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Treatment of Post-operative Endophthalmitis

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Published Online: May 22nd 2012 European Ophthalmic Review, 2012;6(3):149-156 DOI: http://doi.org/10.17925/EOR.2012.06.03.149
Authors: Leopoldo Spadea, Arianna Fiasca
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Abstract:
Overview

The rates of post-operative endophthalmitis have been low for many years, but recent reports suggest that this type of ocular infection may be on the rise. Fluctuations in the number of cases appear to correlate with the type of intraocular surgery performed. Post-operative endophthalmitis has been reported as a consequence of nearly every type of ocular surgery, but is most common following cataract surgery. Numerous reports have demonstrated that Gram-positive bacteria cause the vast majority of post-operative endophthalmitis cases. Coagulase-negative staphylococcal isolates are the most common. Most intraocular infections resulting from infection with coagulase-negative staphylococci can be treated with antibiotic and anti-inflammatory agents, resulting in restoration of partial or complete vision. However, the more virulent the bacterial strain, the more devastating the visual outcome. Intraocular infections with Staphyloccus aureus, enterococci, Bacillus or Gram-negative strains are often intractable, and blindness or loss of the eye itself is not uncommon. The therapeutic success of treating post-operative endophthalmitis depends largely on accurate and prompt diagnosis. Antibiotic therapy can be topical, sub-conjunctival, systemic or intravitreal. Vitrectomy must be reserved for patients who present with initial visual acuity of light perception. Only in these cases has vitrectomy been shown to be more advantageous with respect to the intravitreal antibiotic injection.

Keywords

Endophthalmitis, bacteria, cataract, infections, retina, vitreous, therapy

Article:

Endophthalmitis is a severe inflammation of the interior of the eye caused by the introduction of contaminating micro-organisms following trauma, surgery or haematogenous spread from a distant infection site. Despite appropriate therapeutic intervention, bacterial endophthalmitis frequently results in visual loss, if not loss of the eye itself.

The two types of endophthalmitis are endogenous (metastatic) and exogenous. Endogenous endophthalmitis results from the haematogenous spread of organisms from a distant source of infection (i.e. endocarditis). Endogenous endophthalmitis is rare, occurring in only 2–15 % of all cases of endophthalmitis. Average annual incidence is about five per 10,000 hospitalised patients. In unilateral cases, the right eye is twice as likely to become infected as the left eye, probably because of its more proximal location to direct arterial blood flow from the right innominate artery to the right carotid artery.

Since 1980, candidal infections reported in intravenous drug users have increased. The number of people at risk may be increasing because of the spread of AIDS, more frequent use of immunosuppressive agents and more invasive procedures (i.e. bone marrow transplantation).1 Exogenous endophthalmitis results from direct inoculation as a complication of ocular surgery, foreign bodies and/or blunt or penetrating ocular trauma. Most cases of exogenous endophthalmitis (about 60 %) occur after intraocular surgery. Under normal circumstances, the blood–ocular barrier provides a natural resistance against invading organisms.2

Destruction of intraocular tissues may be due to direct invasion by the organism and/or inflammatory mediators of the immune response. Endophthalmitis may be as subtle as white nodules on the lens capsule, iris, retina or choroid. It can also be as ubiquitous as inflammation of all the ocular tissues, leading to a globe full of purulent exudates. In addition, inflammation can spread to involve the orbital soft tissue.

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Article Information:
Disclosure

The authors have no conflicts of interest to declare.

Correspondence

Leopoldo Spadea, Via Benozzo Gozzoli 34, 00142 Rome, Italy. E: lspadea@cc.univaq.it

Support

Financial support received from the Department of Surgical Sciences, University of L’Aquila, Italy.

Received

2011-09-16T00:00:00

References

  1. Romero CF, Rai MK, Lowder CY, Adal KA, Endogenous endophthalmitis: case report and brief review, Am Fam Phys, 1999;60:510–4.
  2. Streilein JW, Ocular immune privilege: therapeutic opportunities from an experiment of nature, Nat Rev Immunol, 2003;3:879–88.
  3. Albert DM, Jakobiec FA, Postoperative endophthalmitis. In: Albert DM, Jakobiec FA (eds), Principles and Practice of Ophthalmology, Philadelphia: WB Saunders, 2000;2441–62.
  4. Ness T, Pelz K, Hansen LL, Endogenous endophthalmitis: microorganisms, disposition and prognosis, Acta Ophthalmol Scand, 2007;85:852–6.
  5. Mandelbaum S, Forster RK, Postoperative endophthalmitis, Int Ophthalmol Clin, 1987;27:95–106.
  6. Taban M, Behrens A, Newcomb RL, Acute endophthalmitis following cataract surgery: a systematic review of the literature, Arch Ophthalmol, 2005;123:613–20.
  7. Aaberg TM, Flynn HW, Schiffman J, Newton J, Nosocomial acute-onset postoperative endophthalmitis survey: a 10-year review of incidence and outcomes, Ophthalmology, 1998;105:1004–10.
  8. Kattan HM, Flynn HW, Pflugfelder SD, et al., Nosocomial endophthalmitis survey: current incidence of infection after intraocular surgery, Ophthalmology, 1991;98:227–38.
  9. Lundstrom M, Wejde G, Stenevi U, et al., Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location, Ophthalmology, 2007;114:866–70.
  10. Behndig A, Montan P, Stenevi U, et al., One million cataract surgeries: Swedish National Cataract Register 1992–2009, J Cat Refract Surg, 2011;37:1539–45.
  11. Thompson JT, Parver LM, Enger CL, et al., Infectious endophthalmitis after penetrating injuries with retained intraocular foreign bodies. National Eye Trauma System, Ophthalmology, 1993;100:1468–74.
  12. Taban M, Behrens A, Newcomb RL, et al., Incidence of acute endophthalmitis following penetrating keratoplasty: a systematic review, Arch Ophthalmol, 2005;123:605–9.
  13. Han DP, Wisniewski SR, Wilson LA, et al., Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study, Am J Ophthalmol, 1996;122:1–17.
  14. Towler H, Aqueous contamination during small incision cataract surgery: a lesson in study design, Br J Ophthalmol, 1995;79:873.
  15. Speaker MG, Milch FA, Shah MK, et al., Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis, Ophthalmology, 1991;98:639–50.
  16. Microbiologic factors and visual outcome in the Endophthalmitis Vitrectomy Study, Am J Ophthalmol, 1996;122:830–46.
  17. Clark WL, Kaiser PK, Flynn HW, et al., Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis, Ophthalmology, 1999;106:1665–70.
  18. Scott IU, Flynn HW, Feuer W, et al., Endophthalmitis associated with microbial keratitis, Ophthalmology, 1996;103:1864–70.
  19. Song A, Scott IU, Flynn HW Jr, Budenz DL, Delayed-onset bleb-associated endophthalmitis: clinical features and visual acuity outcomes, Ophthalmology, 2002;109:985–91.
  20. Okhravi N, Adamson P, Carroll N, et al., PCR-based evidence of bacterial involvement in eyes with suspected intraocular infection, Invest Ophthalmol Vis Sci, 2000;41:3474.
  21. Wilson FM 2nd, Causes and prevention of endophthalmitis, Int Ophthalmol Clin, 1987;27:67–73.
  22. Lundstrom M, Wejde G, Stenevi U, et al., Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location, Ophthalmology, 2007;114:866–70.
  23. Ng JQ, Morlet N, Pearman JW, et al., Management and outcomes of postoperative endophthalmitis since the endophthalmitis vitrectomy study: the Endophthalmitis Population Study of Western Australia (EPSWA)’s fifth report, Ophthalmology, 2005;112:1199–206.
  24. Donahue SP, Kowalski RP, Jewart BH, Friberg TR, Vitreous cultures in suspected endophthalmitis. Biopsy or vitrectomy? Ophthalmology, 1993;100:452–5.
  25. Jager RD, Aiello LP, Patel SC, Cunningham ET Jr, Risks of intravitreal injection: a comprehensive review, Retina, 2004;24:676–98.
  26. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group, Arch Ophthalmol, 1995;113:1479–96.
  27. Streilein JW, Regulation of ocular immune responses, Eye, 1997;11:171–5.
  28. Bohigian GM, Olk RJ, Factors associated with a poor visual result in endophthalmitis, Am J Ophthalmol, 1986;101:332–41.
  29. Rowsey JJ, Stonecipher KG, Jensen H, et al., Culture and sensitivities of infectious endophthalmitis: a microbiological analysis of 302 intravitreal biopsies, Invest Ophthalmol Vis Sci, 1992;33(Suppl.):745.
  30. Johnson MW, Doft BH, Kelsey SF, et al., The Endophthalmitis Vitrectomy Study. Relationship between clinical presentation and microbiologic spectrum, Ophthalmology, 1997;104:261–72.
  31. Okhravi N, Towler HMA, Hykin P, et al., Assessment of a standard treatment protocol on visual outcome following presumed bacterial endophthalmitis, Br J Ophthalmol, 1997;81:719–22.
  32. Kresloff MS, Castellarin AA, Zarbin MA, Endophthalmitis, Surv Ophthalmol, 1998;43:193–224.
  33. Lam SR, Devenyi RG, Berger AR, Dunn W, Visual outcome following penetrating globe injuries with retained intraocular foreign bodies, Can J Ophthalmol, 1999;34:389–93.
  34. Baum J, Peyman GA, Barza M, Intravitreal administration of antibiotic in the treatment of bacterial endophthalmitis. III Consensus, Surv Ophthalmol, 1982;26:204–6.
  35. Brod RD, Flynn HW, Endophthalmitis: current approaches to diagnosis and therapy, Curr Opin Infect Dis, 1993;6:628–37.
  36. Ferencz JR, Assia EI, Diamantstein L, Rubinstein E, Vancomycin concentration in the vitreous after intravenous and intravitreal administration for postoperative endophthalmitis, Arch Ophthalmol, 1999;117:1023–7.
  37. Fleisher LN, Ferrell JB, McGahan MC, Synergistic uveitic effects of tumor necrosis factor-alpha and interleukin-1 beta, Investig Ophthalmol Vis Sci, 1992;33:2120–7.
  38. Morlet N, Graham GG, Gatus B, et al., Pharmacokinetics of ciprofloxacin in the human eye: a clinical study and population pharmacokinetic analysis, Antimicrob Agents Chemother, 2000;44:1674–9.
  39. Johnson MW, Doft BH, Kelsey SF, et al. The Endophthalmitis Vitrectomy Study Group. The Endophthalmitis Vitrectomy Study: relationship between clinical presentation and microbiologic spectrum, Ophthalmology, 1997;104:261–72.
  40. Campochiaro PA, Lim JI, Aminoglycoside toxicity in the treatment of endophthalmitis, Arch Ophthalmol, 1994;112:48–53.
  41. D’Amico DJ, Caspers-Velers L, Libert L, et al., Comparative toxicity of intravitreal aminoglycoside antibiotics, Am J Ophthalmol, 1985;100:264–75.
  42. Stevens SX, Fouraker BD, Jensen HG, Intraocular safety of ciprofloxacin, Arch Ophthalmol, 1991;109:1737–43.
  43. Wiechens B, Neumann D, Grammer JB, et al., Retinal toxicity of liposome-incorporated and free ofloxacin after intravitreal injection in rabbit eyes, Int Ophthalmol, 1998;22:133–43.
  44. Merino G, Fujino Y, Hanashiro RK, Lipoteichoic acid as an inducer of acute uveitis in the rat, Investig Ophthalmol Vis Sci, 1998;39:1251–6.
  45. Callegan MC, Booth MC, Jett BD, Gilmore MS, Pathogenesis of Gram-positive bacterial endophthalmitis, Infect Immun, 1999;67:3348–56.
  46. Mo JS, Matsukawa A, Ohkawara S, Yoshinaga M, Role and regulation of IL-8 and MCP-1 in LPS-induced uveitis in rabbits, Exp Eye Res, 1999;68:333–40.
  47. Ozturk F, Kurt E, Inan UU, et al., Effect of propolis on endotoxin-induced uveitis in rabbits, Jpn J Ophthalmol, 1999;43:285–9.
  48. Rooney P, Bilbe G, Zak O, O’Reilly T, Dexamethasone treatment of lipopolysaccharide-induced meningitis in rabbits that mimics magnification of inflammation following antibiotic therapy, J Med Microbiol, 1995;43:37–44.
  49. Smith MA, Sorenson JA, D’Aversa G, et al., Treatment of experimental methicillin-resistant Staphylococcus epidermidis endophthalmitis with intravitreal vancomycin and intravitreal dexamethasone, J Infect Dis, 1997;175:462–6.
  50. Yoshizumi MO, Lee GC, Equi RA, et al., Timing of dexamethasone treatment in experimental Staphylococcus aureus endophthalmitis, Retina, 1998;18:130–5.
  51. Shah GK, Stein JD, Sharma S, et al., Visual outcomes following the use of intravitreal steroids in the treatment of postoperative endophthalmitis, Ophthalmology, 2000;107:486–9.
  52. Kim IT, Chung KH, Koo BS, Efficacy of ciprofloxacin and dexamethasone in experimental Pseudomonas endophthalmitis, Korean J Ophthalmol, 1996;10:8–17.
  53. Meredith TA, Aguilar HE, Drews C, et al., Intraocular dexamethasone produces a harmful effect on treatment of experimental Staphylococcus aureus endophthalmitis, Trans Am Ophthalmol Soc, 1996;94:241–52.
  54. Adenis JP, Robert PY, Mounier M, Denis F, Anterior chamber concentrations of vancomycin in the irrigating solution at the end of cataract surgery, J Cataract Refract Surg, 1997;23:111–14.
  55. Gan IM, van Dissel JT, Beekhuis WH, et al., Intravitreal vancomycin and gentamicin concentrations in patients with postoperative endophthalmitis, Br J Ophthalmol, 2001;85:1289–93.
  56. Haider SA, Hassett P, Bron AJ, Intraocular vancomycin levels after intravitreal injection in post-cataract extraction endophthalmitis, Retina, 2001;21:210–13.
  57. Gentamicin, Drug information provided by Lexi-Comp, The Merck Manual Professional. Available at: www.merckmanuals.com/professional/lexicomp/gentamicin. html (accessed 26 July 2012).
  58. Solomon R, Farbowitz M, Ciardella A, et al., Investigation of the safety of intravitreal ceftriaxone in an experimental rabbit model, Cutaneous Ocular Toxicol, 2000;19:131–6.
  59. Aguilar HE, Meredith TA, Shaarawy A, et al., Vitreous cavity penetration of ceftazidime after intravenous administration, Retina, 1995;15:154–9.
  60. Martin DF, Ficker LA, Aguilar HA, et al., Vitreous cefazolin levels after intravenous injection. Effects of inflammation, repeated antibiotic doses, and surgery, Arch Ophthalmol, 1990;108:411–4.
  61. Christmas NJ, Smiddy WE, Vitrectomy and systemic fluconazole for treatment of endogenous fungal endophthalmitis, Ophthalmic Surg Lasers, 1996;27:1012–18.
  62. Hariprasad SM, Mieler WF, Lin TK, et al., Voriconazole in the treatment of fungal eye infections: a review of current literature, Br J Ophthalmol, 2008;92:871–8
  63. Beigi B, Westlake W, Chang B, et al., The effect of intracameral, per-operative antibiotics on microbial contamination of anterior chamber aspirates during phacoemulsification, Eye, 1998;12:390–4.
  64. Romero P, Mendez I, Salvat M, Fernandez J, Almena M, Intracameral cefazolin as prophylaxis against endophthalmitis in cataract surgery, J Cataract Refract Surg, 2006;32:438–41.
  65. Mayer E, Cadman D, Ewings P, et al., A 10 year retrospective survey of cataract surgery and endophthalmitis in a single eye unit: injectable lenses lower the incidence of endophthalmitis, Br J Ophthalmol, 2003;87:867–9
  66. Montan PG, Koranyi G, Setterquist HE, et al., Endophthalmitis after cataract surgery: risk factors relating to technique and events of the operation and patient history: a retrospective case–control study, Ophthalmology, 1998;105:2171–7.
  67. Kodjikian L, Burillon C, Roques C, et al., Bacterial adherence of Staphylococcus epidermidis to intraocular lenses: a bioluminescence and scanning electron microscopy study, Invest Ophthalmol Vis Sci, 2003;44:4388–94.
  68. Colleaux KM, Hamilton WK, Effect of prophylactic antibiotics and Incision type on the incidence of endophthalmitis after cataract surgery, Can J Ophthalmol, 2000;35:373–8.
  69. Wallin T, Parker J, Jin Y, et al., Cohort study of 27 cases of endophthalmitis at a single institution, J Cataract Refract Surg, 2005;31:735–41.

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