Redefining evidence in the management of acute post-cataract surgery endophthalmitis in India - The 2014 Adenwalla Oration, All India Ophthalmological Society

Antibiotic susceptibility in Endophthalmitis Management Study and intravitreal antibiotic practice trend in India-EMS Report #5

AIM

Analyze antibiotic susceptibility in the Endophthalmitis Management Study (EMS) and compare it with the current intravitreal antibiotic practice trend of members of the Vitreoretinal Society of India (VRSI) practicing in India.

METHODS

The microbiology work-up of undiluted vitreous included microscopy, culture-susceptibility, polymerase chain reaction (PCR), and next-generation sequencing (NGS). VRSI members were invited to the survey. The EMS conventional culture-susceptibility (PCR and NGS excluded) results were compared vis-a-vis gram-positive cocci (GPC), gram-negative bacilli (GNB), and less commonly used antibiotics with the current recommended intravitreal antibiotics. p < 0.05 was considered significant.

RESULTS

Culture and positivity (culture + PCR/NGS) positivity was 28.8% and 56.1%, respectively. GPC was most susceptible to cefazolin, linezolid, and vancomycin; GNB was most susceptible to amikacin, ceftazidime, colistin, and imipenem. There was no susceptibility difference between cefazolin and vancomycin (p = 0.999) and between ceftazidime and imipenem (p = 1.0). Colistin was superior to ceftazidime (p = 0.047) against GNB. The GNB resistant to amikacin (n = 14) were equally susceptible to ceftazidime and colistin; resistant to ceftazidime (n = 16) were susceptible to colistin; and resistant to colistin (n = 7) were susceptible to ceftazidime. The preference of VRSI members (n = 231) practicing in India was a vancomycin-ceftazidime combination (82%), vancomycin for GPC (94%), ceftazidime for GNB (61%), and voriconazole for fungi (74%).

CONCLUSION

In EMS, GPC had good susceptibility to vancomycin; GNB had good susceptibility to ceftazidime and colistin. Given the lower resistance of colistin, a vancomycin-colistin combination could be an alternative empiric treatment in post-cataract endophthalmitis in India.

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 Management Study-A Prospective Randomized Clinical Trial on Postoperative Endophthalmitis Management in India: An Interim Analysis. Endophthalmitis Management Study Report #3

PURPOSE

An interim analysis of the Endophthalmitis Management Study to examine the outcome of inflammation score (IS)-based treatment and antibiotic susceptibility.

DESIGN

A prospective randomized study.

PATIENTS AND METHODS

IS was measured on a 0-4 scale from presenting signs in 4 cardinal ocular tissues. The eyes with IS <10 received vitreous tap and intravitreal antibiotics, whereas eyes with IS ≥10 received vitrectomy and intravitreal antibiotics. These eyes were randomized to 2 intravitreal antibiotic combinations: (1) vancomycin and ceftazidime and (2) vancomycin and imipenem. Microbiology workup of undiluted vitreous included microscopy, culture-susceptibility, Sanger, and targeted next-generation sequencing. The clinical and microbiology outcomes were analyzed for advanced (IS = ≥20) and less advanced (IS = <10) endophthalmitis.

RESULTS

Interim analysis was performed after the Endophthalmitis Management Study recruited 56.85% (248/436) of patients and completed 54.6% (238/436) of microbiology workup. A 90-day follow-up was completed in 90.8% (168/185) of eligible people. In eyes with IS ≥20, the time to symptoms was shorter (5.8 ± 6.7 vs 8.5 ± 9.1 d; P = 0.015), and the need for additional treatment was higher (95.8% vs 53.1%; P = 0.0267). Good final vision was associated with good presenting vision (r = 0.30) and IS-based treatment decisions (r = 0.170). Microbiology positivity was 55.9%. Eyes with IS <10 had a higher Gram-positive cocci (33.9% vs 4.8%; P = 0.013) infection. Gram-positive cocci were most susceptible to vancomycin (95.7%), and Gram-negative bacilli to colistin (95.7%).

CONCLUSIONS

Considering both IS and presenting vision, rather than only one of them, helps in making appropriate management decisions for acute postoperative endophthalmitis.

Fungi of the human eye: Culture to mycobiome

The focus of the current review is multi-fold and compares the diversity and abundance of fungi on the ocular surface by the conventional culture-based method with the more sensitive, high throughput, culture-independent NGS method. The aim is to highlight the existence of a core ocular mycobiome and explore the transition of the ocular fungal microbiota from the normal eye to the diseased eye. PubMed, Google Scholar and Medline were used to search for publications and reviews related to cultivable fungi and the mycobiome of the normal and diseased eye. The conventional cultivable approach and the NGS approach confirm that the eye has its own mycobiome and several confounding factors (age, gender, ethnicity etc.) influence the mycobiome. Further, dysbiosis in the mycobiome appears to be associated with ocular diseases and thus impacts the health of the human eye. Considering that the mycobiome of the eye is influenced by several confounding factors and also varies with respect to the disease status of the eye there is a need to extensively explore the mycobiome under different physiological conditions, different ethnicities, geographical regions etc. Such studies would unravel the diversity and abundance of the mycobiomes and contribute to our understanding of ocular health. Research focused on ocular mycobiomes may eventually help to build a targeted and individualized treatment.

All India Ophthalmological Society (AIOS) Task Force guidelines to prevent intraocular infections and cluster outbreaks after cataract surgery

Infectious endophthalmitis is a serious and vision-threatening complication of commonly performed intraocular surgeries such as cataract surgery. The occurrence of endophthalmitis can result in severe damage to the uveal and other ocular tissues even among patients undergoing an uncomplicated surgical procedure. If the infections result from common factors such as surgical supplies, operative or operation theater-related risks, there can be a cluster outbreak of toxic anterior segment syndrome (TASS) or infectious endophthalmitis, leading to several patients having an undesirable outcome. Since prevention of intraocular infections is of paramount importance to ophthalmic surgeons, the All India Ophthalmological Society (AIOS) has taken the lead in the formation of a National Task Force to help ophthalmic surgeons apply certain universal precautions in their clinical practice. The Task Force has prepared a handy checklist and evidence-based guidelines to minimize the risk of infectious endophthalmitis following cataract surgery.

Clinical features and microbiology of post-cataract surgery endophthalmitis with and without intracameral moxifloxacin prophylaxis: Endophthalmitis prophylaxis study report 3

Purpose:

This study aimed to analyze the clinical presentations, microbiology, and management outcomes of post–cataract surgery endophthalmitis, with and without intracameral moxifloxacin prophylaxis.

Methods:

This study was designed as a retrospective, consecutive, comparative case series. Records of consecutive cataract surgery from January 1, 2015, till June 30, 2020, were analyzed. The cases that developed endophthalmitis were analyzed. The endophthalmitis cases were divided by their prophylaxis treatment into two groups: with intracameral moxifloxacin (ICM) and without (N-ICM). Inclusion criteria were (1) age ≥ 18 years, (2) cataract surgery with intraocular lens implantation, (3) endophthalmitis within 6 weeks of cataract surgery, and (4) cataract surgery in the institute by any of the three methods—phacoemulsification, manual small incision cataract surgery, and extracapsular cataract extraction.

Results:

In the study period, 66,967 cataract surgeries were performed; 48.7% (n = 32,649) did not receive ICM. There was no difference between the N-ICM and ICM groups in the incidence of clinical (n = 21, 0.064% and n = 15, 0.043%; P = 0.23) and culture proven (n = 19, 0.033% and n = 11, 0.023%; P = 0.99) endophthalmitis, respectively. Greater number of patients in the N-ICM group had lid edema (76.2% vs. 40%; P = 0.03), corneal edema (71.4% vs. 33.3%; P = 0.03) and lower presenting vision with available correction (logMAR [logarithm of the minimum angle of resolution] 1.26 ± 1.2 vs. logMAR 0.54 ± 0.85; P = 0.02). The final best-corrected visual acuity following treatment was worse in the N-ICM group (logMAR 1.26 ± 1.2 vs. 0.54 ± 0.85; P = 0.02).

Conclusion:

Endophthalmitis after intracameral moxifloxacin may have relatively milder signs and symptoms and may respond better to treatment.

Endophthalmitis management study. Report #1. Protocol

To date, the Endophthalmitis Vitrectomy Study (EVS) has remained the hallmark of evidence-based management of acute bacterial endophthalmitis after cataract surgery with an intraocular lens. In the last quarter-century since its publication, several studies have reported that the microbiological spectrum of endophthalmitis is not the same across the world; there is emerging antibiotic resistance of gram-negative microorganisms to the EVS recommended antibiotics; there are newer molecules that could cross the blood-retinal barrier; the advances in vitreous surgery have become safer than before, and there are newer methods of microbiological evaluation. One of the often-mentioned drawbacks of the EVS was not recruiting grossly infected eyes with poor visibility of the iris and vitreous. Keeping these factors in mind, a new prospective multi-centered randomized study, the Endophthalmitis Management Study (EMS), is designed. The EMS will recruit all post-cataract surgery endophthalmitis patients irrespective of severity (including suspected fungal infection); the EMS will use quantifiable inflammatory score instead of the presenting vision to allocate for surgery, randomize the eyes to two different combinations of intravitreal antibiotics and use the newer microbiological diagnostic techniques. We believe the EMS findings will complement the EVS recommendations.

Endophthalmitis prophylaxis study. Report 1: Intracameral cefuroxime and moxifloxacin prophylaxis for the prevention of postcataract endophthalmitis in rural India

Purpose:

Intracameral antibiotics are known to reduce the incidence of acute endophthalmitis. Various drugs are available for intracameral use. This prospective study was carried out to compare the efficacies of intracameral cefuroxime and moxifloxacin prophylaxis in reducing the incidence of acute endophthalmitis after cataract surgery in rural India.

Methods:

This was a prospective, nonrandomized, comparative, interventional study. Between October 2016 and March 2018, 15 eye care facilities spread over four Indian states were preselected to use either of the intracameral antibiotics, cefuroxime or moxifloxacin, following cataract surgery (phacoemulsification or manual small incision cataract surgery, SICS). The main outcome measure was the occurrence of acute clinical endophthalmitis within six weeks of the surgery. This was compared with the earlier rate of endophthalmitis in the same locations.

Results:

The study was done in 42,466 eyes. Of the total, 42.2% received intracameral cefuroxime and 57.8% received intracameral moxifloxacin. SICS was performed more often. Clinical acute endophthalmitis occurred in 15 eyes. This accounted to a 72.22% reduction, from the earlier 0.126% to 0.035%, of postcataract surgery acute endophthalmitis. The reduction in the incidence of endophthalmitis after intracameral cefuroxime was 0.017% and that after intracameral moxifloxacin was 0.049%. With either intracameral antibiotics, the reduction in incidence was statistically significant (P < 0.001), but not between the molecules. Intracameral cefuroxime showed 66.67% reduction and intracameral moxifloxacin showed 74.74% reduction.

Conclusion:

A 3.6-fold decrease in postcataract surgery endophthalmitis was observed upon the use of intracameral antibiotics in rural India. Both intracameral cefuroxime and moxifloxacin proved efficacious.

All India Ophthalmological Society members survey results: Cataract surgery antibiotic prophylaxis current practice pattern 2017

Purpose

The purpose of this article is to document the current practice pattern of Indian ophthalmologists for antibiotic prophylaxis in cataract surgery to prevent endophthalmitis.

Methods

Fifteen structured questions were sent online to all ophthalmologists registered with the All India Ophthalmological Society. The questionnaire was divided into three main categories of prophylaxis - preoperative, intraoperative, and postoperative. A web-based anonymous survey was conducted, and a unique response link allowed completing the survey only once. We compared the results with a similar 2014 survey among the members of the American Society of Cataract and Refractive Surgeons (ASCRS).

Results

The response was received from 30.2% (n = 4292/14,170) ophthalmologists. The results were as follows: all respondents do not prepare the eye with 5% povidone-iodine (83% of them use povidone iodine), majority (90%) use topical antibiotic both pre- and post-operatively, 46% use subconjunctival antibiotic at the end of surgery, and 40% use intracameral antibiotic (46% of them in high-risk patients only). Moxifloxacin was the preferred antibiotic for topical and intracameral use. Comparison with the 2014 ASCRS survey results showed a similarity in decision for pre- and post-operative antibiotics and intracameral antibiotic but dissimilarity in the choice of intracameral antibiotic and decision for subconjunctival antibiotic.

Conclusion

The antibiotic prophylaxis practice by the Indian ophthalmologists is not too dissimilar from the practice in North American Ophthalmologists (ASCRS) though all ophthalmologists in India must be nudged to preoperative preparation of the eye with povidone-iodine and discontinue the practice of postoperative subconjunctival and systemic antibiotic.