The treatment of postoperative endophthalmitis. Results of differing approaches to treatment

Post-cataract surgery endophthalmitis: Brief literature review

PURPOSE

To investigate recent evidence in prophylaxis and management of post-cataract surgery endophthalmitis.

METHODS

We conducted a literature search using Pubmed database for post cataract surgery endophthalmitis, and relevant articles were selected from original English papers published since 2015.

RESULTS

Forty-nine articles were published regarding post-cataract surgery endophthalmitis from January 2015 to February 2016. A low incidence of post-cataract surgery endophthalmitis has been reported. A growing number of articles are focusing on preventing endophthalmitis using intracameral antibiotics.

CONCLUSION

Based on the current evidence, intracameral antibiotics seems to be effective in preventing endophthalmitis after cataract surgery.

Evisceration techniques and implant extrusion rates: A retrospective review of two series and a survey of ASOPRS surgeons

PURPOSE

To compare implant extrusion rates in two retrospective series of patients, treated by different surgeons, and to determine if there are preferred evisceration and implant insertion techniques among oculoplastic surgeons.

METHODS

A retrospective review of cases of evisceration and implant insertion and a survey of oculoplastic surgeons.

RESULTS

The implant extrusion rate was zero in the author's series of 53 patients, compared with 27.1% (54 of 192 implants) in series treated by other surgeons. Statistically significant differences were found between the two series in surgical technique, wound care, and duration of antibiotic administration. The author routinely performed posterior sclerotomy, whereas the other surgeons did not. Average implant size was 18.8 mm in the author's series, compared with 13.7 mm in the other series. Antibiotic therapy was administered for 10 to 18 days in the author's series, compared with 28 to 46 days in patients treated by other surgeons. The response rate to the survey was 65% (223 of 343 surveys). Among the surgeons surveyed, immediate and secondary implant techniques were used in nearly equal frequency. Delayed implant technique is used least frequently. Reported implant extrusion rates varied greatly among surgeons, ranging from 0% to 20%. Only 3.9% of surgeons expressed a concern over sympathetic ophthalmia.

CONCLUSIONS

Injudicious antibiotic use and smaller implants do not decrease the risk of implant extrusion. The survey revealed that immediate and secondary implant techniques are used with equal frequency. The theoretical risk of sympathetic ophthalmia does not appear to be a concern to most surgeons.

MANAGING SEVERE ENDOPHTHALMITIS WITH THE USE OF AN ENDOSCOPE

BACKGROUND

To demonstrate the value of ophthalmic endoscopy in treating patients with severe vision-threatening endophthalmitis in whom visualization through the anterior ocular structures is compromised.

METHOD

In this retrospective study of patients with endophthalmitis operated on with the use of an endoscope between 1997 and 2003, demographics, cause of endophthalmitis, preoperative and postoperative vision, comorbid factors, complications, intraoperative retinal appearance, etiology, and additional procedures required were recorded.

RESULTS

Fifteen patients were included. A variety of causes were observed: endogenous endophthalmitis (n=3), penetrating trauma (n=2), post-cataract extraction (n=7), bleb infections (n=2), and post-retinal detachment surgery (n=1). Six-month follow-up is reported. Positive cultures were obtained in all but one case. Several patients had aggressive pathogenic organisms. Eight patients retained useful vision. Six of eight patients without retinal necrosis by endoscopic examination had improved vision, with final visual acuity varying between counting fingers and 20/20. Only 1 of 6 patients with retinal necrosis retained useful vision at 20/50.

CONCLUSION

The ophthalmic endoscope aids in performing safe, diagnostic, and therapeutic vitrectomy in endophthalmitis. Prognosis is dependent on preoperative visual acuity and retinal appearance seen at the time of endoscopic surgery.

Surgical management of postoperative endophthalmitis: comparison of 2 techniques

PURPOSE

To evaluate the results of 2 surgical techniques in eyes with postoperative endophthalmitis.

SETTING

Department of Ophthalmology, Dokuz Eylul University, School of Medicine, Izmir, Turkey.

METHODS

Twenty-four eyes with endophthalmitis after cataract surgery had vitrectomy as an initial procedure according to the Endophthalmitis Vitrectomy Study (EVS) criteria (Group 1, n = 24). These eyes were compared with 28 eyes that had total pars plana vitrectomy with an encircling band, silicone tamponade, and endolaser (Group 2, n = 28). The visual and anatomical outcomes and the need for additional procedures (repeat vitrectomy) were evaluated in the 2 groups.

RESULTS

In Group 1, 6 eyes (25.0%) had an additional procedure, 3 eyes (12.5%) had phthisis, and 21 eyes (87.5%) had successful surgery. In Group 2, no eye had an additional procedure, 1 eye (3.5%) had phthisis, and 27 eyes (96.4%) had successful surgery. The number of additional procedures was significantly less and the rate of surgical success was significantly higher in Group 2 than in Group 1 (P<.01).

CONCLUSION

Despite the poor visual prognosis of endophthalmitis surgery, more radical intervention can increase the chance of surgical success and decrease the number of additional procedures in eyes with postoperative endophthalmitis.

Revisiting early postoperative follow-up after phacoemulsification

PURPOSE

To determine whether postoperative evaluation of routine phacoemulsification can be safely and effectively performed on the day of surgery and 4 days postoperatively and evaluate the incidence and management of early intraocular pressure (IOP) elevations 3 to 7 hours postoperatively in patients with or without glaucoma.

SETTING

Community-based hospital.

METHODS

This retrospective series comprised 465 consecutive patients who had phacoemulsification and intraocular lens implantation. All patients had postoperative follow-up on the day of surgery (3 to 7 hours postoperatively) and at 4 days. Patients were classified into 2 groups: nonglaucoma (NG), 396 patients; and glaucoma (GL), 69 patients. The main outcome measures were the incidence and management of postoperative complications including IOP spikes, wound leaks, uveitis, and endophthalmitis.

RESULTS

Three to 7 hours postoperatively, 73 NG (18.4%) and 32 GL (46.4%) patients had IOP elevations greater than 28 mm Hg, a significant change from baseline (P <.0001). Fourteen NG (3.6%) and 13 GL (18.8%) patients had IOP elevations greater than 40 mm Hg (P <.0001). Significant IOP elevations were effectively managed with a paracentesis with or without short-term antiglaucoma medications on the day of surgery, with 75 NG (18.9%) and 39 GL (56.5%) patients requiring IOP intervention. There were no IOP elevations greater than 21 mm Hg on the next day or at 4 days. There were no complications that were missed at the same-day evaluation that may have been identified at the 1-day postoperative visit.

CONCLUSIONS

The results indicate that after routine phacoemulsification, patients can be safely and effectively reviewed on the day of surgery and 4 days postoperatively to identify and manage early postoperative IOP spikes. A significant number of patients, particularly those with preexisting glaucoma, had potentially harmful IOP spikes 3 to 7 hours postoperatively.

Visual outcomes following the use of intravitreal steroids in the treatment of postoperative endophthalmitis

OBJECTIVE

To compare visual outcomes between cases of acute postoperative endophthalmitis that did or did not receive intravitreal steroids.

DESIGN

Retrospective nonrandomized comparative trial.

PARTICIPANTS

Fifty-seven patients with postoperative endophthalmitis.

INTERVENTION

Thirty-one patients with postoperative endophthalmitis resulting from cataract extraction received both intravitreal antibiotics and steroids, whereas the remaining 26 received only intravitreal antibiotics.

MAIN OUTCOME MEASURES

Improvement in visual acuity.

RESULTS

Multivariate logistic regression was used to analyze the variables that potentially influence a three-line visual acuity improvement. The mean baseline visual acuities of both groups were comparable. The use of intravitreal steroids reduced the probability of developing a three-line improvement in visual acuity (odds ratio [OR] = 0.287; 95% confidence interval [CI] [0.072-0.852]). On the basis of logistic regression analysis using our multivariate model, gender, baseline visual acuity, and pars plana vitrectomy were not significantly associated with visual outcome differences between the two groups.

CONCLUSIONS

Patients who received intravitreal steroids had a significantly reduced likelihood of obtaining a three-line improvement in visual acuity. At a minimum our study provides no support for their use and, therefore, steroids may not be efficacious for acute endophthalmitis related to cataract extraction.

Endophthalmitis

Endophthalmitis is an inflammatory reaction of intraocular fluids or tissues. Infectious endophthalmitis is one of the most serious complications of ophthalmic surgery. Occasionally, infectious endophthalmitis is the presenting feature of an underlying systemic infection. Successful management of infectious endophthalmitis depends on timely diagnosis and institution of appropriate therapy. Recognition of the different clinical settings in which endophthalmitis occurs and awareness of the highly variable presentation it may have facilitate timely diagnosis. Biopsy of intraocular fluid/tissue is the only method that permits reliable diagnosis and treatment. The different presenting clinical settings, a rational approach to diagnosis (i.e., when, what, and how to biopsy), and the treatment of infectious endophthalmitis are reviewed.

Epidemic Bacillus endophthalmitis after cataract surgery I: acute presentation and outcome

OBJECTIVE

The purpose of the study is to report the clinical outcome of acute Bacillus endophthalmitis after cataract surgery.

DESIGN

The study design is a cohort study.

PARTICIPANTS

Fourteen eyes of 14 patients with epidemic acute postoperative inflammation after exposure to bacteria-contaminated viscoelastic material were studied.

INTERVENTION

Three patients with milder clinical presentations were treated without vitrectomy or antibiotics. Eleven patients with more severe infection were treated with vitrectomy as well as intravitreous and topical fortified antibiotics.

MAIN OUTCOME MEASURES

Final visual acuities were obtained in all 14 study patients. Results of microbiologic studies of aqueous and vitreous specimens from 11 vitrectomized eyes also were analyzed.

RESULTS

One patient with late presentation had severe inflammation and had phthisis bulbi develop with no light perception. The remaining 13 patients had successful resolution of inflammation after treatment by 1 month of follow-up. Twelve of these 13 patients, including 1 nonvitrectomized patient, had final visual acuities of 20/100 or better at 6 months' follow-up. Six patients, including two patients with nonvitrectomized eyes, had outcomes of 20/40 or better visual acuity. Bacillus species were grown from all 11 (100%) vitreous and 7 (88%) of 8 aqueous specimens obtained from vitrectomized patients, as well as from the contaminated viscoelastic material remaining in the operating room.

CONCLUSIONS

Postoperative Bacillus endophthalmitis need not result in poor outcome. Results depend on factors including bacterial load, specific bacterial species, timing of treatment, and immune status of the patient.

Assessment of a standard treatment protocol on visual outcome following presumed bacterial endophthalmitis

AIMS

The aim of this prospective study was, firstly, to judge the effect of early aggressive treatment with a standardised regimen of high dose broad spectrum intraocular and systemic antibiotics on visual outcome and, secondly, to assess the sensitivity of isolated organisms to the treatment regimen utilised.

METHODS

Thirty two consecutive patients presenting with presumed bacterial endophthalmitis were treated and completed follow up. In every case, intraocular sampling was undertaken and treatment with intraocular vancomycin, amikacin, and systemic ciprofloxacin was commenced immediately, followed by systemic steroids 1 day later.

RESULTS

In 69% of patients vision improved with 47% achieving a final visual acuity of 6/36 or better and 31% achieving 6/12 or better. Of the intraocular samples taken from post-surgical and post-traumatic cases, 10/27 (37%) and 3/5 (60%) were culture positive, respectively. All the bacteria isolated were sensitive to at least one of the three antibiotics used.

CONCLUSIONS

The study demonstrated that the combination of vancomycin, amikacin, and ciprofloxacin is adequate as a standard regimen for the treatment of most patients with suspected bacterial endophthalmitis. The prognosis for a good visual outcome, however, remains poor with 15/27 (55%) post-surgical and 2/5 (40%) post-traumatic cases achieving a final acuity of 6/60 or less.

The Endophthalmitis Vitrectomy Study. Relationship between clinical presentation and microbiologic spectrum

PURPOSE

The authors determine if specific features of the clinical presentation of acute postoperative endophthalmitis correlated with the microbiologic culture results.

METHODS

A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation were evaluated as part of a randomized clinical trial. Results of cultures performed on aqueous and vitreous specimens obtained at presentation were categorized as follows: gram-positive coagulase-negative micrococci, "other" gram-positive, gram-negative, and equivocal/no growth.

RESULTS

Eleven features of the initial clinical presentation were associated with significant differences in the microbiologic spectrum (P < 0.05). Baseline factors correlating with higher rates of both gram-negative and other gram-positive isolates were: corneal infiltrate, cataract wound abnormalities, afferent pupillary defect, loss of red reflex, initial light perception-only vision, and symptom onset within 2 days of surgery. Gram-negative organisms did not grow in any eyes in which a retinal vessel could be visualized, and 61.9% of these eyes had equivocal or no growth. Diabetes mellitus was associated with a higher yield of gram-positive, coagulase-negative micrococci. Eye pain was not a discriminator for culture results.

CONCLUSIONS

The presenting characteristics of acute endophthalmitis after cataract surgery may be helpful in predicting the most likely culture results. Such predictions do not appear sufficiently strong to guide the initial empiric choice of intravitreal antibiotics.

Endophthalmitis: immediate management using posterior capsulorhexis and anterior vitrectomy through reopened cataract surgery incision

An alternative tap/biopsy technique for early management of endophthalmitis is described. The technique uses the cataract surgery wound for anterior chamber washout and for a posterior continuous curvilinear capsulorhexis through which anterior vitrectomy, removal of part or all the vitreous abscess, and injection of antibiotics can be performed. The approach is safe, avoids pars plana incisions, and maintains capsule support for the intraocular lens or for removal and reimplantation of a posterior chamber lens in the bag.

Endophthalmitis associated with microbial keratitis

PURPOSE

The purpose of the study is to investigate possible risk factors, organisms cultured, and visual acuity outcomes of endophthalmitis associated with microbial keratitis.

METHODS

Records were reviewed of all patients with both positive corneal and positive intraocular cultures at the Bascom Palmer Eye Institute between January 1, 1990, and March 31, 1995.

RESULTS

Thirteen (92.9%) of 14 patients identified had documented keratitis before the diagnosis of endophthalmitis was made. Thirteen (92.9%) patients recently had used 1% prednisolone acetate eye drops, 2 (14.3%) received oral prednisone, and 5 (35.7%) were being treated for systemic conditions associated with relative immune dysfunction. Eight (57.1%) patients had a history of ocular surgery, and seven (50.0%) had wound abnormalities. Eight (57.1%) patients lacked an intact posterior capsule, four (28.6%) had a corneal perforation, and three (21.4%) had a history of dry eye. Gram-negative organisms (7), Staphylococcus aureus (3), streptococcal species (2), and fungi (4) were the most frequently isolated organisms. Coagulase-negative staphylococci were not isolated. Six (42.9%) patients achieved a post-treatment visual acuity of 20/200 or better. Three (21.4%) patients underwent enucleation or evisceration. Although not statistically significant, there was an association between appropriate initial antibiotic therapy and improved visual outcomes.

CONCLUSION

Patients in whom endophthalmitis associated with microbial keratitis develops have a frequent history of corticosteroid use, systemic conditions associated with relative immune dysfunction, lack of an intact posterior capsule, dry eye, wound abnormalities, and/or corneal perforation. In general, agents cultured consisted of organisms less frequently reported to be the causative agents in series of postoperative and post-traumatic endophthalmitis. Post-treatment visual outcomes generally were poor.

Minimum bactericidal concentrations of Propionibacterium acnes isolates from cases of chronic endophthalmitis

Six isolates of Propionibacterium acnes recovered from cases of chronic infectious endophthalmitis following extracapsular cataract extraction were tested for antibiotic susceptibility. All isolates were susceptible to penicillin, cefazolin, and vancomycin with a macrobroth dilution method. Minimum bactericidal concentrations testing at 72 h revealed that six of six isolates were killed by < or = 1.0 micrograms of vancomycin/ml, one of six isolates by < or = 1.0 micrograms of penicillin/ml, and zero of six isolates by < or = 1.0 micrograms cefazolin/ml.

Effects of norfloxacin on the retina in rabbits

BACKGROUND

Fluoroquinolones have a strong affinity with melanin, and their ocular effects have been reevaluated. Norfloxacin, one of the fluoroquinolones, has broad-spectrum activity against aerobic gram-positive and gram-negative bacteria. We examined the retinal toxicity and intraocular pharmacokinetics of intravitreal norfloxacin in rabbits.

METHODS

Twenty-three albino and 23 pigmented rabbits were divided into three groups to evaluate retinal toxicity and two groups to investigate the intraocular pharmacokinetics. Each of these five groups was further divided into two subgroups (albino rabbits and pigmented rabbits).

RESULTS

With 500 micrograms norfloxacin, the oscillatory potential of the electroretinogram was transiently and selectively deteriorated in albino and pigmented rabbits, whereas the electroretinogram remained unchanged with 50 micrograms in pigmented rabbits. No changes were observed in the visual evoked potential or on histology of the retina 7 days after an intravitreal injection of 50 or 500 micrograms norfloxacin. The electroretinogram and the retinal histology became abnormal 7 days after four intravitreal injections of 500 micrograms norfloxacin at 7-day intervals. As regards the intraocular pharmacokinetics after an intravitreal injection, the norfloxacin concentration in the chorioretina was as high as that in the vitreous 3 h after injection and was much higher than that in the vitreous 7 days after injection. Similar results were obtained after multiple injections.

CONCLUSIONS

These results indicate a high concentration of norfloxacin in the melanin-containing ocular tissues.

The treatment of endophthalmitis after cataract surgery: review of 26 cases

A retrospective study of 26 cases of postoperative endophthalmitis occurring after extracapsular cataract extraction and lens implantation was conducted between January 1989 and December 1992. Twenty-one of the 26 cases (81%) were diagnosed within two weeks after surgery. The most common organism isolated was Staphylococcus saprophyticus (23%). After the bacterial samples had been taken, cefotaxime or gentamicin was injected into anterior chamber and vitreous space. The therapy regimen consisted of topical tobramycin, Polysporin (polymyxinsulfate, neomycinsulfate and gramicidin), dexamethasone and atropine and parabulbar cefotaxime, netilmicin and betamethasone. Cefotaxime or, alternatively, clindamycin, ciprofloxacin and prednisolone were given systemically. The final visual acuity of 20/40 or more was obtained in 15 cases (58%). Twenty-one patients (81%) achieved a visual acuity of 20/400 or better. Three patients had no light perception after the treatment of endophthalmitis. Silk as suture material in wound closure and rupture of the posterior capsule were found to be risk factors in the development of endophthalmitis. The results of the present study show that effective drug treatment also results in good visual outcome.

Growth curve for Propionibacterium acnes

We established growth curves for Propionibacterium acnes isolates recovered from eyes with chronic postoperative endophthalmitis. The growth curve plotted the average of the duplicate bacterial concentration against time. The generation time for P. acnes calculated from the growth curves was approximately 5.1 hours. The growth of P. acnes is slower than other anaerobic bacteria. This may account for its delayed appearance in culture of ocular specimens. It may also explain treatment failure if the concentration of an antibiotic injected into the vitreous does not remain at an effective level during the critical replicative phase of the organism.

Concurrent endophthalmitis and retinal detachment

PURPOSE

Eyes with concurrent endophthalmitis and retinal detachment usually have a poor anatomic and visual outcome after treatment. The purpose of this study is to define the relation among the causative organism, the results of retinal detachment repair, and the final visual acuity.

METHODS

Data were retrieved by a retrospective, computer-assisted review of the coded inpatient diagnoses from April 1987 through March 1992.

RESULTS

This study included 16 patients (9 males, 7 females) ranging in age from 5 to 88 years (average, 58.7 years). Endophthalmitis was classified as exogenous in 13 (81%) patients and endogenous in 3 (19%). Two groups were identified: a virulent group that included eight (50%) patients (Staphylococcus aureus, streptococci, gram-negative, Bacillus), and a less-virulent group that included eight (50%) patients (Staphylococcus epidermidis, Propionibacterium acnes, fungal). The initial surgical procedure consisted of diagnostic vitreous fluid collection by pars plana vitrectomy (11 cases), anterior vitrectomy (1 case), or vitreous aspiration (4 cases). Additional initial adjunctive surgical procedures included pars plana lensectomy (2 cases), scleral buckling (6 cases), fluid-gas exchange (7 cases), and intraocular antibiotic injections (9 cases). In six (75%) of eight patients with endophthalmitis in the virulent group, the retina remained detached. However, in seven (88%) of eight patients with endophthalmitis in the less-virulent group, the retina remained reattached postoperatively, and the remaining patient had a stable, nonprogressive peripheral tractional retinal detachment. None of the eight patients with endophthalmitis in the virulent group retained a postoperative visual acuity of better than 3/200, and four (50%) lost all light perception. Five (62%) of the eight patients with endophthalmitis in the less-virulent group retained a postoperative visual acuity of 5/200 or better, and none lost all light perception.

CONCLUSIONS

Concurrent endophthalmitis and retinal detachment patients with virulent organisms have a poor prognosis. Visual and anatomic outcomes were better in the less-virulent group.

Aggressive management of an epidemic of chronic pseudophakic endophthalmitis: results and literature survey

Six cases of chronic endophthalmitis following extracapsular cataract extraction and lens implantation are reviewed. All were referred for tertiary management by one surgeon over a period of just over 2 years. In two of the cases coagulase negative staphylococci were isolated and in three Propionibacterium spp were retrieved. In the remaining case a mixed growth of coagulase negative staphylococci and Propionibacterium acnes was cultured. The surgical management, microbiological results, and eventual visual outcome are discussed. To our knowledge, this is the first documented outbreak of chronic pseudophakic endophthalmitis with commensal organisms from a single centre.

Antimicrobial efficacy and aqueous humor concentration of preoperative and postoperative topical trimethoprim/polymyxin B sulfate versus tobramycin

We compared trimethoprim sulfate 0.1%/polymyxin B sulfate 10,000 units/mL with tobramycin 0.3% for preoperative sterilization of the ocular surface, aqueous humor concentration, and ocular safety and comfort in 99 patients who had cataract extraction and intraocular lens implantation. The organisms most frequently cultured from the conjunctiva at baseline were Staphylococcus epidermidis, Corynebacterium species, and Staphylococcus aureus, which were isolated from 66%, 15%, and 8% of the 95 specimens eligible for evaluation. All organisms identified in positive baseline conjunctival cultures except Staphylococcus epidermidis were completely eradicated in both groups on the day of surgery and five to seven days postoperatively. Staphylococcus epidermidis was eradicated on the day of surgery in 58% of patients in the trimethoprim/polymyxin group and in 68% in the tobramycin group. This organism was eradicated five to seven days postoperatively in 85% of patients in both groups. Mean aqueous humor concentration of trimethoprim sulfate at surgery was greater than the mean tobramycin concentration, but neither reached clinically significant inhibitory levels for most organisms. No significant differences were found in ocular safety and comfort.

Endophthalmitis caused by Staphylococcus aureus

The medical records of 27 patients (27 eyes) with culture-positive Staphylococcus aureus endophthalmitis, diagnosed between December 1984 and February 1992, were reviewed. In 20 of the 27 eyes, endophthalmitis occurred within seven days of ocular surgery. All tested isolates were sensitive to vancomycin, gentamicin, and ceftazidime. In 13 eyes treated by initial vitrectomy and intraocular antibiotic injection, ten eyes achieved 20/400 or better visual acuity, compared to seven of 14 eyes in the initial vitreous tap and intraocular antibiotic injection group. For the eight eyes treated initially with intraocular corticosteroids, seven eyes achieved 20/400 or better visual acuity, compared to ten of 19 eyes in the group receiving no initial intraocular corticosteroids (P = .190). The use of vitrectomy and intraocular corticosteroids with intraocular antibiotics was associated with the best visual outcomes in this group of eyes with endophthalmitis caused by S. aureus.

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.

Endophthalmitis at the Bristol Eye Hospital: an 11-year review of 47 patients

We reviewed data from 47 patients who were treated for endophthalmitis at our hospital during the 11-year period 1980-90. The most common clinical features were hypopyon (75%), diminished vision (72%), ocular pain (68%), discharge (57%), corneal oedema (51%), conjunctival injection (49%), abnormal red reflex (34%), corneal ulcer (32%) and corneal perforation (6%). A total of 54 isolates were obtained from 41 (87%) of the 47 patients. Gram-positive bacteria were more common (72%), than Gram-negative organisms (22%). Two cases were due to fungi, and herpes simplex virus was isolated from one case. The two most common Gram-positive organisms were coagulase-negative staphylococci (25%), and Staphylococcus aureus (11%), while Pseudomonas aeruginosa predominated among the Gram-negative bacteria isolated (15%). Mixed bacterial species were obtained from 29% of the infected patients, including one from whom Vibrio fluvialis was isolated. Predisposing factors included ocular surgery (60%)--mostly for cataract extraction (47%), penetrating trauma (15%) and periocular (15%) or systemic (11%) infections. All patients received antibiotics (generally chloramphenicol and/or a beta-lactamase-stable penicillin plus an aminoglycoside) prior to culture, when treatment was adjusted according to specific aetiological agents. Seventy-nine per cent of patients received topical or systemic steroids. Vitrectomy (diagnostic and therapeutic) was performed on 21% of patients. Sixty-three per cent of culture-positive patients lost vision (no perception of light) in the affected eye, compared to 17% of culture-negative cases (P < 0.05 Fisher exact test). Similarly, a better visual outcome (acuity of 6/12 or better) was associated with coagulase-negative staphylococcal infection than with streptococcal or fungal infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Endophthalmitis following extracapsular cataract surgery: a review of 32 cases

Thirty two cases of endophthalmitis following extracapsular cataract surgery that had occurred within our department and had undergone intraocular diagnostic tap between May 1982 and May 1991 were reviewed. An infectious agent was identified in 20 cases (62.5%). The commonest organism was Staphylococcus epidermidis (11 cases) (55%). Proteus was the only gram negative organism identified (four cases) (20%). Both of these organisms were associated with a favourable visual outcome. In the culture positive subgroup 15 eyes (75%) achieved a final acuity of 6/60 or better with 10 eyes (50%) gaining 6/12 or better. Thirteen (65%) of the culture positive cases were managed without vitreal intervention. Of these 11 (85%) achieved 6/60 or better with eight (62%) gaining 6/12 or better. It appears that when an endophthalmitis follows uncomplicated extracapsular cataract surgery delivery of antibiotic by the 'conventional' routes (topical, subconjunctival and systemic) is consistent with a favourable visual result in many cases. A modified anterior chamber diagnostic tap technique is described.

Diagnosis and therapy of bacterial endophthalmitis, and serum levels of inflammation markers

A review of 27 cases of bacterial endophthalmitis diagnosed and treated at the Specialized Outpatient Department for Infectious Eye Diseases at the 2nd Department of Ophthalmology of the University of Vienna over a period of eight years (January 1983-April 1991) is presented. In 70% of the cases the patients had undergone surgical intervention. Conjunctival samples were routinely taken for microbiological investigations (aerobic as well as anaerobic cultures). In 19 patients (70.4%) aqueous specimens were obtained, in 22 cases (81.5%) vitreous specimens collected during vitrectomy for the removal of infected material were used for microbiological diagnosis. The results for the patient population described showed the poor reliability of conjunctival cultures from intraocular infections with only 36.84% being identical with those of the vitreous specimens. In the most recent 11 patients three serological parameters of inflammation were tested on various occasions: C-reactive protein, PMN- elastase and light immunoglobulin chain assembling (kappa/lambda). Clinical results, microbiological findings and therapeutic approaches are presented and discussed.

Vitreous replacement by gas as a therapeutic modality in bacterial endophthalmitis

We investigated vitreous replacement by long-lasting gas in the management of severe Staphylococcus aureus endophthalmitis in 19 rabbits randomized for vitrectomy (9 animals) and for vitrectomy followed by replacement of the vitreous by a 20% perfluoropropane-80% air mixture (10 animals). Both groups received systemic antibiotics and achieved comparable intraocular antibiotic levels. Clinically and histopathologically, gas-filled eyes demonstrated less inflammation than did eyes without gas (P less than 0.01). Replacement of vitreous by gas offers an effective adjunct to vitrectomy by eliminating a culture medium, preventing vitreous abscess formation, enabling fundus visualization, and delaying the onset of retinal detachment.

Intraocular levels of cefuroxime in uninflamed rabbit eyes

Intraocular levels of cefuroxime following subconjunctival, intravitreal and combined intravitreal and intravenous administration were determined in uninflamed rabbit eyes. Intraocular levels of the antibiotic were assayed by a biological method. Penetration of cefuroxime into the vitreous following subconjunctival administration was poor. Subconjunctival administration produced higher levels of cefuroxime in the aqueous when compared to parenteral administration alone. Higher levels of cefuroxime were achieved both in the aqueous and in the vitreous after an intravitreal injection. Intravitreal injection of 100 and 1000 micrograms cefuroxime produced intravitreal levels close to the minimum inhibitory concentration (MIC) for most ocular pathogens up to 24 h after drug administration. Intravenous supplementation did neither enhance the intraocular levels nor did it delay the clearance of the intravitreally injected antibiotic. Mild histopathological changes were seen with equal frequency both in the control and the test eyes and are attributed to the sampling techniques. Electroretinography (ERG) showed no definite changes suggestive of retinal toxicity up to 55 days after intravitreal administration.