Postoperative Endophthalmitis and Toxic Anterior Segment Syndrome Prophylaxis: 2020 Update

Incidence of Postsurgical Intraocular Inflammation 6 Months After Implantation with a Multifocal Intraocular Lens

Purpose

This study assessed the incidence of postsurgical intraocular inflammation after cataract extraction by phacoemulsification and implantation with AcrySof IQ ReSTOR intraocular lenses (IOLs) produced using an updated manufacturing process. Incidence rates were compared with historical rates of postsurgical intraocular inflammation.

Methods

This was a prospective, multicenter, post-approval study at 34 sites. Patients aged ≥22 years received a study lens in at least 1 eye. Postsurgical intraocular inflammation (aqueous cell grade ≥3+ within 14 days after surgery, aqueous cell ≥2+ at 14 to ≤60 days after surgery, or aqueous cell ≥1+ at >60 days) was assessed within a 180-day period after implantation. Rates of toxic anterior segment syndrome (TASS), acute postoperative endophthalmitis, chronic postoperative endophthalmitis, and uncategorized cases of postsurgical intraocular inflammation were assessed. Ocular adverse events (AEs) and ocular adverse device effects (ADEs) were evaluated. Historical rates of postsurgical intraocular inflammation were determined from the 2011-2013 Medicare Limited Data Set files (a 5% sample of the Medicare data set representative of patients aged ≥65 years).

Results

Final safety analysis set included 3357 eyes (1792 patients; mean age, 68.6 ± 7.9 years). Postsurgical intraocular inflammation (any type) rate was 5.1 per 1000 attempted IOL implants (95% CI, 2.95, 8.10). TASS, acute postoperative endophthalmitis, and uncategorized inflammation rates were 0.6 (95% CI, 0.07, 2.15), 0.3 (95% CI, 0.01, 1.66), and 4.2 (95% CI, 2.28, 6.99) per 1000 attempted IOL implants, respectively. There were no events of chronic postoperative endophthalmitis. Ocular AEs and ADEs were reported in 17% and 1.5% of eyes, respectively. Most common ADEs were halo (0.63%) and glare (0.51%). The historical postsurgical inflammation rate from 221,519 cataract procedures was 10.3/1000 cataract surgeries, and the endophthalmitis rate was 1.2/1000 surgeries.

Conclusion

The updated IOL manufacturing process resulted in postoperative intraocular inflammation rates that were substantially lower than the historic rate.

Bilateral simultaneous endophthalmitis after immediately sequential bilateral cataract surgery

Purpose

Immediately sequential bilateral cataract surgery (ISBCS) has recently been considered effective due to faster visual rehabilitation and further improvements in quality of life. We report on the treatment course of a case of early postoperative endophthalmitis in both eyes after ISBCS.

Observations

The patient was a 75-year-old woman undergoing anticancer treatment for lung cancer, who had been receiving eye drops for bilateral uveitis and secondary glaucoma since 2019. She underwent ISBCS at another hospital in 2022. In that surgery, the same instruments were used for the surgery of both eyes, without resterilization between eyes. On the night of the following day, she became aware of vision loss in both eyes, and at the examination the next day, hypopyon and corneal edema were found and she was diagnosed with bilateral postoperative endophthalmitis, and referred to our hospital. On the same day, anterior chamber irrigation, posterior capsulotomy, and vitrectomy were performed on both eyes, and the intraocular lenses were preserved. There was no recurrence of postoperative inflammation, and visual acuity was 20/30 in both eyes 6 months after vitrectomy.

Conclusion

ISBCS is recommended to be performed with complete aseptic separation of the patient's two procedures. This important rule was not followed in this case. ISBCS should be performed in accordance with accepted protocols, such as those of the International Society of Bilateral Cataract Surgeons, the Royal College of Ophthalmologists, and the Canadian Ophthalmological Society.

Endophthalmitis caused by Burkholderia cepacia complex (BCC): clinical characteristics, antibiotic susceptibilities, and treatment outcomes

PURPOSE

To report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.

STUDY DESIGN

Retrospective, observational case series.

METHODS

Clinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed wisth culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.

RESULTS

Endophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1 mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).

CONCLUSIONS

Endophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

Endophthalmitis caused by Burkholderia cepacia complex (BCC): Clinical characteristics, antibiotic susceptibilities, and treatment outcomes

Purpose

To report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.

Study design

Retrospective, observational case series.

Methods

Clinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed with culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.

Results

Endophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).

Conclusions

Endophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

Meibomian gland dysfunction and blepharitis: A common and still unsolved ophthalmic problem

Blepharitis and meibomian gland dysfunction (MGD) are very common, usually underdiagnosed and underappreciated diseases. More than 50% of patients seeking ophthalmologic consultations have symptoms and signs indicating one or both entities. We summarize the key points of diagnosis and management of both diseases, comparing the work of Dry Eye Workshop II (2017) with the dry eye blepharitis syndrome unification theory. The impact of MGD/blepharitis on ocular surgery also is described. Although MGD and blepharitis seem to be uncurable, most of the time they can be successfully controlled. Different management options are available, but the key to success remains simple-routine eyelid hygiene and moisturizing with the use of preservative-free lubricants.

Evaluation of the effect of gentamicin in surgical perfusion solution on cataract postoperative endophthalmitis

Objective

To evaluate the effect of gentamicin in surgical perfusion solution on endophthalmitis incidence after cataract surgery.

Methods

A retrospective analysis of endophthalmitis incidence was conducted in two groups of patients who underwent cataract surgery, with (Group B) or without gentamicin (Group A) in the surgical perfusion solution. Endophthalmitis incidence, the isolated pathogenic bacteria strains and their antibiotic sensitivity, and the drug-resistant genotype of the pathogens were examined.

Results

The incidence of endophthalmitis in patients of group A was 0.8‰. Thirteen pathogenic bacterial strains were isolated from the patient samples in group A, including 8 strains of Staphylococcus epidermidis, 1 Staphylococcus aureus, 1 Streptococcus pneumoniae, 1 Streptococcus bovis, 1 Enterococcus faecium and 1 Morganella sp. The incidence of endophthalmitis in group B patients was 0.2‰, which was significantly lower than that in group A (P<0.05). Five strains of pathogenic bacteria were successfully isolated, including 2 strains of Enterococcus faecium, 1 Enterococcus faecalis, 1 Staphylococcus epidermidis and 1 Staphylococcus aureus. There was no significant difference in the proportion of Staphylococcus strains in all isolated bacteria between the two groups (P > 0.05). However, the proportion of Enterococci isolated in group B samples was higher than that in group A (P < 0.05). There were more gentamicin-sensitive strains than levofloxacin-sensitive strains identified (P < 0.05). Interestingly, aminoglycoside-inactivating enzyme resistance gene was detected in Enterococcus strains.

Conclusion

Our data suggest that gentamicin-containing perfusion solution can reduce the incidence of postoperative endophthalmitis in cataract patients. However, the selective pressure imposed by gentamicin may facilitate the development of aminoglycoside-resistant Enterococcos strains.

Incidence of endophthalmitis after phacoemulsification cataract surgery: a Meta-analysis

AIM

To evaluate the overall endophthalmitis incidence and the effectiveness of potential prophylaxis measures following phacoemulsification cataract surgery (PCS).

METHODS

The PubMed and Web of Science databases were searched from inception to April 30th, 2021. We included studies that reported on the incidence of endophthalmitis following PCS. The quality of the included studies was critically evaluated with the Newcastle-Ottawa quality assessment scale. The random effect or the fixed-effects model was used to evaluated the pooled incidence based on the heterogeneity. The publication bias was assessed by Egger's linear regression and Begg's rank correlation tests.

RESULTS

A total of 39 studies containing 5 878 114 eyes were included and critically appraised in the Meta-analysis. For overall incidence of endophthalmitis after PCS, the Meta-analysis yielded a pooled estimate of 0.092% (95%CI: 0.083%-0.101%). The incidence appeared to decrease with time (before 2000: 0.097%, 95%CI: 0.060%-0.135%; 2000 to 2010: 0.089%, 95%CI: 0.076%-0.101%; after 2010: 0.063%, 95%CI: 0.050%-0.077%). Compared with typical povidone-iodine solution (0.178%, 95%CI: 0.071%-0.285%) and antibiotics subconjunctival injections (0.047%, 95%CI: 0.001%-0.095%), the use of intracameral antibiotics significantly reduced the incidence of endophthalmitis after PCS (0.045%, 95%CI: 0.034%-0.055%, RR: 7.942, 95%CI: 4.510-13.985).

CONCLUSION

Due to the advancement of phacoemulsification technology and the widespread use of intracameral antibiotics, the incidence of endophthalmitis following PCS shows a decreasing trend over time. The use of intracameral antibiotics administration will significantly reduce the risk of endophthalmitis.

Four Cases of Toxic Anterior Syndrome after Cataract Surgery under Intracameral 0.5% Lidocaine Anesthesia

Purpose: To report four cases of toxic anterior segment syndrome after cataract surgery under intracameral 0.5% lidocaine anesthesia.Case summary: Four patients had a decrease in visual acuity within 3 days of undergoing cataract surgery. There was evidence of anterior chamber inflammation with corneal edema and opacity. Toxic anterior segment syndrome was diagnosed on the basis of negative microbial cultures and clinical features. Three patients were treated with systemic and topical steroids, and one was treated with topical steroids only. Three months postoperatively, three patients had good visual acuity without inflammation or corneal edema. However, one patient, who did not receive systemic steroids, exhibited persistent corneal edema and required endothelial keratoplasty.Conclusions: Toxic anterior segment syndrome is a surgical complication that requires immediate treatment. Systemic steroids can be helpful with topical steroids. Clinicians should ensure that measures are taken to avoid contamination of surgical procedure with toxic substances to prevent toxic anterior segment syndrome.

The effect of postoperative oral antibiotic therapy on the incidence of postoperative endophthalmitis after phacoemulsification surgery in dogs: 368 eyes (1997-2010)

Purpose

To assess the effectiveness of postoperative administration of oral antibiotics at reducing the incidence of endophthalmitis following phacoemulsification cataract extraction in dogs.

Methods

Medical records of the University of Tennessee College of Veterinary Medicine were reviewed for cases having undergone phacoemulsification and divided according to whether or not they had received oral antibiotics postoperatively. Records were then evaluated for a diagnosis of endophthalmitis and incidence rates between the group receiving postoperative oral antibiotics and the group not receiving postoperative oral antibiotics were compared.

Results

A total of 215 patients (368 eyes) were identified by the search. One-hundred twelve patients (197 eyes) were treated with oral antibiotics postoperatively. One-hundred and three patients (171 eyes) were not treated with oral antibiotics postoperatively. Three cases of endophthalmitis were identified, with one in the antibiotic-treated group and two in the non-antibiotic treated group (P > 0.05, Fisher’s exact test).

Conclusions

The overall incidence of endophthalmitis at the University of Tennessee from 1997–2010 was 0.82%. The rate of post-phacoemulsification endophthalmitis was unaffected by the postoperative administration of oral antibiotics.

Intracameral r-tPA for the management of severe fibrinous reactions in TASS after cataract surgery

BACKGROUND

To describe the use of intracameral recombinant tissue plasminogen activator (r-tPA) in the treatment of severe fibrinous reactions in toxic anterior segment syndrome (TASS) after cataract surgery.

METHODS

A case series of 59 eyes of 59 patients with severe fibrinous anterior chamber reaction following cataract surgery who received intracameral r-tPA (25 µg/0.1 ml). The main outcome measures after intracameral r-tPA were the incidence of complete fibrinolysis, time of maximal effect, visual acuity, and complications.

RESULTS

Severe fibrinous reactions appeared 11.5 ± 5.3 days after cataract surgery. Fibrinolysis was observed 2.33 ± 2.70 days after rtPA use and 36 eyes (61%) exhibited resolution of the fibrin by the end of the first day following injection (p < 0.001). Transient corneal edema observed at 1-day after injection was the only complication reported during the injection of r-tPA or at follow-up. Eight eyes (13.6%) required a second r-tPA injection. Best-corrected visual acuity improved from 0.88 ± 0.67 logMAR units before rtPA injection to 0.48 ± 0.49 logMAR units at 1-month (p < 0.001).

CONCLUSIONS

The application of r-tPA was a quick and efficacious therapeutic approach for the management of severe fibrinous reactions in TASS after cataract surgery. In a clinical setting, intracameral r-tPA may be useful when rapid visual recovery is needed.