Acute-Onset Endophthalmitis after Clear Corneal Cataract Surgery (1996–2005): Clinical Features, Causative Organisms, and Visual Acuity Outcomes

doi:10.1016/j.ophtha.2007.06.006

Ophthalmology

Volume 115, Issue 3, March 2008, Pages 473-476

Presented at: American Society of Retinal Specialists Annual Meeting, September 2006, Cannes, France, and American Academy of Ophthalmology Annual Meeting, November 2006, Las Vegas, Nevada.

https://doi.org/10.1016/j.ophtha.2007.06.006 Get rights and content

Purpose

To report the clinical features, causative organisms, and visual acuity outcomes associated with endophthalmitis after clear corneal cataract surgery and to compare outcomes with those of the Endophthalmitis Vitrectomy Study (EVS).

Design

Retrospective consecutive case series.

Participants

The study included 73 eyes of 73 patients, mean age 76 years (range, 48–94 years), with endophthalmitis after clear corneal cataract surgery, including both referred and in-house patients.

Methods

The clinical and microbiology records were reviewed of all patients treated at a single medical center between January 1, 1996, and December 31, 2005, for clinically diagnosed, culture-positive endophthalmitis occurring within 6 weeks of clear corneal cataract surgery.

Main Outcome Measures

Presence of hypopyon, mean time to endophthalmitis diagnosis, organisms cultured, and presenting and final visual acuities.

Results

The mean time between cataract surgery and diagnosis of endophthalmitis was 13 days (median, 9 days; range, 1–39 days). Visual acuity at the time of diagnosis was <5/200 in 61 of 73 (83.6%) patients, including light perception in 11 of 73 (15.1%). Hypopyon was present in 60 of 73 (82.2%) eyes. The initial treatment included intravitreal vancomycin, ceftazidime, and dexamethasone. A vitreous tap and intravitreal injection was performed in 54 of 73 (74.0%) eyes and pars plana vitrectomy in 19 of 73 (26.0%) eyes. Coagulase-negative Staphylococcus was isolated in 50 of 73 (68.4%) eyes. Other isolates included Staphylococcus aureus in 5/73 (6.8%) and Streptococcus species in 6 of 73 (8.2%). A visual acuity of ≥20/40 was achieved in 36 of 73 patients (49.3%) at final follow-up.

Conclusions

The features and outcomes of endophthalmitis associated with clear corneal cataract surgery are similar to those reported in the EVS, which are associated with scleral incisions, but time to diagnosis was later with clear corneal incisions.

Section snippets

Patients and Methods

The study protocol was approved by the Institutional Review Board of the University of Miami School of Medicine. The clinical and microbiology records were reviewed of all patients treated at Bascom Palmer Eye Institute between January 1, 1996, and December 31, 2005, for clinically diagnosed, culture-positive endophthalmitis occurring within 6 weeks of clear corneal cataract surgery. The study included patients who were operated elsewhere and referred for care and patients who underwent

Results

The study included 73 eyes (34 right eyes and 39 left eyes) of 73 patients with a mean age of 76 years (range, 48–94). The mean length of follow-up was 460 days (range, 1 day to 8 years; median, 130 days). At the time of presentation with endophthalmitis, 2 (2.7%) of the 73 eyes had corneal wound sutures and 4 (5.5%) had a documented open posterior capsule, including 3 (4.1%) eyes that had undergone an anterior vitrectomy during cataract surgery. Two patients were treated with limbal relaxing

Discussion

The incidence of endophthalmitis after cataract surgery may or may not have increased in association with the use of the clear corneal technique.3, 4, 5, 6 In the studies that reported an increased incidence, numerous theories have been proposed to explain this increase. One such hypothesis is related to wound architecture and stability.⁶ An experimental study evaluated the dynamic status of clear corneal wounds in cadaver eyes; the authors demonstrated the ingress of India ink through all of

References (12)

D.V. Leaming
Practice styles and preferences of ASCRS members—2003 survey
J Cataract Refract Surg
(2004)
J.J. Miller et al.
Acute-onset endophthalmitis after cataract surgery (2000–2004): incidence, clinical settings, and visual acuity outcomes after treatment
Am J Ophthalmol
(2005)
D.B. Roth et al.
Antibiotic selection in the treatment of endophthalmitis: the significance of drug combinations and synergy
Surv Ophthalmol
(1997)
M.N. Iyer et al.
Subconjunctival antibiotics for acute postcataract extraction endophthalmitis—is it necessary?
Am J Ophthalmol
(2004)
G. Brian et al.
Cataract blindness—challenges for the 21st century
Bull World Health Org
(2001)
B.A. Colleaux et al.
Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery
Can J Ophthalmol
(2000)

There are more references available in the full text version of this article.

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Manuscript no. 2006-1400.

Supported in part by Research to Prevent Blindness, New York, New York.

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Original articleAcute-Onset Endophthalmitis after Clear Corneal Cataract Surgery (1996–2005): Clinical Features, Causative Organisms, and Visual Acuity Outcomes

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

J Cataract Refract Surg

Am J Ophthalmol

Surv Ophthalmol

Am J Ophthalmol

Cataract blindness—challenges for the 21st century

Bull World Health Org

Effect of prophylactic antibiotics and incision type on the incidence of endophthalmitis after cataract surgery

Can J Ophthalmol

Original article
Acute-Onset Endophthalmitis after Clear Corneal Cataract Surgery (1996–2005): Clinical Features, Causative Organisms, and Visual Acuity Outcomes