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Current Strategies for Prevention and Treatment of Postoperative Endophthalmitis

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Ashley Brundrett
Ashley Brundrett
Ashley Brundrett
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Christopher D. Conrady
Christopher D. Conrady
Christopher D. Conrady
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Akbar Shakoor
Akbar Shakoor
Akbar Shakoor
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Amy Lin
Amy Lin
Amy Lin
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Purpose of review We review the prevention and treatment of postoperative endophthalmitis. Recent findings Postoperative endophthalmitis is rare but has potentially blinding consequences. There is no consensus on prevention, but there are a few controlled studies with methods of decreasing the infection rate, such as use of povidone iodine and intracameral antibiotics. There remains only one randomized controlled study (Endophthalmitis Vitrectomy Study or EVS) on the treatment of postoperative endophthalmitis, but there are retrospective studies which examine the timing and various methods of vitrectomy and intravitreal antibiotics. Summary The application of povidone iodine remains a proven method of preventing endophthalmitis, but evidence suggests that intracameral antibiotics further minimize this risk. Further research is needed to define the efficacy of intravitreal antibiotics at the time of cataract surgery. There are many questions regarding treatment, including performance of vitrectomy for eyes with visual acuities better than light perception, smaller vitrectomy port sizes, and intravitreal antibiotics and/or oral steroids.
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OCULAR MICROBIOLOGY AND IMMUNOLOGY (B JENG AND L SCHOCKET, SECTION EDITORS)
Current Strategies for Prevention and Treatment
of Postoperative Endophthalmitis
Ashley Brundrett
1
&Christopher D. Conrady
1
&Akbar Shakoor
1
&Amy Lin
1
Published online: 16 April 2018
#Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract
Purpose of review We review the prevention and treatment of postoperative endophthalmitis.
Recent findings Postoperative endophthalmitis is rare but has potentially blinding consequences. There is no consensus on
prevention, but there are a few controlled studies with methods of decreasing the infection rate, such as use of povidone iodine
and intracameral antibiotics. There remains only one randomized controlled study (Endophthalmitis Vitrectomy Study or EVS)
on the treatment of postoperative endophthalmitis, but there are retrospective studies which examine the timing and various
methods of vitrectomy and intravitreal antibiotics.
Summary The application of povidone iodine remains a proven method of preventing endophthalmitis, but evidence suggests
that intracameral antibiotics further minimize this risk. Further research is needed to define the efficacy of intravitreal antibiotics
at the time of cataract surgery. There are many questions regarding treatment, including performance of vitrectomy for eyes with
visual acuities better than light perception, smaller vitrectomy port sizes, and intravitreal antibiotics and/or oral steroids.
Keywords Endophthalmitis .Postoperative endophthalmitis .Intracameral antibiotics
Introduction
Cataract surgery is one of the most common surgeries
performed in the USA. While the risks are low, postoper-
ative endophthalmitis has gained significant attention due
to potentially poor visual outcomes [1]. Review of the
Medicare claims data in the USA in 2003–2004 and
2010–2014 found rates of endophthalmitis between 1.2
and 1.33 cases per 1000 cataract cases resulting in an
83% rise in cost compared to cases that did not develop
postoperative endophthalmitis [2,3]. Consequently, en-
dophthalmitis and strategies to prevent the infection have
gained considerable attention due to the significant cost of
treating the infection and the substantial risk of poor vi-
sual acuities. In the following manuscript, we discuss both
perioperative preventative strategies and potential treat-
ment algorithms based on the current literature available.
Part I: Preventing Endophthalmitis
Postoperative endophthalmitis is a rare but potentially devas-
tating complication after ocular surgery. Although this can
occur after any type of ocular surgery, the majority of cases
occur after cataract surgery since it is the most commonly
performed eye surgery [4].Current practice patterns for post-
operative endophthalmitis prophylaxis including surgical
technique, aseptic protocols, and perioperative antibiotic uti-
lization vary worldwide, making it difficult to establish a stan-
dard of care [5–11]. Randomized, controlled trials are imprac-
tical given the low prevalence of postoperative endophthalmi-
tis and the very large number of patients that would be re-
quired. Current practice patterns are most influenced by the
growing evidence from published observational studies with
few controlled studies to solidify a standard of care.
Commonly used prophylactic strategies include preoperative
topical antibiotic drops, application of povidone-iodine to the
conjunctival cul de sac and the peri-ocular skin, proper
This article is part of the Topical Collection on Ocular Microbiology and
Immunology
*Amy Lin
Amy.Lin@hsc.utah.edu
1
John A. Moran Eye Center, University of Utah, 65 Mario Capecchi
Dr, Salt Lake City, UT 84132, USA
Current Ophthalmology Reports (2018) 6:105–114
https://doi.org/10.1007/s40135-018-0171-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... On the other hand, the standard treatment of care for endogenous fungal chorioretinitis is systemic antifungals and is usually sufficient in cases that lack sight-threatening lesions or vitreous involvement [42]. Additionally, peripheral toxoplasmosis chorioretinitis is routinely managed with systemic medication alone. ...
... Thus, eradication of the pathogen can be successfully achieved with systemic therapy through either oral or intravenous routes alone. The EVS had some significant limitations, most notably that it utilized intravenous ceftazidime, which has poor activity against the most common Gram (+) organisms, and amikacin, which has very poor intraocular penetration [7,23,42]. The emergence of fluoroquinolones, specifically moxifloxacin, which has shown to concentrate within the vitreous at concentrations required to inhibit bacterial growth, has led some to question recommendations from the EVS that systemic antibiotics are of no additional benefit in the battle to sterilize the aqueous and vitreous of bacterial infection [7,42]. ...
... The EVS had some significant limitations, most notably that it utilized intravenous ceftazidime, which has poor activity against the most common Gram (+) organisms, and amikacin, which has very poor intraocular penetration [7,23,42]. The emergence of fluoroquinolones, specifically moxifloxacin, which has shown to concentrate within the vitreous at concentrations required to inhibit bacterial growth, has led some to question recommendations from the EVS that systemic antibiotics are of no additional benefit in the battle to sterilize the aqueous and vitreous of bacterial infection [7,42]. Until a large, randomized study using newer, better intraocular penetrating systemic antibiotics is performed, the use of adjuvant oral or intravenous antibiotics will remain controversial. ...
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Uveitis refers to a broad group of inflammatory disorders of the eye that often require medical and surgical management to improve or stabilize vision and prevent vision-threatening pathological changes to the eye. Drug delivery to the eye to combat inflammation and subsequent complications from uveitic conditions is complex as there are multiple barriers to absorption limiting availability of the needed drug in the affected tissues. As such, there has been substantial interest in developing new drugs and drug delivery platforms to help reduce intraocular inflammation and its complications. In this review, we discuss the challenges of drug delivery, novel technologies recently approved for uveitis patient care and promising drug delivery platforms for uveitis and sequelae of ocular inflammation.
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... Given the significant ocular morbidity associated with intraocular infections, and despite the introduction of systemic antibiotics with better ocular penetrance (i.e.fluoroquinolones), and the use of smaller vitrectomy port sizes, the Endophthalmitis Vitrectomy Study (EVS) published in 1995 remains the foundation of current treatment algorithms [4]. Due to the lack of more recent randomized controlled trials and significant exclusion criteria in the EVS such as the exclusion of non-cataractassociated procedures, cases with severe intraocular inflammation, and indolent courses, there is no consensus as to the management of post-procedure endophthalmitis [5]. This has become increasingly apparent with the advent and expansion of intravitreal injections for multiple chorioretinal diseases since the EVS was conducted [5,6]. ...
... Due to the lack of more recent randomized controlled trials and significant exclusion criteria in the EVS such as the exclusion of non-cataractassociated procedures, cases with severe intraocular inflammation, and indolent courses, there is no consensus as to the management of post-procedure endophthalmitis [5]. This has become increasingly apparent with the advent and expansion of intravitreal injections for multiple chorioretinal diseases since the EVS was conducted [5,6]. Despite a lack of randomized trials, groups have questioned the applicability of the EVS recommendation of performing vitrectomies only in those eyes with light perception or worse visual acuities; however, data has been mixed from these studies [7][8][9]. ...
... Despite a lack of randomized trials, groups have questioned the applicability of the EVS recommendation of performing vitrectomies only in those eyes with light perception or worse visual acuities; however, data has been mixed from these studies [7][8][9]. Recent attention has been directed towards prevention strategies and early detection of post-operative endophthalmitis rather than management to improve long-term outcomes once an infection has manifested [5,10]. ...
Long-term visual outcomes of endophthalmitis and the role of systemic steroids in addition to intravitreal dexamethasone
Article
Full-text available
  • May 2020
  • BMC Ophthalmol
Background: The purpose of this study was to evaluate the role of systemic steroids in post-procedural endophthalmitis as the role of intravitreal steroids in treatment algorithms of endophthalmitis remain controversial. Methods: This is a retrospective analysis from a single tertiary referral center of all patients older than 18 years old that developed presumed post-procedure endophthalmitis and were treated at our center from 2009 to 2018. Results: Eighty-three patients were followed after being treated for post-procedural endophthalmitis that either received systemic steroids or did not around the time of diagnosis. Almost 30 % of all patients regained a final visual acuity of 20/40 or better, while 31.2% had poor visual outcomes of count fingers or worse. Non-clearing debris was the most significant long-term complication. Visual improvement plateaued in 67.7% by 1 month after diagnosis and initial treatment in both groups. There was no difference in visual outcomes when comparing the sixteen patients that received systemic steroids and the sixty-seven that did not; however, no enucleation or evisceration was required in patients receiving systemic steroids. Five patients that did not receive systemic steroids required an enucleation or evisceration due to a blind, painful eye. Conclusions: The use of systemic steroids does not seem to worsen long-term outcomes of endophthalmitis compared to those patients that did not receive them and they may prove beneficial in the most severe cases by reducing the risk of losing the globe altogether.
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... While bacterial infections of the retina are rare, bacterial endophthalmitis is one of the most devastating complications of any intraocular procedure, and despite the current strategies for prevention, early identification, and aggressive treatment, substantial vision loss still frequently occurs [12,[146][147][148][149][150]. Endophthalmitis can more rarely be associated with blood-borne infections (endogenous), or more commonly, following trauma or surgery to the eye (exogenous). ...
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Ocular infectious diseases are an important cause of potentially preventable vision loss and blindness. In the following manuscript, we will review ocular immunology and the pathogenesis of herpesviruses and Pseudomonas aeruginosa infections of the cornea and posterior segment. We will highlight areas of future research and what is currently known to promote bench-to-bedside discoveries to improve clinical outcomes of these debilitating ocular diseases.
View
... Postoperative endophthalmitis (POE) is a rare, destructive complication of cataract surgery [1][2][3]. Recent advancements have significantly decreased POE rates and severity [4]. Gram-positive bacteria are the most common cause, but Gram-negatives, particularly ...
Burkholderia Postoperative Endophthalmitis and an Outbreak Including Bilateral Simultaneous Postoperative Endophthalmitis
Article
Full-text available
  • Jan 2022
Purpose: To describe a single-center series of the first Burkholderia contaminans postoperative endophthalmitis (POE) cases and the first suspected Burkholderia cepacia complex (Bcc) bilateral simultaneous postoperative endophthalmitis (BSPOE) in the context of Burkholderia bacteria and systemic Burkholderia infections. Setting: The Narvik Eye Clinic, Narvik, Norway. Design: Retrospective study of all 5 unilaterally and one bilaterally infected patients, the surgical environment, Burkholderia bacteriology and the likely cause of the infections. Methods: Meticulous review of the case series occurring during unusual winter weather in arctic Norway in January 2019, detailed examination of the surgical clinic, dismantled for this assessment, followed by detailed review of the biology of Bcc species and the infections it can cause. Results: Six patients developed postoperative Bcc endophthalmitis within 4 months postoperatively, with one case suffering BSPOE. All cases, except one eye of the BSPOE patient, were vitreous-culture positive for B. contaminans. The Bcc strain was genetically identical to the ones later cultured from the surgical center's ventilation system. All patients recovered visual acuity of 20/25 or better after aggressive treatment. Conclusions: Bcc-induced postoperative endophthalmitis is rare and can occur if operating room ventilation is tampered with. It is challenging to treat with generally poor outcomes prior to the current series, in which all cases did well.
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Bilateral simultaneous postoperative endophthalmitis (BSPOE): Review of cases reported over the past 50 years
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  • Dec 2021
A detailed retrospective analysis and literature review were conducted for all previously published reports of bilateral simultaneous postoperative endophthalmitis (BSPOE) since 1970. There have been 7 (9, with 2 currently being reported elsewhere) cases of BSPOE after immediately sequential bilateral cataract surgery (ISBCS) reported over 50 years. Generally, in these cases, the surgical protocol recommended by the International Society of Bilateral Cataract Surgeons ( i SBCS) was breached or uncertain. Bacterial causes were Pseudomonas aeruginosa (3), Staphylococcus epidermidis (3), and Burkholderia cepacia complex (1). One case showed negative results for bacterial infection and 1 was not determined. Visual recovery was light perception, or worse, for Pseudomonas cases, generally good for Staphylococcus and Burkholderia cases, and mixed in cases of unknown etiology. Therefore, BSPOE is rare and causes vary. Strict adherence to the i SBCS General Principles of Excellence in ISBCS 2009 surgical protocol and care with operating room construction seem to considerably lessen the risk.
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Antibiotic prophylaxis practice patterns for cataract surgery in India – Results from an online survey
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Purpose: The aim of this study is to assess the current antibiotic prophylaxis practice patterns for cataract surgery in India. Methods: This was a questionnaire-based E-survey carried out at a tertiary eye care center in India. An E-mail invitation to complete an online 20 point questionnaire survey was sent to all members of the All India Ophthalmological Society with valid E-mail addresses using a digital E-mail service. Duplicate entries were prevented. Results: Out of 1228 total respondents (8.2%) who completed the survey 38% reported using routine intracameral (IC) antibiotic prophylaxis. Another 7% place antibiotics in the irrigating solution. Of those using IC antibiotic prophylaxis, 91% adopted this practice within the past 2 years; 92% are using moxifloxacin with 56% using a commercially available moxifloxacin formulation. Those predominantly performing phacoemulsification (43% vs. 25% performing mostly manual small incision cataract surgery, P < 0.001) and more than 500 cataract surgeries annually (45% vs. 33%, P < 0.001) reported greater use of IC moxifloxacin. Self-reported endophthalmitis rates were statistically significantly greater in those not using IC antibiotics (0.045% vs. 0.036, P = 0.04). Although a majority of respondents believe that IC antibiotics are an important option (54%) and that it is important to have a commercially available solution (68%), many believe that other antibiotic prophylaxis methods are sufficient (31%). Conclusion: IC antibiotic prophylaxis for cataract surgery has sharply increased in India. In contrast to the West, intraocular moxifloxacin, which is commercially available in India, is preferred by the vast majority of users.
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Povidone-Iodine 3-Minute Exposure Time is Viable in Preparation for Cataract Surgery
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  • Apr 2017
Purpose: Povidone-iodine (PI) is widely used to reduce the preoperative conjunctival bacterial load. This study aimed to evaluate the employment of PI 10% in an attempt to sterilize the ocular surface prior to cataract surgery, and to show that PI could be left in contact for 3 minutes. The viability of this exposure time in clinical practice, associated adverse events, and visual outcomes were documented. Methods: In this prospective cohort study, phacoemulsification cataract surgery was performed in 604 patients by a single surgeon. Preoperative preparation was undertaken with PI 10%, applied to the cornea, conjunctival sac, eyelids, and periorbital skin with sterile cotton gauze. Povidone-iodine was then flushed onto the ocular surface. Operating room staff timed the precise duration of exposure. After the 3-minute preparation, the lids were thoroughly dried with fresh dry gauze. Results: The median PI exposure time was 3.17 minutes, with an interquartile range of 0.25. All cases were followed up postoperatively at 1 day, 1 week, and 1 month. There were no complications attributable to PI. Visual outcomes were satisfactory. Conclusions: Implementation of a preoperative prophylaxis protocol that used PI 10% with a 3-minute exposure time can be performed in clinical practice. The 3-minute exposure time had no adverse sequelae.
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Reduced anterior chamber contamination by frequent surface irrigation with diluted iodine solutions during cataract surgery
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Endophthalmitis Prophylaxis for Cataract Surgery
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Endophthalmitis after cataract surgery is a rare but potentially devastating complication. There is great variability in endophthalmitis prophylaxis practice patterns worldwide. Treatment varies globally and is based on the microbiological profile and availability of formulations. Periocular povidone-iodine antisepsis is universally adopted and considered the standard of care in most practices. Perioperative topical antibiotics are also very popular despite the lack of level 1 evidence confirming efficacy. Based on growing observational evidence, routine intracameral antibiotic prophylaxis is increasing, especially where approved commercial intraocular preparations are available. This review updates recent trends and evidence regarding endophthalmitis prophylaxis and the preferred choice of intracameral antibiotics.
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Endophthalmitis prophylaxis by intracameral antibiotics: In vitro model comparing vancomycin, cefuroxime, and moxifloxacin
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  • Jun 2017
  • J CATARACT REFR SURG
Purpose To compare the efficacy of intracameral vancomycin, cefuroxime, and moxifloxacin on postoperative bacterial endophthalmitis rates. Setting Norwalk Hospital, Norwalk, Connecticut, USA. Design Experimental study. Methods Bacteria and intraocular lenses (IOLs) were incubated with vancomycin, cefuroxime, moxifloxacin, or combinations. Antibiotic concentrations were high, corresponding to clinical maximum intracameral doses (1.0 mg vancomycin or cefuroxime, 0.5 mg moxifloxacin), or low (one third of clinical maximum dose). The following bacteria were isolated from patients with endophthalmitis: 18 strains including 6 staphylococci, 6 streptococci, 3 pseudomonad, and 3 propionibacteria. Samples were diluted by half every 2 hours to model the half-life of intracameral antibiotics. At 24 hours, samples were vortexed to shake bacterial biofilms loose from the IOLs. The bacterial broth was plated and colonies were counted 24 hours later. Results Efficacy against staphylococci was concentration dependent; all antibiotics were effective at high concentrations, while low concentrations were in general ineffective. Streptococci and propionibacteria were nearly eliminated by all antibiotics at low concentrations. Pseudomonads were most effectively treated by high-dose moxifloxacin and its combinations. Conclusions Broadest coverage against common pathogens should be obtained by high-dose moxifloxacin (0.5 mg intracameral). Submaximum dosing, which could occur if aqueous is released to lower intraocular pressure after injection, compromises the efficacy against staphylococci and pseudomonads. All antibiotics, even at low doses, were effective against streptococci and propionibacteria, suggesting that many of the worst endophthalmitis outcomes could be prevented by intracameral use of any of the 3 antibiotics used in this study.
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Trends in Fluoroquinolone Nonsusceptibility Among Coagulase-Negative Staphylococcus Isolates Causing Endophthalmitis, 1995-2016
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Coagulase-negative Staphylococcus (CoNS) is the most common cause of acute-onset post–cataract surgery endophthalmitis.¹ Fluoroquinolones are frequently used prophylactically (either topical or intracameral) in an attempt to reduce the rates of postoperative endophthalmitis. In this study, the susceptibilities of CoNS-causing endophthalmitis to fluoroquinolones over a 22-year period at the Bascom Palmer Eye Institute, Miami, Florida, are reported.
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HEMORRHAGIC VASCULITIS AND RETINOPATHY HERALDING AS AN EARLY SIGN OF BACTERIAL ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION
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Purpose: To describe a case series of postintravitreal injection, bacterial endophthalmitis heralded by hemorrhagic retinal vasculitis. Methods: Observational case series of three patients with a history of intravitreal injections for age-related macular degeneration at a tertiary referral center who presented with vision changes and eye pain that were eventually found to have bacterial endophthalmitis. Clinical course was then followed. Results: All patients developed bacterial endophthalmitis and hemorrhagic retinal vasculitis. Conclusion: These three cases highlight the importance of hemorrhagic retinal vasculitis as the presenting fundus finding of bacterial endophthalmitis and that this finding in a postinjection patient should be treated as endophthalmitis until proven otherwise.
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Effect of the administration period of perioperative topical levofloxacin on normal conjunctival bacterial flora
Article
  • Jan 2017
  • J CATARACT REFR SURG
Purpose To assess the long-term and short-term effects of post-cataract surgery antibiotic therapy on the drug-resistance profile of normal conjunctival bacterial flora. Setting Miyata Eye Hospital, Miyazaki, Japan. Design Randomized prospective clinical trial. Methods Patients aged 20 years or older who had cataract surgery between May and September 2015 were given levofloxacin 1.5% ophthalmic solution for 3 days preoperatively. The patients were randomly assigned to a 1-week postoperative group or a 1-month postoperative group according to postoperative administration duration. Conjunctival sacs were scraped for bacterial culturing before administration, 1 week postoperatively, at the completion of administration, and 1, 3, and 6 months after administration completion. The bacterial culture growth and minimum inhibitory concentrations (MICs) of levofloxacin against recovered strains of Staphylococcus epidermidis were assessed. Results The study enrolled 104 patients. The MICs of levofloxacin against S epidermidis increased during levofloxacin administration compared with before administration in both groups and then declined after administration completion. However, by 3 months, the MICs in the 1-month group were approximately twice those in the 1-week group. Antibiotic susceptibility before administration, at completion of administration, and at 3 months was 73.6%, 20.2%, and 38.5%, respectively, in the 1-week group and 63.0%, 0.0%, and 19.3%, respectively, in the 1-month group. The results indicate that from completion of administration to 3 months, the susceptible strains were approximately 20% lower in the 1-month postoperative group than in the 1-week postoperative group. Conclusion Administration duration of perioperative levofloxacin 1.5% influenced the MICs and susceptibility of S epidermidis isolated from the conjunctival sac.
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