Abstract
Background
Endophthalmitis after cataract surgery is an uncommon but devastating complication. Prophylactic intracameral injection of cefuroxime 1 mg at the end of surgery decreases the incidence five-fold. The visual outcome can be good (53% of cases having a visual acuity [VA] of better than 20/40) if treatment is initiated rapidly and follows the Endophthalmitis Vitrectomy Study (EVS) guidelines; but even with the best treatment, some patients end up with a poor visual outcome. Previous studies on postoperative endophthalmitis mainly focus on the cases performed in metropolitan tertiary hospitals; however, little information is available on the cases performed in local hospitals in rural areas.
Methods
We retrospectively reviewed the medical records of patients with acute endophthalmitis following cataract surgery, which were performed in local hospitals and later treated at the Zhongshan Ophthalmic Center between 1 January 1998 and 31 December 2009. Details of each case, including the interval from symptoms to presentation, initial treatment in local hospitals, microorganisms isolated, treatment, and visual outcome, were recorded. Cross-tabulations were conducted in order to identify the prognostic factors of final visual outcome.
Results
Forty-six patients referred from 36 local hospitals and later treated at the Zhongshan Ophthalmic Center were reviewed over the audit period. Most of these cases occurred in April. Gram-positive bacteria were the predominant etiology, with fungal infection accounting for 15%. Even though 54% of patients had symptoms within 3 days post-cataract surgery, they did not present to a tertiary center until a mean of 10 days. The main initial treatment in local hospitals is systemic antibiotics, instead of the intravitreal injection of antibiotics. A high proportion of cases (27/46) received immediate pars plana vitrectomy (PPV) in the tertiary center, and the antibiotic used for intravitreal injection was mainly tobramycin. The final visual outcome was poor, with only three cases having a VA ≥20/40.
Conclusion
A relatively high rate of fungal endophthalmitis suggests that sterilization patterns in local hospitals should be further revised. A delayed presentation, inappropriate treatment procedures, poor presenting VA, and causative organism virulence may account for the unfavorable visual outcome in this study.
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References
Kattan HM, Flynn HW Jr, Pflugfelder SC, Robertson C, Forster RK. Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery. Ophthalmology. 1991;98:227–38.
Javitt JC, Vitale S, Canner JK, Street DA, Krakauer H, McBean AM, Sommer A. National outcomes of cataract extraction. Endophthalmitis following inpatient surgery. Arch Ophthalmol. 1991;109:1085–9.
Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978–88.
Kresloff MS, Castellarin AA, Zarbin MA. Endophthalmitis. Surv Ophthalmol. 1998;43:193–224.
[No authors listed]. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995;113:1479–96.
Li J, Morlet N, Ng JQ, Semmens JB, Knuiman MW; Team EPSWA. Significant nonsurgical risk factors for endophthalmitis after cataract surgery: EPSWA fourth report. Invest Ophthalmol Vis Sci. 2004;45:1321–8.
Altan T, Acar N, Kapran Z, Unver YB, Yurttaser S, Küçüksümer Y, Eser I. Acute-onset endophthalmitis after cataract surgery: success of initial therapy, visual outcomes, and related factors. Retina. 2009;29:606–12.
Mollan SP, Gao A, Lockwood A, Durrani OM, Butler L. Postcataract endophthalmitis: incidence and microbial isolates in a United Kingdom region from 1996 through 2004. J Cataract Refract Surg. 2007;33:265–8.
Carrim ZI, Richardson J, Wykes WN. Incidence and visual outcome of acute endophthalmitis after cataract surgery—the experience of an eye department in Scotland. Br J Ophthalmol. 2009;93:721–5.
[No authors listed]. Microbiologic factors and visual outcome in the endophthalmitis vitrectomy study. Am J Ophthalmol. 1996;122:830–46.
Pijl BJ, Theelen T, Tilanus MA, Rentenaar R, Crama N. Acute endophthalmitis after cataract surgery: 250 consecutive cases treated at a tertiary referral center in the Netherlands. Am J Ophthalmol. 2010;149:482-7.e1–2.
Montan P, Lundström M, Stenevi U, Thorburn W. Endophthalmitis following cataract surgery in Sweden. The 1998 national prospective survey. Acta Ophthalmol Scand. 2002;80:258–61.
Cheng JH, Chang YH, Chen CL, Chen YH, Lu DW, Chen JT. Acute endophthalmitis after cataract surgery at a referral centre in Northern Taiwan: review of the causative organisms, antibiotic susceptibility, and clinical features. Eye (Lond). 2010;24:1359–65.
Kamalarajah S, Silvestri G, Sharma N, Khan A, Foot B, Ling R, Cran G, Best R. Surveillance of endophthalmitis following cataract surgery in the UK. Eye (Lond). 2004;18:580–7.
Chakrabarti A, Shivaprakash MR, Singh R, Tarai B, George VK, Fomda BA, Gupta A. Fungal endophthalmitis: fourteen years’ experience from a center in India. Retina. 2008;28:1400–7.
Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U, Athmanathan S, Rao TN. Microbiologic spectrum and susceptibility of isolates: part I. Postoperative endophthalmitis. Endophthalmitis Research Group. Am J Ophthalmol. 1999;128:240–2.
Anand AR, Therese KL, Madhavan HN. Spectrum of aetiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol. 2000;48:123–8.
Fahmy JA. Endophthalmitis following cataract extraction. A study of 24 cases in 4,498 operations. Acta Ophthalmol (Copenh). 1975;53:522–36.
Narang S, Gupta A, Gupta V, Dogra MR, Ram J, Pandav SS, Chakrabarti A. Fungal endophthalmitis following cataract surgery: clinical presentation, microbiological spectrum, and outcome. Am J Ophthalmol. 2001;132:609–17.
Krikonis TS, Panagiotoglou TD, Tsika C, Alegakis A, Pallikaris IG, Tsilimbaris MK. Endophthalmitis after cataract extraction: incidence, treatment, and outcome in Crete, Greece, during period 2000–2008. Semin Ophthalmol. 2009;24:234–8.
Al-Mezaine HS, Kangave D, Al-Assiri A, Al-Rajhi AA. Acute-onset nosocomial endophthalmitis after cataract surgery: incidence, clinical features, causative organisms, and visual outcomes. J Cataract Refract Surg. 2009;35:643–9.
Bohigian GM, Olk RJ. Factors associated with a poor visual result in endophthalmitis. Am J Ophthalmol. 1986;101:332–41.
Wong TY, Chee SP. The epidemiology of acute endophthalmitis after cataract surgery in an Asian population. Ophthalmology. 2004;111:699–705.
Horster S, Bader L, Seybold U, Eschler I, Riedel KG, Bogner JR. Stenotrophomonas maltophilia induced post-cataract-surgery endophthalmitis: outbreak investigation and clinical courses of 26 patients. Infection. 2009;37:117–22.
Lemley CA, Han DP. Endophthalmitis: a review of current evaluation and management. Retina. 2007;27:662–80.
Mamalis N, Kearsley L, Brinton E. Postoperative endophthalmitis. Curr Opin Ophthalmol. 2002;13:14–8.
Flynn HW Jr, Scott IU, Brod RD, Han DP. Current management of endophthalmitis. Int Ophthalmol Clin. 2004;44:115–37.
Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg. 2006;32:324–33.
Callegan MC, Gilmore MS, Gregory M, Ramadan RT, Wiskur BJ, Moyer AL, Hunt JJ, Novosad BD. Bacterial endophthalmitis: therapeutic challenges and host–pathogen interactions. Prog Retin Eye Res. 2007;26:189–203.
Ramadan RT, Ramirez R, Novosad BD, Callegan MC. Acute inflammation and loss of retinal architecture and function during experimental Bacillus endophthalmitis. Curr Eye Res. 2006;31:955–65.
Baum J, Peyman GA, Barza M. Intravitreal administration of antibiotic in the treatment of bacterial endophthalmitis. III. Consensus. Surv Ophthalmol. 1982;26:204–6.
Ferencz JR, Assia EI, Diamantstein L, Rubinstein E. Vancomycin concentration in the vitreous after intravenous and intravitreal administration for postoperative endophthalmitis. Arch Ophthalmol. 1999;117:1023–7.
Han DP, Wisniewski SR, Wilson LA, Barza M, Vine AK, Doft BH, Kelsey SF. Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol. 1996;122:1–17.
Ng JQ, Morlet N, Pearman JW, Constable IJ, McAllister IL, Kennedy CJ, Isaacs T, Semmens JB; Team EPSWA. Management and outcomes of postoperative endophthalmitis since the endophthalmitis vitrectomy study: the Endophthalmitis Population Study of Western Australia (EPSWA)’s fifth report. Ophthalmology. 2005;112:1199–206.
Miller D, Flynn PM, Scott IU, Alfonso EC, Flynn HW Jr. In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol. 2006;124:479–83.
Hariprasad SM, Shah GK, Mieler WF, Feiner L, Blinder KJ, Holekamp NM, Gao H, Prince RA. Vitreous and aqueous penetration of orally administered moxifloxacin in humans. Arch Ophthalmol. 2006;124:178–82.
Bratzler DW, Houck PM; Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg. 2005;189:395–404.
Acknowledgments
This project was supported by a grant from the Natural Science Foundation of China (30672276). The authors thank Jianxian Lin and Jianliang Zheng for their assistance in preparing the histologic specimens, and acknowledge our colleagues who referred these patients to our service.
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Y. Ding and M. Lin contributed equally to this work.
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Ding, Y., Lin, M., Liu, H. et al. Outcomes of post-cataract surgery endophthalmitis referred to a tertiary center from local hospitals in the south of China. Infection 39, 451–460 (2011). https://doi.org/10.1007/s15010-011-0138-0
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DOI: https://doi.org/10.1007/s15010-011-0138-0