Post-cataract surgery endophthalmitis: Difference between revisions
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*Sterile inflammation | *Sterile inflammation | ||
*Rebound inflammation (related to abrupt discontinuation of steroid drops) | *Rebound inflammation (related to abrupt discontinuation of steroid drops) | ||
*[[Iris]] or [[vitreous]] incarceration in the wound (low-grade inflammation) | |||
*Uveitis-glaucoma-hyphema syndrome | |||
*Fungal endophthalmitis. | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Revision as of 14:42, 9 August 2016
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Acute post-cataract endophthalmitis is an ocular inflammation resulting from the introduction of an infectious agent, most commonly coagulase-negative staphylococci, into the posterior segment of the eye. Nearly every type of ocular surgery may be able to disturb the eye globe integrity and contaminate the aqueous humor and/or vitreous. Cataract surgery accounts for approximately 90% of all cases of post-operative enndophthalmitis.
Historical Perspective
Classification
Based on the latancy of onset, post-cataract endophthalmitis may be classified into:
- Acute post-catarct endophthalmitis
- Delayed post-cataract endophthalmitis
Additionally, post-cataract enophthalmitis may be classified according to causative organisms into 2 subtypes: bacterial or fungal.
Pathophysiology
Pathogenesis
Acute post-cataract endophthalmitis is an ocular inflammation, which may occur within hours to few days after cataract surgery. Acute post-cataract endophthalmitis is mainly caused by the introduction of an infectious agent, most commonly coagulase-negative staphylococci, into the posterior segment of the eye. Nearly every type of ocular surgery may be able to disturb the eye globe integrity and contaminate the aqueous humor and/or vitreous. Cataract surgery accounts for approximately 90% of all cases of post-operative enndophthalmitis. Preoperative topical antimicrobial agents can decrease colony counts in the tear film, but they do not sterilize the area. The exact low rate of clinical infection following eye surgery (despite the relatively high prevalence of microorganisms in the eye) is not fully understood. It is thought that low rate of clinical infection following surgical procedure is explained by combination of low inoculum levels, low pathogenicity, and the innate ocular defenses against infection.[1][2][3]
Post-operative endophthalmitis may also occur weeks to years following surgery. It presents as a low-grade inflammation in the anterior chamber. The exact pathogenesis of delayed post-operative endophthalmitis is not fully understood. It is thought that delayed post-operative endophthalmitis is caused by either sequestration of low-virulence organisms introduced at the time of surgery or delayed inoculation of organisms to the eye through wound abnormalities, suture tracks, or filtering blebs. Propionibacterium acnes is the most common microorganism encountered in delayed post-operative bacterial endophthalmitis. [1][2]
Gross Pathology
On gross pathology, eyelid swelling, eyelid erythema, injected conjunctiva and sclera, hypopyon, chemosis, and mucoprulunt dischage are characteristic findings of post-cataract endophthalmitis.
Microscopic histopathological analysis
On microscopic histopathological analysis, infiltration of polymorphonuclear leukocytes or chronic inflammatory cells (depending on the duration of the inflammation) and destruction of ocular structures are characteristic findings of post cataract bacterial endophthalmitis.
Causes
Acute Post-operative Endophthalmitis
Post-operative endophthalmitis has been reported following nearly every type of ocular surgery. Common causes of acute post-cataract endophthalmitis include:
Delayed Post-operative Endophthalmitis
Common causes of delayed post-operative endophthalmitis include:
- Propionibacterium acnes (most common)
- Streptococcus spp
- Corynebacterium spp
- Xanthomonas maltophilia
- Alcaligenes xylosoxidans
Differentiating Post-cataract Surgery Endophthalmitis from Other Diseases
Acute post-cataract endophthalmitis must be differentiated from:[9]
- Phacoanaphylactic endophthalmitis
- Toxic anterior segment syndrome (TASS)
- Aseptic endophthalmitis (a severe sterile uveitis which usually resolves with topical steroid treatment)
Delayed post-cataract endophthalmitis must be differentiated from:
- Uveitis
- Sterile inflammation
- Rebound inflammation (related to abrupt discontinuation of steroid drops)
- Iris or vitreous incarceration in the wound (low-grade inflammation)
- Uveitis-glaucoma-hyphema syndrome
- Fungal endophthalmitis.
Epidemiology and Demographics
- In 1910, the incidence of post-cataract endophthalmitis was estimated 10,000 cases per 100,000 individuals with cataract surgery.
- In developed country between 1970-1990, the incidence of post-cataract endophthalmitis was estimated to range from 72 to 120 cases per 100,000 individuals with cataract surgery.
- Since the introduction of phacoemulsification and clear cornea incision, the incidence of post-cataract endophthalmitis was estimated to range from 300 to 500 cases per 100,000 individuals with cataract surgery.[10][11]
Geographical Distribution
In tropical regions such as India, 10–20% of all cases of acute post-cataract endophthalmitis are caused by fungi.[4]
Developed Country
- In the USA and Europe, nearly all cases of acute post-cataract endophthalmitis are caused by bacteria,
Risk Factors
Common risk factors in the development of post-catarct endophthalmitis include:[2][12][13][14][15][16]
- Secondary intraocular lens placement
- Intra-ocular lenses (IOLs) with polypropylene
- Intracapsular cataract extraction
- Clear corneal incisions
- Vitreous contamination following cataract surgery (break in the posterior lens capsule)
- Implantation of an intraocular lens without a heparinized surface
- Diabetes
- immunosuppressive therapy
- Wound dehiscence or leak
- Age ≥85
- Eyelid abnormalities (blepharitis, conjunctivitis, cannuliculitis, lacrimal duct obstructions, and contact lens wear)
Screening
Natural History, Complications, and Prognosis
Natural History
Complications
Prognosis
Diagnosis
Diagnostic Criteria
History
Symptoms
- Acute post-cataract endophthalmitis may occur within hours to few days after cataract surgery in 75% of cases.
- Delayed post-operative endophthalmitis may occur several weeks or month after surgery and often include less virulent bacteria.
Symptoms of post-cataratc endophthalmitis may include the following:
- Deep pain
- Decreased vision (with intraocular lens implantation (IOL) it can be the initial symptom)
- Lid swelling
- Red eye
- Photophobia
- Eye discharge
Physical Examination
A thorough physical and eye examination from the patient is necessary. Common ophthalmoscope examination findings of exogenous bacterial endophthalmitis include:[1][2]
- Visual acuity less than 5/200
- Light perception
- No retinal vessel visible by indirect ophthalmoscopy
- Conjunctival injection
- eyelid edema
- Hypopyon
- Clumps of exudate in the anterior chamber (around the pupillary margin)
- Cloudy cornea
- Decreased red reflex
- Anterior chamber and vitreous inflammatory reactions
- Retinitis
Laboratory Findings
Imaging Findings
X Ray
CT
MRI
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
- The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retina specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics and also prepare for an urgent pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.
- Endogenous endophthalmitis is caused by the hematologic dissemination of an infection to the eyes. Systemic antibiotics are recommended in endogenous bacterial endophthalmitis because the source of the infection is distant from the eye.
- Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
- Immediate vitrectomy is often necessary
Antimicrobial Regimens
- Infectious endophthalmitis[1]
- 1. Causative pathogens
- 2. Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
- Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
- Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary
- Note (3): Intravitreal and intravenous Amphotericin B may be added to the regimen if fungal endophthalmitis is suspected
- 3. Pathogen-directed antimicrobial therapy
- 3.1 Bacillus spp.
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
- Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
- 3.2 Non-Bacillus gram-positive bacteria
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks
- Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
- 3.3 Gram-negative bacteria
- Preferred regimen: Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks
- Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
- 3.4 Candida spp.
- Preferred regimen: (Fluconazole 400-800 mg IV/PO qd for 6-12 weeks OR Voriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks OR Amphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
- Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
- 3.5 Aspergillus spp.
- Preferred regimen: Amphotericin B 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose AND Dexamethasone 400 microgram intravitreal injection, single dose
- Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
- Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy
- 4. Special Considerations
- 4.3 Post-operative endophthalmitis
- 4.3.1 Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose
- Note (1): In addition to intravitreal antibiotic therapy, vitrectomy is necessary
- Note (2): If there is no improvement in 48 h, a repeat intravitreal injection may be administered
- Note (3): Late post-operative endophthalmitis is often caused by Propionibacterium acnes (several years post-op)
- 4.3.2 Pathogen-directed antimicrobial therapy
- 4.3.2.1 Gram-positive bacteria
- Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose
- 4.3.2.2 Gram-negative bacteria
- Preferred regimen: Amikacin 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
- Note: Intravitreal amikacin is associated with the development of retinal microvasculitis
- 4.4 Post-traumatic endophthalmitis
Surgery
Prevention
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
- ↑ Keay L, Gower EW, Cassard SD, Tielsch JM, Schein OD (2012). "Postcataract surgery endophthalmitis in the United States: analysis of the complete 2003 to 2004 Medicare database of cataract surgeries". Ophthalmology. 119 (5): 914–22. doi:10.1016/j.ophtha.2011.11.023. PMC 3343208. PMID 22297029.
- ↑ 4.0 4.1 4.2 Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P; et al. (2003). "Spectrum and clinical profile of post cataract surgery endophthalmitis in north India". Indian J Ophthalmol. 51 (2): 139–45. PMID 12831144.
- ↑ Frahmy JA. Endophthalmitis following cataract extraction: A study of 24 cases in 4498 operations. Acta Ophthalmol 1975;53:522-36. Back to cited text no.
- ↑ Theodore FH. Symposium: Postoperative endophthalmitis. Etiology and diagnosis of fungal endophthalmitis. Trans Am Acad Ophthalmol Otolaryngol 1978;85;327-29
- ↑ Frahmy JA. Endophthalmitis following cataract extraction: A study of 24 cases in 4498 operations. Acta Ophthalmol 1975;53:522-36. Back to cited text no.
- ↑ Theodore FH. Symposium: Postoperative endophthalmitis. Etiology and diagnosis of fungal endophthalmitis. Trans Am Acad Ophthalmol Otolaryngol 1978;85;327-29
- ↑ Kutty PK, Forster TS, Wood-Koob C, Thayer N, Nelson RB, Berke SJ; et al. (2008). "Multistate outbreak of toxic anterior segment syndrome, 2005". J Cataract Refract Surg. 34 (4): 585–90. doi:10.1016/j.jcrs.2007.11.037. PMID 18361979.
- ↑ Koc, F., et al. "Factors influencing treatment results in pseudophakic endophthalmitis." European journal of ophthalmology 12.1 (2001): 34-39.
- ↑ Kattan, H. M., Flynn, H. W. Jr., Pflugfelder, S. C., Robertson, C., Forster, R. K.: Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery. Ophthalmology 98, 1991, 227 - 238
- ↑ Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM; et al. (2005). "Acute endophthalmitis following cataract surgery: a systematic review of the literature". Arch Ophthalmol. 123 (5): 613–20. doi:10.1001/archopht.123.5.613. PMID 15883279.
- ↑ Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons (2007). "Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors". J Cataract Refract Surg. 33 (6): 978–88. doi:10.1016/j.jcrs.2007.02.032. PMID 17531690.
- ↑ Krall EM, Arlt EM, Jell G, Strohmaier C, Bachernegg A, Emesz M; et al. (2014). "Intraindividual aqueous flare comparison after implantation of hydrophobic intraocular lenses with or without a heparin-coated surface". J Cataract Refract Surg. 40 (8): 1363–70. doi:10.1016/j.jcrs.2013.11.043. PMID 25088637.
- ↑ Cooper BA, Holekamp NM, Bohigian G, Thompson PA: Case-control study of endophthalmitis after cataract surgery comparing scleral tunnel and clear corneal wounds. Am J Ophthalmol 2003; 137:598–599.
- ↑ Menikoff JA, Speaker MG, Marmor M, Raskin EM: A case-control study of risk factors for post-operative endophthalmitis. Ophthalmology 1991; 98:1761–1768.