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Post-operative endophthalmitis is an ocular inflammation resulting from the introduction of an infectious agent into the posterior segment of the eye following ocular surgeries.
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.
Based on the latency of onset, post-operative endophthalmitis may be classified into acute and delayed.
*Acute post-operative endophthalmitis occurs within 1 week postoperatively in 75% of cases and is usually caused by coagulase-negative staphylococci.
*Delayed post-operative endophthalmitis occurs weeks to years following surgery and is usually caused by Propionibacterium acnes. It presents as a low-grade inflammation in the anterior chamber.
*Post-intravitreal injection endophthalmitis is another post-procedural subtype. It commonly occurs following intravitreal injection of either triamcinolone acetone or anti-vascular endothelial growth factors (anti VEGF). Intravitreal injections are generally safe; however, endophthalmitis is a rare, visually devastating complication.[1]
Post-cataract endophthalmitis must be differentiated from Toxic anterior segment syndrome (TASS), uveitis, retained lens material, and dehemoglobinized vitreous hemorrhage.[2][3]
The visual outcome of post operative endophthalmitis is highly correlated with the bacteriology.
Early diagnosis and treatment with antimicrobial therapy are fundamental to optimize visual outcome.
Endophthalmitis is a clinical diagnosis supported by culture of intra-ocular fluids.[2][4]
Laboratory studies consistent with the diagnosis of post-cataract endophthalmitis include culture, gram stain, or polymerase chain reaction (PCR) of aqueous humor as well as the vitreous humor.[2][5][6]
The patient needs urgent examination by an expert ophthalmologist to provide intravitreal injection of potent antibiotics and possible urgent pars plana vitrectomy as needed.[2][5]
Acute post-operative endophthalmitis is an ocular inflammation, which may occur within hours to days following ocular surgery.
Acute post-operative endophthalmitis is primarily 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 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 endophthalmitis.
Preoperative topical antimicrobial agents can decrease colony counts in the tear film; however, they do not sterilize the area. The exact incidence 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 incidence of clinical infection following ocular procedures is explained by low inoculum levels, low pathogenicity, and the innate ocular defenses against infection.[2][4][7]
Delayed post-operative endophthalmitis
Post-operative endophthalmitis may 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.[2][4]
Post-operative endophthalmitis is a medical emergency. If left untreated, it may lead to panophthalmitis, corneal infiltration, corneal perforation, and permanent vision loss.
Post-intravitreal injection endophthalmitis
Post-intravitreal injection endophthalmitis occurs following intravitreal injection of either triamcinolone acetone or anti-vascular endothelial growth factors (anti VEGF). Intravitreal injections are generally safe; however, endophthalmitis is a rare visually devastating complication.[8]
Post-intravitreal injection endophthalmitis is usually caused by bacterial pathogens. Bacteria can gain access into the vitreous cavity either at the time of injection or, rarely, later through the needle tract.
Common sources of infection include:
Contaminated needle or instruments by periocular flora
On gross pathology, characteristic findings of post-operative endophthalmitis include eyelid swelling, eyelid erythema, injected conjunctiva, hypopyon, chemosis, and mucopurulunt discharge.
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-operative bacterial endophthalmitis.
Post-operative endophthalmitis has been reported following nearly every type of ocular surgery.
Common causes of acute post-operative endophthalmitis include:
In 1910, the incidence of post-cataract endophthalmitis was estimated to be 10,000 cases per 100,000 individuals with cataract surgery.
Between 1970 to 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 is estimated to range from 300 to 500 cases per 100,000 individuals.[18][19]
The incidence of Post-intravitreal injection endophthalmitis is estimated to range from 20 to 50 cases per 100,000 individuals with intraocular injections.[20]
In the United States, post-cataract endophthalmitis is the most common form of bacterial endophthalmitis.
In the United States, the incidence of post-cataract endophthalmitis was estimated to range from 80 to 360 cases per 100,000 individuals with ocular surgery.[21]
In the United States and Europe, nearly all cases of acute post-cataract endophthalmitis are caused by bacteria.
In the United States, the incidence of culture-proven post-operative endophthalmitis caused by cataract surgery with or without intraocular lens (IOL) was estimated to be 80 cases per 100,000 individuals.
In the United States, the incidence of culture-proven post-operative endophthalmitis caused by secondary IOL placement was estimated to be 360 cases per 100,000 individuals.
Post-operative endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal infiltration, corneal perforation, and ultimately permanent vision loss.
Early diagnosis and treatment with antimicrobial therapy are fundamental to optimize visual outcome.[4][28] Overall, 50% of eyes with post-cataract endophthalmitis obtain a final visual acuity 20/40 vision, and 10% obtain a final visual acuity of 20/400.[2]
The visual outcome of post operative endophthalmitis is highly correlated with the bacteriology.
Post-operative endophthalmitis caused by streptococcus is associated with very poor visual outcome.
Post-operative endophthalmitis caused by coagulase-negative staphylococcus (causes milder endophthalmitis) is associated with better visual outcome than streptococci.
Delayed post-operative endophthalmitis is associated with particularly good prognosis with treatment.[29]
A detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from a patient with post-cataract surgery endophthalmitis include:
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 months after surgery and often include less virulent bacteria and only of the patients may present with eye pain.
Symptoms of post-cataract endophthalmitis may include the following:[30][22]
A thorough physical and eye examination of the patient is necessary.
Common ophthalmoscopic examination findings of post-operative endophthalmitis include:[2][4]
Conjunctival and eyelid cultures in patients with blepharitis; wound dehiscence may indicated
Vitreous cultures are more likely to be positive after vitrectomy than vitreous aspirate (90% vs. 75%), and aqueous cultures are positive in 40% of all cases with endophthalmitis.
Orbital echography is helpful for assessment of vitreous opacification, status of the posterior hyloid face, and retinal detachment in a post-surgical patient.[4][31]
Patients with endophthalmitis require urgent examination by an expert ophthalmologist and/or vitreo-retinal specialist who will determine the need 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.[2][5] Systemic antibiotics are not recommended, but may be considered in severe cases, especially with orbital involvement. In delayed post-operative endophthalmitis, treatment should include vitrectomy with posterior capsulectomy and intravitreal injection.
Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose ANDVancomycin 1 g IV bid for 2 weeks ANDCeftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose ANDCeftazidime 1 g IV bid for 2 weeks ANDClindamycin 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 ANDVancomycin 1 g IV bid for 2 weeks ANDClindamycin 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 ANDVancomycin 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 ANDCeftazidime 1 g IV bid for 2 weeks ORAmikacin 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
Note: Intravitreal amikacin is associated with the development of retinal microvasculitis
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 ORVoriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks ORAmphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) ANDAmphotericin 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 ANDDexamethasone 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
Vitrectomy surgically debrides the vitreous humor, similarly to draining an abscess, and is the fastest way of clearing infection in eyes with fulminant endophthalmitis.[2][5][32]
Vitrectomy is recommended for all patients who develop post cataract endophthalmitis
A vitrectomy is almost always indicated in all patients with delayed post-operative endophthalmitis
The benefits of vitrectomy include:
Better vitreous sample
Rapid and complete sterilization of the vitreous
Removal of toxic bacterial products
Enhancement of systemic antimicrobial penetration in to the eye
↑ 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
↑ 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
↑Gregori, Ninel Z., et al. "Current infectious endophthalmitis rates after intravitreal injections of anti-vascular endothelial growth factor agents and outcomes of treatment." Ophthalmic Surgery, Lasers and Imaging Retina 46.6 (2015): 643-648.
↑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.
↑Isenberg, Sherwin J., et al. "Efficacy of topical povidone-iodine during the first week after ophthalmic surgery." American journal of ophthalmology 124.1 (1997): 31-35.
↑Classen, David C., et al. "The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection." New England Journal of Medicine 326.5 (1992): 281-286.
↑Barry, Peter, et al. "ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study." Journal of Cataract & Refractive Surgery 32.3 (2006): 407-410.