Pathological findings in poststrabismus surgery endophthalmitis

Endophthalmitis after strabismus surgery: incidence and outcome in relation to age, operated eye muscle, surgical technique, scleral perforation and immune state

PURPOSE

Identify risk factors for endophthalmitis after strabismus surgery (EASS) and relate these to incidence and outcome.

METHODS

Ophthalmologists, who had operated, diagnosed or treated EASS, completed a case record form with 71 questions in six domains: Preoperative, Surgery, Perforation, Postoperative, Outcome and Experts' opinion. To estimate the age-specific incidence per number of strabismus operations in the Netherlands during 1994-2013, the age distribution of Dutch cases was compared with the age-specific rates of strabismus surgery in the Dutch Registry of Strabismus Operations and with population data. Exploratory data analysis was performed. The immune state was evaluated in six patients. Five enucleated eyes were studied histopathologically.

RESULTS

None of the 26 patients (27 eyes with EASS) were between 9 and 65 years old, except for one patient with retinal haemorrhage followed by endophthalmitis. In the Netherlands during 1994-2013, the rate of EASS was approximately one per 11 000 strabismus operations, but one per 4300 for children aged 0-3 and one per 1000 for patients 65 and older. Endophthalmitis was diagnosed on postoperative day 1-4 in children aged 0-3. In all 15 children aged 0-5, the 16 affected eyes were phthisical, eviscerated or enucleated. The involved eye muscle had been recessed in 25 of 27 cases. It was a medial rectus in 15 of 16 children aged 0-6. It was a lateral (6), inferior (2) or medial (1) rectus in elderly. Scleral perforation went unnoticed in all children (no record in three) and in two of seven elderly (no record in two). Histopathology showed transscleral scarring compatible with scleral perforation in four patients but, in a two-year-old girl who had EASS together with a transient medial rectus palsy, the sclera underneath the former suture tract was not perforated but did contain the long posterior ciliary artery.

CONCLUSIONS

Endophthalmitis after strabismus surgery (EASS) affects children and elderly, with a grave outcome in young children. It occurs after recession of the medial rectus muscle in children, and it may occur without scleral perforation. Age and perforation are key determinants that interact with other factors that determine the occurrence and fulminance of EASS.

Endophthalmitis Following Strabismus Surgery: IPOSC Global Study

PURPOSE

To examine the characteristics of patients with endophthalmitis after strabismus surgery (PSSE), the characteristics of the strabismus surgery, treatment, and prognosis as reported by pediatric ophthalmologists who are members of the American Association for Pediatric Ophthalmology and Strabismus (AAOPS) around the world.

METHODS

An email communication was sent to all members of AAPOS. The email included a web link to a survey that included 34 questions that examined the characteristics of patients with endophthalmitis after strabismus surgery.

RESULTS

Three hundred forty-nine ophthalmologists responded to the questionnaire. Two hundred sixty four (76%) had practiced pediatric ophthalmology for over 10 years. Twenty-seven cases of endophthalmitis were reported. The medial rectus muscle (MR) was the most common muscle undergoing surgery (55%). In 5 patients (21%), perforation was observed at the time of surgery. In all cases, endophthalmitis was diagnosed 3-7 days after surgery. The final visual acuity of 34% was no light perception (NLP).

DISCUSSION

This series is the largest existing series on PSSE. Our data suggest that PSSE can occur also in healthy patients and in patients without a visualized scleral perforation. The majority of PSSE occurs during the first week after surgery. Therefore, we believe that all patients that underwent strabismus surgery should be examined in this time frame. The prognosis was poor with 48% demonstrating a visual acuity of LP or NLP at the final follow-up.

A Case of Endophthalmitis After Bilateral Medial Rectus Recession

A 9-month-old male infant with a history of Down syndrome underwent bilateral medial rectus recession. Two weeks postoperatively, he developed leukocoria of the left eye with a white opacity posterior to the lens, numerous undulations, necrosis, and hemorrhages in the retrolental space. His contralateral eye had white retinal lesions nasally. Ultrasound examination of the left eye showed a funnel retinal detachment, loculated debris, and a small, central, hyperechoic area concerning for calcification. He underwent enucleation because retinoblastoma could not be definitively ruled out. Given this patient's low visual potential, enucleation was a definitive and safe treatment option. Ocular pathology showed significant inflammation and necrosis. There was an area of scleral perforation by a suture adherent to the retina and vitreous, surrounded by inflammatory cells. This case uniquely demonstrates pediatric endophthalmitis following strabismus surgery, secondary to scleral perforation confirmed by histopathological analysis. Care must be taken during scleral passage of sutures to prevent inadvertent scleral perforation and the potential complication of endophthalmitis. [J Pediatr Ophthalmol Strabismus. 2017;54:e37-e41.].

CONCURRENT ENDOPHTHALMITIS AND ANTERIOR SEGMENT ISCHEMIA AFTER STRABISMUS SURGERY

BACKGROUND/PURPOSE

To report a case of simultaneous endophthalmitis and anterior segment ischemia (ASI) that occurred in a patient after strabismus surgery. This is the first known case of both complications occurring at the same time.

METHODS

Case report.

RESULTS

A 60-year-old woman presented with eye pain and loss of vision 6 days after uncomplicated strabismus surgery for thyroid eye disease. On examination, she had corneal edema, anterior segment fibrin, an atonic iris, and no view to the posterior segment. On fluorescein angiography of the anterior segment, a large portion of the iris was nonperfused. Posterior segment ultrasound showed dense vitritis and a choroidal abscess. Intraoperative cultures grew methicillin-resistant Staphylococcus aureus.

CONCLUSIONS

Endophthalmitis and anterior segment ischemia are both exceedingly rare complications of strabismus surgery. It is possible that each one occurred independently, but more likely one process potentiated the other. One possible mechanism is inflammation-induced thrombosis.

Complications of strabismus surgery: incidence and risk factors

PURPOSE

To perform a systematic review of the complications of strabismus surgery, focusing on incidence and risk factors.

MATERIAL AND METHODS

A systematic literature search was performed using the Medline and Cochrane databases.

RESULTS

Local complications, such as conjunctival injection and mild scarring, are almost universal but only rarely have long-term clinical significance. There are several important complications that are uncommon but associated with significant long-term sequelae, including slipped muscles, lost muscles, stretched scars, incarcerated muscles, pulled-in-two syndrome, periocular infections, orbital cellulitis, scleral perforations, retinal detachments, endophthalmitis, anterior segment ischemia, and surgical errors.

DISCUSSION

Strabismus surgery is associated with a number of common and serious complications, and it is important for both surgeons and patients to be aware of the risks.

Bacterial Species and Surgical Sites Involved in Contamination During Strabismus Surgery

PURPOSE

Residual bacterial colonization of the eye after strabismus surgery is common. This study aimed to identify the bacterial pathogens and contaminated sites involved during strabismus surgery.

DESIGN

A prospective, case-control study of 44 patients aged 1-78 years who underwent strabismus surgery.

METHODS

Before participation, we received clinical research board approval, and informed consent was obtained from each of the patients or the parents. Five percent povidone-iodine was used to sterilize the surgical site in all cases. Intraoperative swabs were taken from conjunctival incision site, plain gut suture, scleral surgery site, Vicryl suture, and lid specula. Bacteria isolates were identified by culture growth and Gram staining. Positive and negative control samples were collected.

RESULTS

Samples from 13 (29.5%) of 44 cases were positive for growth of bacteria. The conjunctival incision site was involved in 9 cases (20.5%), and the lid speculum in 7 cases (15.9%). All 13 colonized plates grew the coagulase-negative Staphylococcus strain. Staphylococcus aureus was cultured in 1 case (2.3%) and was associated with the only case of postoperative infection. The S. aureus cultures came from both the conjunctival incision site and the lid speculum.

CONCLUSIONS

Despite a high contamination rate of 29.5%, incidence of clinically significant infection was low. Our study suggests involvement of the eyelids and conjunctiva in harboring bacteria even after the use of povidone-iodine. Regardless of the mechanism of contamination, we should continue to focus our efforts on reducing intraoperative conjunctival bacterial load. Irregular tear film can contribute to postoperative complications.