131 cataract surgery cases with IOL implantation were performed from 1998 to 2002 by 1 surgeon at a single institute. The surgeon used a blue-line incision at the superior location, povidone- iodine prophylaxis, and postoperative injection of subconjunctival antibiotics. The incidence of endophthalmitis in the study was compared with the general incidence in the United States (range 0.07% to 0.13%) and in published studies (range 0.02% to 0.57%). The 5,131 cases were followed for a mean of 2 years (range 3 months to 4 years). The mean patient age was 69.6 years +/- 10.9 (SD). No case of endophthalmitis occurred. The zero incidence of endophthalmitis was below the general incidence in the United States and in published studies. The findings suggest that the absence of postoperative endophthalmitis may be related to 4 factors: povidone-iodine prophylaxis, meticulous draping of the eyes, operative technique (blue-line incision), and postoperative injection of subconjunctival antibiotics.

Endophthalmitis in Auckland 1983–1991

A review was made of 58 cases of suspected endophthalmitis presenting to Auckland Public Hospital between January 1983 and July 1991 (103 months). Thirty culture positive cases were found comprising 13 early onset postoperative, six delayed onset postoperative, five bleb-associated, four post-traumatic and two endogenous cases. The most frequent organism grown in postoperative endophthalmitis was Staphylococcus epidermidis. No conclusion could be reached as to the effectiveness of early versus delayed vitrectomy. Endophthalmitis due to S. epidermidis usually had a good prognosis while streptococcal endophthalmitis had a poor prognosis. Delayed-onset postoperative endophthalmitis most often had a good prognosis while bleb-associated endophthalmitis had a uniformly poor visual outcome. Two isolates responsible for cases of delayed-onset postoperative endophthalmitis, Propionibacterium acnes and Rhodococcus species, did not grow on agar plates until the seventh day of culture. Significant bacterial resistance to cephazolin was identified with 33% of Gram-positive and 75% of Gram-negative isolates resistant. Prevention of postoperative endophthalmitis is discussed.

Incidence of postoperative bacterial infections after planned intraocular interventions

Between August 1982 and August 1984 3059 intraocular operations were performed with topical prophylactic antibiotics. Results of conjunctival cultures did not influence the surgical schedule. 8179 intraocular operations were performed between September 1984 and August 1988. An intraocular operation was postponed until conjunctival cultures were negative using topical antibiotics administered at hourly intervals. The rate of postoperative intraocular infections decreased significantly (p less than 0.0001) from 21 (0.69%) of 3059 during the first to 9 (0.11%) of 8179 intraocular operations during the second observation period. In the first period 11 vitrectomies and 2 enucleations due to bacterial endophthalmitis had to be performed. In the second period 2 vitrectomies and no enucleations were necessary (p less than 0.0001). Our results indicate, that decontamination of the conjunctiva may be an import factor for the prevention of postoperative endophthalmitis following elective intraocular surgery.

Bakterielles Keim- und Resistenzspektrum der reizfreien Konjunktiva - 7845 präoperative Abstriche der Erlanger Univ.-Augenklinik

The type and extent of bacterial colonization of the conjunctiva at the time of an intraocular operation may have a major influence on the risk of post-operative endophthalmitis. Between March 1986 and December 1988 a total of 7845 preoperative conjunctival smears were therefore examined by culture of Erlangen University Eye Hospital, in cooperation with the Department of Clinical Microbiology. Altogether, 1221 (15.6%) of the smears were classified as positive. Surgery on the patients concerned was postponed and gentamicin eye drops were administered for decontamination of their conjunctivae until the smears were negative. From the positive smears 1393 strains were cultured, identified, and submitted to a resistance test. The present paper reports the frequency distribution of the species of bacteria isolated and their resistance behavior, and compares the results with those of other authors. The value of preoperative cultures in the prevention of postoperative endophthalmitis and the importance of resistance tests in the context of topical application of antibiotics are discussed.

A Randomized, Controlled Comparison of Anterior and Posterior Periocular Injection of Antibiotic in the Prevention of Postoperative Endophthalmitis

A randomized, controlled, prospective comparison of the effectiveness of anterior and posterior injections of antibiotics in the prevention of endophthalmitis following cataract extraction was carried out in a village hospital in Pakistan. The study involved 77,015 cataract operations performed mainly by two surgeons. Anterior subTenon injections ("subconjunctival") and posterior subTenon injections ("retrobulbar") were equally effective in preventing postoperative infection.

Prevention of Postoperative Endophthalmitis

Prevention of postoperative endophthalmitis (POE) requires (1) environmental control, (2) tissue control, and (3) anticipation of eyes at special risk of infection. Environmental control entails an adequate supply of finely filtered air and absolute sterility of solutions, medications, and objects and materials used during surgery. Tissue control involves degerming the skin of the operative field, inhibition of the flora of the lid margins by an antibiotic ointment use preoperatively, and pretreatment of the conjunctival tear film by soluble antibiotics possessing activity against Proteus and Pseudomonas as well as gram-positive species. Eyes at special risk of infection include those of diabetics, chronic alcoholics, and individuals who have been maintained for long periods of time on systemic or topical corticosteroids. Patients who have had multiple eye operations, recurrent uveitis, and who are scheduled for surgery on the second eye during a single hospital admission should receive special consideration preoperatively.

Introduction: Incidence and Etiology

Postoperative endophthalmitis (POE) can occur after any type of intraocular surgery including operations for cataract, glaucoma, penetrating keratoplasty, retinal detachment, vitrectomy, and the repair of perforating trauma. Notwithstanding a gradual reduction in the overall incidence of POE, sporadic cases and occasional multiple outbreaks continue to cause the loss of eyes. This symposium is concerned with the incidence, epidemiology, diagnosis, therapy, and prevention of POE caused by bacteria and fungi.