Subconjunctival Antibiotic Injection Research Articles

Risk Factors for Endophthalmitis Following Open Globe Injuries: A 17-Year Analysis.

Background/AimsTo determine the rate of endophthalmitis and assess risk factors for development of endophthalmitis following open globe injury (OGI).MethodsA retrospective chart review of all patients treated for OGI at the University of Michigan from January 2000 to July 2017 was conducted. Exclusion criteria included intravitreal injection or intraocular surgery in the 30 days prior to injury or less than 30 days of follow-up. A total of 586 out of 993 open globe injuries were included in the study. The main outcome measure was the rate of endophthalmitis.ResultsIn this study, 25/586 eyes (4.3%) had endophthalmitis. Of these, 12/25 eyes (48.0%) presented with endophthalmitis and 13/25 eyes (52.0%) developed endophthalmitis after globe closure. Multivariate analysis identified time to globe repair (OR 4.5, CI 1.9–10.7, p = 0.0008), zone I injury (OR 3.6, CI 1.1–11.0, p = 0.0282), and need for additional surgery (OR 5.5, CI 1.5–19.7, p = 0.0092) as factors associated with increased risk of developing endophthalmitis. Subconjunctival antibiotic injection at the time of globe closure (OR 0.3, CI 0.1–0.7, p = 0.0036) was associated with decreased risk of developing endophthalmitis.ConclusionPrompt globe closure and subconjunctival antibiotics may reduce the risk of endophthalmitis in OGI. Furthermore, our practice of a one-time dose of systemic prophylactic antibiotics, and intravitreal antibiotics if intraocular foreign body (IOFB) removal is delayed, was not found to increase the rate of endophthalmitis.

Perioperative Antibiotics to Prevent Acute Endophthalmitis after Ophthalmic Surgery: A Systematic Review and Meta-Analysis.

BackgroundPost-operative endophthalmitis is a rare and dreaded complication in ophthalmic operations because it often induces irreparable vision loss. Although many ophthalmological studies aimed at reducing the rate of endophthalmitis have been performed around the world, controversy continues to surround some issues, including the choice of antimicrobials and their route of administration, duration and timing. The aim of this study is to investigate some of these unresolved issues.MethodsA systematic review and meta-analysis of randomized controlled trials and observational studies was performed. The PubMed, EMBASE, Cochrane Library and Clinical Trials databases were searched to identify studies published until Feb. 2016. The relative risk (RR) for each clinical outcome data is presented with 95% confidence intervals (CIs). Pooled estimates of effects were calculated using random-effect models.ResultsThirty-four studies from twenty-four reports involving 1264797 eyes were included in this analysis. Endophthalmitis occurred, on average, in one out of 6177 eyes when intracameral vancomycin/moxifloxacin were used and in one out of 1517 eyes when intracameral vancomycin/moxifloxacin were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.20 (0.10, 0.42) when intracameral antibiotics were used (p<0.0001). The subconjunctival injection of antibiotics was not superior to other administration routes included in this study (RR = 1.67, 95% CI (0.55, 5.05), p = 0.36). A statistically significant difference was found in the rate of endophthalmitis between the use and lack of use of topical antibiotics (RR = 0.65, 95% CI (0.43, 0.99), p = 0.04). However, no statistically significant difference was found in microbial isolation rates between these groups (RR = 0.77, 95% CI (0.34, 1.75), p = 0.53). When long-term and short-term use of topical antibiotics before surgery were compared, a statistically significant difference was found in microbial isolation rates (RR = 0.57, 95% CI (0.44, 0.74), p<0.0001).ConclusionsThis meta-analysis concluded intracameral antibiotics are effective at preventing endophthalmitis in ocular surgery. A randomized controlled trial confirms the efficacy of cefuroxime but recent large cohort studies support the efficacy of vancomycin/moxifloxacin intracamerally. Intracameral antibitoics are superior to subconjunctival injections but that irrigation antibitoic data are not of enough quality to make a comparison. Different results were found in two clinical outcomes between the use or lack of use of topical antibiotic therapy, we did not find sufficient evidence to conclude that its use prevents endophthalmitis.

Late onset endophthalmitis associated with unexposed glaucoma valved drainage device

We report an extremely rare presentation of late-onset endophthalmitis in a young adult patient with an unexposed Ahmed tube implant. The implant was inserted 11years prior to presentation. There was no history of trauma or any obvious exposure on clinical examination and the tube plate was filled with purulent material. After aqueous and vitreous tap, the patient underwent intracameral, intravitreal subconjunctival antibiotic injections and was started on systemic antibiotics with good response. Endophthalmitis associated with tube drainage device can present as late as 11years and even without an unexposed tube.

Survey of Japanese ophthalmic surgeons regarding perioperative disinfection and antibiotic prophylaxis in cataract surgery.

PurposeTo elucidate Japanese trends for perioperative disinfection and antibiotic selection during cataract surgeries.MethodsPerioperative iodine use and antibiotic prophylaxis for cataract surgery were surveyed in eight regions in Japan by mail or through interviews from February 1 to March 1, 2014.ResultsWe surveyed 572 surgeons, of whom 386 (67%) responded. Most of the surgeons (94%) used iodine compounds before surgery for periocular skin disinfection (povidone–iodine [PI]: 79%; polyvinyl alcohol-iodine [PAI]: 15%) or conjunctival disinfection (85%; PI: 36%; PAI: 49%). Preoperative conjunctival iodine was primarily used as an eye wash (irrigation: 95%) and less often as an eye drop (5%). It was determined that 31% of surgeons waited 30 seconds or more between periocular disinfection and conjunctival disinfection. During surgery, 14% of surgeons used iodine several times, including immediately before intraocular lens insertion, and 7% used the Shimada technique (repeated iodine irrigation). Preoperative antibiotic eye drops were used by 99% of surgeons, and antibiotics were added to the irrigation bottle by 22%. The surgeons reported use of subconjunctival antibiotic injections (23%), antibiotic ointments (79%), and intracameral antibiotics (7%: 22 moxifloxacin; 6 levofloxacin). All surgeons prescribed postoperative eye drops, with 10% initiating the drops on the day of surgery.ConclusionIodine compounds are commonly used preoperatively, but few institutions use iodine compounds intraoperatively, particularly with repeated application. The selection of antibiotic administration and disinfection technique has to be at the surgeon’s discretion. However, intracameral antibiotic and intraoperative iodine compound use are techniques that should be widely recognized.

Sub-Conjunctival Injection of Antibiotics vs. Povidone-Iodine Drop on Bacterial Colonies in Phacoemulsification Cataract Surgery.

Background:Postoperative endophthalmitis is one the most serious complications of cataract surgery. The majority of causative organisms in this destructive infection come from the patient’s own periocular flora. Efforts have been made to reduce the virulence of organisms in the eyelid and conjunctiva with perioperative topical antibiotics, preparation of surgical field, covering eyelids and conjunctival surface with 5% povidone–iodine solution and intracameral antibiotics at the time of surgery to minimize the risk of endophthalmitis.Objectives:We assessed the effect of subconjunctival injection of cefazolin and pouring povidone-iodine on the conjunctiva bacterial colony forming units (CFU) in phacoemulsification cataract surgery.Patients and Methods:In this prospective, randomized, double-blind clinical trial, 122 patients having phacoemulsification cataract surgery with clear corneal incision and topical anesthesia were randomized into two groups including group 1 (subconjunctival injection of cefazolin) and group 2 (recipients of a drop of povidone-iodine). Cultures were collected from the bulbar conjunctiva at the injection site and from the corresponding location in the patient’s eye, three different times.Results:The mean of eyelid samples on blood and chocolate agars, on the day after compared to the day before the surgery in group 1 showed a 52% and 56% reduction. These values were 58% and 50% in group 2 (P < 0.05). The mean CFU of conjunctiva before and at the end of surgery on blood and chocolate agars showed 57% and 56% reduction in group one and 51% and 52% reduction in group 2 (P < 0.05). While comparing mean CFU of conjunctiva at the end and one day post-surgery (interval of 14 ± 2 hours) showed 27% and 27% increase in group 1 and 20% and 21% increase in group 2 (P < 0.05), which reflects conjunctival flora proliferation during the early postoperative period.Conclusions:Due to the good tolerance of patients towards topical anesthesia, pouring a drop of povidone-iodine 10% seems to be a simple and acceptable method to reduce the growth of microorganisms of the conjunctiva.

Query to the author of ′comparison of different techniques of cataract surgery in bacterial contamination of the anterior chamber in diabetic and non-diabetic population′

Sir, We have read the article published in the current issue of IJO, titled “Comparison of different techniques of cataract surgery in bacterial contamination of the anterior chamber in diabetic and non-diabetic population.”[1] We have the following observations and would like to have author's comments on them. Side port in phacoemulsification surgery is understandable, but irrigation of the anterior chamber using the side port in MSICS indicates that a side port was made in MSICS patients also. However this is not mentioned in the MSICS steps. Kindly clarify, when was that made and the purpose served by the side port. Sub-conjunctival injection at the end of surgery was not given. As we see it, this is a usual practice in cataract surgery that a sub-conjunctival injection of steroid and antibiotics is given just before patching the eye in surgery under local anesthesia. Apart from a depot of antibiotic and steroid, sub-conjunctival injection helps in reposition of the conjunctival flap. Why this deviation from the routine practice? Only an antibiotic solution drop was instilled at the end of surgery. Was there any specific reason for not instilling steroid solution? As mentioned, the eye patch was opened after 6 h of surgery. Again we would consider this as a deviation from routine practice as the dressing is opened on the next day. Any advantage of not giving sub-conjunctival injection of antibiotic steroid solution and then early opening of the eye dressing to start topical medication? Kindly clarify. The eye drop regimen after opening the eye dressing was too aggressive. One hourly instillation of antibiotic steroid eye drop is not justified routinely without any evidence of excessive inflammation or infection. Kindly comment. The antibiotic steroid combination was started at one hourly frequency and later tapered to once daily. It is incorrect to taper the dose of any antibiotic. The antibiotics should be used in adequate dosage and stopped immediately, with no tapering, to prevent emergence of acquired bacterial resistance. Tapering of antibiotics is not justified at all. Author should have used separate antibiotic and steroid drops if they wanted to taper the steroid drop dosage instead of using fixed dose combination of steroid and antibiotic. It is ironical that the authors have condemned the use of antibiotics in irrigating solution for possibility of inducing resistance and at the same time indulged in tapering the dosage of antibiotic eye drop which itself is capable of inducing resistance by exposing the bacteria to sub-minimal lethal dosage.

How to prevent endophthalmitis in cataract surgeries?

Postoperative endophthalmitis is a very devastating complication and every step should be taken to reduce its occurrence. Unattended air conditioning filter systems are often the culprits and regular maintenance of the filters is of paramount importance. Shedders of pathogenic organisms amongst the theater personnel should be identified by regular screening and should be promptly treated. In addition to the use of Povidone iodine 5% solution in the conjunctival sac few minutes prior to surgery, proper construction of wound, injectable intraocular lenses, use of prophylactic intracameral antibiotics or prophylactic subconjunctival antibiotic injection at the conclusion of cataract surgery, placing a patch after the surgery for at least 4 h and initiating topical antibiotics from the same day of surgery helps to lower the frequency of postoperative endophthalmitis. Intraoperative posterior capsule rupture and anterior vitrectomy are risk factors for acute endophthalmitis, and utmost care to prevent posterior capsular rent should be taken while performing cataract surgery. Also, in case of such complication, these patients should be closely monitored for early signs of endophthalmitis in the postoperative period. In the unfortunate event of endophthalmitis the diagnosis should be prompt and treatment must be initiated as early as possible.

Reducing the risk for endophthalmitis after cataract surgery: Population-based nested case-control study: Endophthalmitis Population Study of Western Australia sixth report

To characterize operative and nonoperative risks for the potentially blinding complication of endophthalmitis after cataract surgery. Ophthalmology services for the whole state of Western Australia. This retrospective population-based nested case-control study in Western Australia covered the period between 1980 and 2000. For each of the 205 cases of endophthalmitis, 4 time-matched controls were randomly selected from all cataract operations performed in the state. Conditional logistic regression was used to estimate multivariate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the risk factors of interest. Wound location, suturing the wound, and type of cataract operation did not affect the risk for postoperative endophthalmitis. Antibiotic prophylaxis reduced the risk, but only if given as a subconjunctival injection (OR, 0.46; 95% CI, 0.29-0.70). The risk for endophthalmitis was greater with same-day surgery (OR, 2.27; 95% CI, 1.52-3.41) than with admission the day before surgery. A concurrent eyelid procedure was a substantial risk. Surgeons within 2 years of obtaining specialist qualifications were more likely to have a case of endophthalmitis, although this was partly the result of more posterior capsule breaches. Posterior capsule breach increased the risk when it occurred in private hospitals (OR, 13.57; 95% CI, 4.00-45.99), but not in public hospitals. Nonoperative as well as operative factors are important in the prevention of endophthalmitis. Subconjunctival injection of antibiotics appears to be beneficial for endophthalmitis prophylaxis. The model showed that active risk management strategies designed to optimize hospitalization and chemoprophylaxis may reduce the incidence of endophthalmitis by up to 81%.

Investigation into postoperative endophthalmitis and lessons learned

To describe an approach to the investigation of a series of endophthalmitis cases to determine whether there was a true outbreak. Outpatient facility, Sunderland, England. Different approaches to statistical analysis of the probability of infrequent events being due to chance occurrence are described. Potential factors leading to an outbreak were reviewed. Bayesian statistical analysis was shown to be appropriate in the determination of an endophthalmitis outbreak. The only factor found to account for the outbreak was the operating surgeon's recent abandonment of subconjunctival antibiotic prophylaxis. This decision was based on the absence of good evidence that subconjunctival antibiotic injection is effective in prophylaxis. These endophthalmitis cases demonstrate that the absence of evidence for effect is not the same as there being no effect. Bayesian statistical analysis has a place in determining whether an outbreak has occurred. Withdrawing treatment simply on the basis of a lack of good evidence can lead to undesirable outcomes.

Prevention of endophthalmitis

We congratulate Buzard and Liapis1 on the absence of endophthalmitis following cataract surgery in their series of 5131 patients. The authors attributed this achievement to 4 factors: povidone–iodine prophylaxis, meticulous draping of the eyes, blue-line incision, and postoperative subconjunctival antibiotic injections. We would like to raise several points that may broaden the discussion. First, the lack of a control group in this retrospective study made it difficult to conclude which surgical steps effectively reduced the rate of endophthalmitis. The presumptive factors suggested by the authors were based solely on evidence from existing literature, together with logical deduction. Second, the 4 factors are commonly practiced perioperative routines. Montan and coauthors2 and Aaberg and coauthors3 have shown that the combination of these factors can effectively reduce the occurrence of postcataract endophthalmitis. However, the zero endophthalmitis rate reported in Buzard and Liapis' series compares favorably with the rate reported by Montan and coauthors (0.20%) and Aaberg and coauthors (0.09%). This suggests additional factors may account for this unusually low endophthalmitis rate. We would like to point out that all 5131 cataract surgeries were done by the same surgeon. This may contribute to the unusually low endophthalmitis rate in the study. Buzard took “meticulous” care in the surgical steps, including preoperative disinfection and draping. In addition, the mean surgery time was 10 minutes. These factors may be the reasons the results in this series stand out from those in other studies. While we fully agree with the authors that the 4 factors mentioned are critical in preventing postcataract endophthalmitis, their series of patients is a very good example that the already low incidence of endophthalmitis can be reduced further or even to zero when coupled with optimal surgical setting and excellent surgical skills provided that strict and meticulous surgical guidelines are followed. Wico W. Lai MD, FACS Hoi Fan MBBS Srinivas K. Rao FRCS Dennis S.C. Lam MD, FRCS Hong Kong, China

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

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

Patient comfort during clear corneal phacoemulsification with sub-Tenon’s local anesthesia

Purpose To assess patient comfort with and without intravenous (IV) cannulation during 1-quadrant sub-Tenon’s anesthesia during phacoemulsification. Setting Royal Alexandra Hospital, Paisley, Scotland, United Kingdom. Methods This prospective masked controlled clinical trial comprised 119 patients having elective clear corneal phacoemulsification. Fifty had sub-Tenon’s anesthesia with an IV cannula; 23, sub-Tenon’s anesthesia without an IV cannula; and 46, topical anesthesia of proparacaine 0.5% without an IV cannula. No patient received sedation. All patients had clear corneal phacoemulsification with foldable posterior chamber intraocular lens implantation. The patients’ subjective pain experience was measured immediately after surgery by a single independent observer using a 10-point visual analog scale. Results The mean patient-reported pain was low in all 3 groups. The mean IV-cannula-related pain score in the sub-Tenon’s group with an IV cannula (1.00; range 0 to 8) was higher than the mean general pain score (0.46; range 0 to 5) and worst pain experienced during surgery score (0.64; range 0 to 3). In the topical anesthesia group, 8 patients (17%) reported greater discomfort directly or indirectly related to the subconjunctival antibiotic injection at the end of surgery. Conclusions Patient-reported pain caused by placing an IV cannula in the sub-Tenon’s group significantly altered overall patient comfort during the surgical experience. Thus, the routine use of IV access during clear corneal phacoemulsification under sub-Tenon’s anesthesia should be avoided to improve patient satisfaction.

Bacterial endophthalmitis prophylaxis for cataract surgery: An evidence-based update

Purpose To assess commonly used cataract surgery bacterial endophthalmitis prophylaxis techniques based on a systematic literature review and evidence rating. Clinical relevance Prophylactic techniques to decrease the risk of bacterial endophthalmitis related to cataract surgery are commonly used, but the evidence justifying their use is unclear. Literature reviewed A MEDLINE search of the literature published in English or with English abstracts from 1966 to 2000 was performed using various combinations of relevant key words. Eighty-eight peer-reviewed papers were identified and judged worthy of review on the basis of predefined criteria. Results No prophylactic technique received the highest of three possible clinical recommendations (A, crucial to clinical outcome). Preoperative povidone-iodine preparation received the intermediate clinical recommendation (B, moderately important to clinical outcome). All other reported prophylactic interventions, including postoperative subconjunctival antibiotic injection, preoperative lash trimming, preoperative saline irrigation, preoperative topical antibiotics, antibiotic-containing irrigating solutions, and the use of intraoperative heparin, received the lowest clinical recommendation (C, possibly relevant but not definitely related to clinical outcome) based on weak and often conflicting evidence justifying their use. Conclusions With regard to bacterial endophthalmitis prophylaxis in cataract surgery, current literature most strongly supports the use of preoperative povidone-iodine antisepsis.

Endophthalmitis in the western Sydney region: a case-control study.

A retrospective case-control study was conducted to investigate risk factors for endophthalmitis following routine intraocular surgery. A review was performed of consecutive cases of endophthalmitis from three teaching hospitals in the western Sydney region and matched controls from the same institutions between 1996 and 1998. There were 31 cases and 66 controls. Eighty procedures were phacoemulsification, 15 conventional extracapsular cataract extraction, and two were penetrating keratoplasties. Of the 80 patients who had phacoemulsification surgery, 50 had a clear corneal incision, and 26 had a scleral incision (four were unknown). Logistic regression showed an increased risk of endophthalmitis with surgical complications (P = 0.002) and clear cornea temporal incisions (P = 0.007). Risk of endophthalmitis was reduced with use of subconjunctival injections (P = 0.008). The yield for the Gram stain was 47% and for culture was 67%. Anterior chamber tap in addition to vitreous biopsy alone did not increase the yield for microorganism (P = 0.78). Mean visual acuity on presentation was hand movement with 13 patients (50%) showing visual improvement following intravitreal injections of antibiotics (P = 0.003). Visual prognosis did not correlate with presenting visual acuity but appeared to be better in those who grew Staphylococcus epidermidis or were culture negative. Although this study is unable to draw definite conclusions regarding risk of endophthalmitis in clear corneal temporal cataract surgery, sufficient data suggest the importance of incision type and location. Surgical complication is an important risk factor for endophthalmitis. Use of subconjunctival antibiotic injections at the conclusion of the procedure is recommended.

Topical anesthesia for phacoemulsification and painless subconjunctival antibiotic injection

Endophthalmitis is a serious postoperative complication of phacoemulsification surgery. Administration of a subconjunctival antibiotic is a common method of prophylaxis in the United Kingdom and other countries. Injection of subconjunctival cefuroxime can be very painful, especially after phacoemulsification under topical anesthesia. Our experience is that this could be the only painful step in the entire operation. We evaluated a technique in which buffered lignocaine is injected into the subconjunctival space before the antibiotic injection. The technique was used in 46 eyes (46 patients) that had phacoemulsification under topical anesthesia. Eighty-seven percent of patients found the injection painless, 6.5% reported that the pain was very negligible, and 6.5% reported a moderate degree of pain.

Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery

Background: There is controversy as to the efficacy of various measures in the prophylaxis of endophthalmitis after cataract surgery. In addition, it has been suggested that clear-corneal incisions may convey an increased risk of postoperative infection. We performed a retrospective review to assess the effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery.Methods: A retrospective chart review and surgeon survey were used to collect data for the 13 886 consecutive cataract operations performed between Sept. I, 1994, and Jan. 31, 1998 by nine surgeons at a hospital-based surgical unit in Saskatoon. All cataract extractions were by phacoemulsification. All cases of endophthalmitis arising from the unit are managed at the hospital except in extenuating circumstances. We assessed the effect of preoperative administration of antibiotic drops, subconjunctival antibiotic injections at the conclusion of surgery and clear-corneal versus scleral tunnel incisions on the incidence of endophthalmitis by means of univariate and multivariate Poisson regression analysis.Results: The incidence of postoperative endophthalmitis was significantly lower with subconjunctival antibiotic injections than without such injections (0.011% vs. 0.179%) (p = 0.009, odds ratio 16.23 [95% confidence interval 1.92 to 137.14]). The difference in the incidence of endophthalmitis with preoperative use of antibiotic drops (0.066%) and with no antibiotic drops preoperatively (0.115%) was not significant. Similarly, the difference in the incidence of endophthalmitis with clearcorneal (0.129%) and scleral tunnel (0.0500 incisions was not significant.Interpretation: Our results suggest that prophylactic subconjunctival antibiotic injections at the conclusion of cataract surgery decrease the incidence of postoperative endophthalmitis.

Outpatient treatment of bleb infection.

To determine the outcome of outpatient treatment of bleb infection after trabeculectomy. Retrospective review. University referral center. Twelve eyes with bleb infection and without clinical vitreous involvement of 11 patients treated as out-patients from January 1994 to May 1996. After culture of the bleb surface, treatment consisted of intensive topical antibiotics alone (9 eyes), combined with subconjunctival antibiotic injection (1 eye), oral antibiotics (1 eye), or both (1 eye). Five eyes received topical corticosteroids. Visual acuity, intraocular pressure, and bleb characteristics. All eyes responded to treatment within 24 to 48 hours, and recovered visual acuity to within 1 line of the preinfection level. Intraocular pressure continued to be controlled after resolution of infection in 11 eyes (92%); 1 bleb failed and medical therapy was resumed. Bleb leaks were noted during treatment of infection in 11 eyes, and 5 eyes (42%) underwent bleb revision. Organisms cultured from the bleb surface included Staphylococcus aureus (8 eyes), Haemophilus influenzae (2 eyes), and Streptococcus (1 eye). Outpatient treatment costs were estimated to be 78% less than inpatient treatment costs, per 24 hours. Outpatient treatment of bleb infection was efficacious in this group of patients.

Acute endophthalmitis outbreak after cataract surgery

Purpose: To evaluate the source of organisms causing an epidemic of postoperative endophthalmitis and to emphasize the importance of prompt intervention with an early diagnosis.Setting: S.B. Ankara Hospital Eye Department, Ankara, Turkey.Methods: Thirteen patients who had surgery on the same day and developed acute postoperative endophthalmitis were evaluated. Clinical patterns were observed and intraocular cultures and stains performed in 10 eyes. Broad-spectrum intravitreal antibiotics were injected on an empirical basis.Results: Intravitreal cultures showed Pseudomonas aeruginosa in four cases and coaguIase-negative staphylococci in three cases; three cases were culture negative. P. aeruginosa were also isolated from irrigation solutions used on the same day. Two patients with P. aeruginosa had a visual acuity of 20/200 and 20/300, respectively.Conclusion: The different culture results were probably related to the amount of inoculation, individual risk factors, and the subconjunctival antibiotic injection given at the end of surgery. That one patient with P. aeruginosa endophthalmitis retained a visual acuity of 20/200 shows the importance of rapid intravitreal antibiotic treatment.

Microbial Keratitis in Children

Forty-seven eyes with microbial keratitis occurring in 44 children under 16 years of age were studied. Under the age of three, 92% of the infections involved Pseudomonas aeruginosa and/or various streptococcal species; later in childhood the typical adult pattern of infection was more common. Overwhelming systemic infections, malignant disease with orbital involvement and congenital ocular adnexal disease were important predisposing factors in the infant years; trauma and acquired external eye disease became increasingly important in mid-childhood. Surgery was necessary in 28% of the eyes. Frequent tearing and lack of patient cooperation preclude reliance on topical antibiotic therapy alone. Despite the difficulties, the mainstay of management involves daily biomicroscopic evaluation and regular subconjunctival antibiotic injections. The logistical problems of achieving these aims are discussed.

The Effect of Fortified Antibiotic Therapy on the Visual Outcome of Severe Bacterial Corneal Ulcers

Twenty-six patients with bacterial corneal ulcers measuring 4 mm or greater in the smallest diameter were evaluated retrospectively to determine the effect of different modes of antibiotic therapy on the ultimate visual result and medical treatment outcome. Eleven patients were treated only with topical commercially-supplied antibiotic solutions; 15 patients were treated with topical “fortified” antibiotics and/or subconjunctival antibiotic injections. No beneficial effect could be demonstrated in the group receiving the fortified antibiotics and subconjunctival injections. The use of subconjunctival antibiotic injections in the treatment of bacterial corneal ulceration is of questionable value. Although no increased benefit was found with the use of “fortified” antibiotic solutions, their probable enhanced antimicrobial effect and lack of increased epithelial toxicity justify their use in the treatment of bacterial keratitis