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An "epidemic" of post cataract surgery endophthalmitis by a new organism

Authors:
Sanita Korah at Christian Medical College Vellore
Sanita Korah
Andrew Braganza at Christian Medical College Vellore
Andrew Braganza
Pushpa Jacob at Christian Medical College Vellore
Pushpa Jacob
Balaji Veeraraghavan at Christian Medical College Vellore
Balaji Veeraraghavan
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Abstract and Figures

We report a case series of endophthalmitis by an organism hitherto not reported in the eye. Nineteen of 63 cataract patients operated in a high-volume setup were urgently referred to us with acute onset of decreased vision one to two days following cataract surgery. All patients had clinical evidence of acute endophthalmitis with severe anterior chamber exudative reaction. Vitreous tap was done in three representative patients and repeated intravitreal injections were given as per established protocol. The vitreous sample from all three patients grew Enterobacter amnigenus Biogroup II, a gram-negative bacillus which, to the best of our knowledge, has never been reported in the eye. With prompt and accurate microbiological support, it was possible to salvage 17 of these eyes without performing vitrectomy. Six eyes regained 6/200 or better vision.
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10/5/2016 An"epidemic"ofpostcataractsurgeryendophthalmitisbyaneworganism
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635971/?report=printable 1/6
IndianJOphthalmol.2007NovDec;55(6):464–466. PMCID:PMC2635971
An"epidemic"ofpostcataractsurgeryendophthalmitisbyanew
organism
SanitaKorah,MS, AndrewBraganza,MS,PushpaJacob,FRCS,andVBalaji,MD
DepartmentofOphthalmology(SK,AB,PJ)andMicrobiology(VB),ChristianMedicalCollege,Vellore,India
Correspondingauthor.
Correspondenceto:Dr.SanitaKorah,DepartmentofOphthalmology,ChristianMedicalCollege,ArniRoad,Vellore632001,India.
Email:sanviji@cmcvellore.ac.in
Received2006Mar28;Accepted2006Dec28.
Copyright:©IndianJournalofOphthalmology
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Abstract
Wereportacaseseriesofendophthalmitisbyanorganismhithertonotreportedintheeye.Nineteenof63
cataractpatientsoperatedinahighvolumesetupwereurgentlyreferredtouswithacuteonsetofdecreased
visiononetotwodaysfollowingcataractsurgery.Allpatientshadclinicalevidenceofacuteendophthalmitis
withsevereanteriorchamberexudativereaction.Vitreoustapwasdoneinthreerepresentativepatientsand
repeatedintravitrealinjectionsweregivenasperestablishedprotocol.Thevitreoussamplefromallthree
patientsgrewEnterobacteramnigenusBiogroupII,agramnegativebacilluswhich,tothebestofour
knowledge,hasneverbeenreportedintheeye.Withpromptandaccuratemicrobiologicalsupport,itwas
possibletosalvage17oftheseeyeswithoutperformingvitrectomy.Sixeyesregained6/200orbettervision.
Keywords:Endophthalmitis,Enterobacteramnigenus,gramnegativebacillus
Endophthalmitisfollowingcataractsurgeryinahighvolumesurgerysettingisdistressingduetothelarge
numbersofpatientsinvolvedandtheresultantpublicityissues.Postsurgicalorposttraumaticinfectionwith
EnterobactercloacaeorEnterobacteraerogeneshasbeenreported,mostlywithdismalresults. We
report19casesofendophthalmitiscausedbyEnterobacteramnigenus:BiogroupII,anorganismhitherto
unreportedinliterature.
CaseReport
Nineteenof63patients,operatedinahighvolumecataractsurgerysettingatanearbyhospitalwerereferred
touswithacuteonsetofrednessanddecreasedvision.Atadmission,allpatientsunderwentslitlamp
examination,applanationtonometry,dilatedfundusevaluationandBscanultrasonography.
Ourcohortcomprisedthelastfewcasesoperatedonday2andalmostallpatientsfromDay3ofthesurgical
"camp".Allpatientshadundergonesuturelessmanualsmallincisioncataractextractionwithsinglepiece
polymethylmethacrylateintraocularlens(IOL)implantation.Theonlyreportedintraoperativecomplication
wasvitreouslossintwoeyes.Ofthese,onewasleftaphakicwhiletheotherhadtheIOLimplantedinthe
ciliarysulcus.Allpatientswereontopicalgentamycin0.3%sixhourly,topicalprednisoloneacetate1%
hourly,homatropine2%dropsthreetimesdailyandoralciprofloxacin500mgtwicedaily.
1,2,3
10/5/2016 An"epidemic"ofpostcataractsurgeryendophthalmitisbyaneworganism
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635971/?report=printable 2/6
Atpresentation[Table1],lidedema,grosscornealedemawithsevereexudativereactionwasseeninall
cases[Figs1and2].Hypopyonwaspresentin15eyes.Relativeafferentpupillarydefectwasnotedinall
theninepatientswhohadinaccurateprojectionofrays.Fourpatientshadraisedintraocularpressure.The
fundalglowwasvisibleinonlyonepatient.Bscanultrasonographyatadmissionrevealedanteriortomid
vitreousechoesinallpatientsat60%gain.Aretinaldetachmentwaspresentinpatientnumber9.Three
patientswerefoundtohavehithertoundetecteddiabetesmellitus.
Diagnosticvitreoustapwasdoneinthreepatients;onerepresentingthosewithhypopyon,onewithout
hypopyonandonewithseverepain.Eighteenpatientsweregivenintravitrealinjectionsofvancomycin(1.0
mg/0.1mlsaline)andceftazidime(2.25mg/0.1mlsaline).Onepatientrefusedsurgicalintervention
(patientno.7).Allpatientswerecontinuedonoralciprofloxacin500mgtwicedaily.Topicalciprofloxacin
(0.3%)hourly,dexamethasonechloramphenicolcombinationhourlyandatropinesulphate1%threetimes
dailywerestarted.Oralacetazolamide250mgsixhourly,antidiabeticandantihypertensivemedication
wereusedasrequired.
Vitrectomycouldnotbeperformedinanypatientduetocornealedemaandsevereanteriorchamber
exudativereaction.
Allthreevitreoussamplesrevealedgramnegativebacillionsmearandprofusegrowthonculture.The
organismwasidentifiedasEnterobacteramnigenus:BiogroupII.Susceptibilitytesting(aspertheclinical
laboratorystandardsinstitute) revealedidenticalsensitivitypatternsinallthreesamples.Itwasresistantto
penicillin,vancomycin,gentamicin,norfloxacin,ciprofloxacin,tetracyclin,chloramphenicol,lomifloxacin,
ofloxacinandtobramycinandsensitivetoceftazidime,cefotaxime,imipenemandmeropenem.
Intravitrealinjectionswererepeatedat48hintervals.Sixteenpatientsreceivedfourdoses,twopatients
refusedthelasttwodosesandonepatientrefusedallsurgicalintervention.Followingthesensitivityreport,
onlyceftazidimewasgivenasthethirdandfourthdoses.Inpoorrespondersandthosepatientswho
developedcornealinfiltrates,thetopicalantibioticwaschangedtoceftazidime(50mg/ml).Durationof
hospitalizationwas14to18daysdependingontheirresponsetotreatment.
Fig.3depictsthevisionatadmissionanddischarge.Patientswithpoorervisionatpresentationdidworse
thanthosewithbettervision.Fourpatientsdevelopedcornealinfiltrates,whicheventuallyresolvedintwo
patients.Theothertworesultedinautoevisceration,oneanewlydetecteddiabeticwhoallowedonlytwo
intravitrealinjectionsandtheotherwhorefusedanysurgicalintervention.
Fiveoutof19eyesregained20/200orbettervision[Table1]within18daysevenwithoutvitrectomy.The
globewaspreservedin17patients.Allthediabeticsandpatientshavingonlytwoorlessintravitreal
injectionsperformedpoorly.
Discussion
Gramnegativeendophthalmitisisadevastatingcomplicationfollowingcataractsurgery.Pseudomonasisthe
commonestgramnegativecausativeorganism. Successfulmanagementdependsonrapidrecognitionand
promptintervention. Vitreoustapforsmearandculture,followedbyimmediateintravitrealadministrationof
broadspectrumantibioticsand,avitrectomyifindicatedisthecurrentstandardofcare.Althoughmost
patientsinthisseriesqualifiedforimmediatevitrectomyaccordingtotheEndophthalmitisVitrectomyStudy
protocol, thiswasdeferredduetoseverestromaledemaobscuringtheview.
HighvolumesurgerystillhasaroleinreducingthecataractloadinIndia. Whenendophthalmitisoccursin
thesesettings,everyeffortshouldbemadetotracethesourceofinfection.Ideally,theefficacyofthe
sterilizerusingteststrips,sterilityoftheairusingsettleplatesandculturingoftheswabs,instrumentsand
remainingfluidsshouldbedone.InanotherseriesofendophthalmitiscausedbyEntrobacterspecies,
inadvertentuseofunsterilizedswabswasfoundtoberesponsible. Investigationintotheoutbreakhowever,
4
5,6
7
8
9
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10/5/2016 An"epidemic"ofpostcataractsurgeryendophthalmitisbyaneworganism
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635971/?report=printable 3/6
couldnotbedonefullyasthepatientscamefromanindependentcenter.Theactualcontainersoffluidsused
hadbeendiscardedimmediatelyfollowingthesurgeries.Onlyunopenedcontainersfromthebatchof
viscoelasticandintraocularfluidsusedforthesurgerieswereprovidedforculture.Thesewere
microbiologicallysterile.Thecausativeorganism,Enterobacteramnigenusisolatedinourseries,isan
environmentalpathogen andnormallyresultsininfectiononlyifinoculatedinhighdoses.Thisimpliesa
seriousbreachofasepticmeasuresduringsurgeryinthesepatients.
Lackoffollowupafterdischargewasanotherlimitationofourstudy.Thepatientswereabsorbedintothe
referralsystemoftheneighboringstatetowhichtheybelongedandcouldnotbesubsequentlyfollowedup
byus.
Thesimilarclinicalpresentationandthefactthatallthreesamplesgrewthesamerareorganism,ofidentical
subtypeandidenticalsensitivitypatterns,stronglysuggeststhatthisorganismwasresponsiblefortheentire
epidemic.
Ashighlightedbythisreport,investigatingoutbreaksofendophthalmitiseveninahighvolumesurgical
setupthusbecomesimportantfromthediagnostic,therapeuticandpublichealthpointofview.
Acknowledgments
Dr.ThomasKuriakoseDO,DNB,FRCS(Edin)andDr.MarySMathewsMDforsupportandhelpwith
preparationofthemanuscript.
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FiguresandTables
Figure1
Eyewithendophthalmitisshowinggrosscornealedemaandsevereanteriorchamberexudation
Figure2
10/5/2016 An"epidemic"ofpostcataractsurgeryendophthalmitisbyaneworganism
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635971/?report=printable 5/6
Eyewithendophthalmitisshowinggrosscornealedemaandalesserdegreeofanteriorchamberreaction
Figure3
Diagrammaticrepresentationofpretreatmentandposttreatmentvision;Xaxispatientnumber;Yaxisvision
Table1
10/5/2016 An"epidemic"ofpostcataractsurgeryendophthalmitisbyaneworganism
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635971/?report=printable 6/6
Patientdemographics
ArticlesfromIndianJournalofOphthalmologyareprovidedherecourtesyofMedknowPublications
... blepharitis, conjunctivitis), the use of topical or oral corticosteroids, and chronic use of topical antibiotics. Instances of clustered endophthalmitis presentations would suggest tainted materials / solutions or fundamental issues with apparatus sterilisation [8]. ...
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... [4] Since then various reports have demonstrated the occurrence of Enterobacter endophthalmitis in different ocular settings like open globe injury, cataract surgery, glaucoma filtering surgery, and as an endogenous infection. [5][6][7][8][9] Though a handful of reports exist, literature on Enterobacter endophthalmitis is relatively sparse. A decade back, we reported the presentations and outcomes of a large series of cases of Enterobacter endophthalmitis was published in literature. ...
Enterobacter endophthalmitis: Clinical settings, susceptibility profile, and management outcomes across two decades
Article
Full-text available
  • Jan 2020
  • Indian J Ophthalmol
Purpose: To describe the clinical presentation and management of Enterobacter endophthalmitis and compare with previous in-house published literature. Methods: This was a retrospective interventional comparative case series involving 44 cases with culture proven Enterobacter endophthalmitis from April 2006 to August 2018 who underwent vitrectomy/vitreous biopsy, intravitreal antibiotics with or without additional procedures as appropriate. The current outcomes were compared to the outcomes previously reported a decade back from our center. The mean age at presentation, predisposing factor, number of interventions, interval between inciting event and presentation, type of intravitreal antibiotic used, anatomic, and the functional outcomes were analyzed and compared to the previous series. Results: There were 30 males. Mean age was 22.73 ± 21.35 years (median 14 years). Inciting event was open globe injury in 34 (77.27%) eyes, 4 (9.09%) eyes following cataract surgery, 3 (6.81%) eyes with endogenous endophthalmitis, 2 (4.54%) eyes following keratoplasty, and 1 eye (2.27%) following trabeculectomy. Presenting visual acuity was favorable (≥20/400) in 2 eyes (4.54%), at the final visit it was in 11 eyes (25%). The organisms were most sensitive to ciprofloxacin (95.12%), amikacin (90.47%), and ceftazidime (85.36%). A comparison of the current study with previous in-house study showed that number of eyes with presenting vision ≥20/400 as well as final vision ≥20/400 were comparable. Susceptibility was highest to ciprofloxacin 39 (95.12%) (previous series) and 33 (92%) (current series). Conclusion: Enterobacter organisms show susceptibility to ciprofloxacin, amikacin, and ceftazidime. Susceptibility profile, clinical presentations, and management remain largely similar over many years. Final outcome is unfavorable.
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... Cluster infection has been reported occasionally in Indian literature. [17,25,[33][34][35][36][37][38][39] These included five reports from South India (Hyderabad, Madurai, Tiruchirappalli, and Vellore) and 6 reports from Central India [ Table 3]. Pseudomonas (73.3%) or related species were the most common cause of infection as confirmed by culture and/or genotyping. ...
A literature review and update on the incidence and microbiology spectrum of postcataract surgery endophthalmitis over past two decades in India
Article
Full-text available
  • Aug 2017
Purpose The purpose of this study was to review the incidence and microbiology of acute postcataract surgery endophthalmitis in India. Methods Systematic review of English-language PubMed referenced articles on endophthalmitis in India published in the past 21 years (January 1992–December 2012), and retrospective chart review of 2 major eye care facilities in India in the past 5 years (January 2010–December 2014) were done. The incidence data were collected from articles that described “in-house” endophthalmitis and the microbiology data were collected from all articles. Both incidence and microbiological data of endophthalmitis were collected from two large eye care facilities. Case reports were excluded, except for the articles on cluster infection. Results Six of 99 published articles reported the incidence of “in-house” acute postcataract surgery endophthalmitis, 8 articles reported the microbiology spectrum, and 11 articles described cluster infection. The clinical endophthalmitis incidence was between 0.04% and 0.15%. In two large eye care facilities, the clinical endophthalmitis incidence was 0.08% and 0.16%; the culture proven endophthalmitis was 0.02% and 0.08%. Gram-positive cocci (44%-64.8%; commonly, Staphylococcus species), and Gram-negative bacilli (26.2%–43%; commonly Pseudomonas species) were common bacteria in south India. Fungi (16.7%-70%; commonly Aspergillus flavus) were the common organisms in north India. Pseudomonas aeruginosa (73.3%) was the major organism in cluster infections. Conclusions The incidence of postcataract surgery clinical endophthalmitis in India is nearly similar to the world literature. There is a regional difference in microbiological spectrum. A registry with regular and uniform national reporting will help formulate region specific management guidelines.
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... In various vitrectomies (Pars plana vitrectomy or 25 gauge vitrectomy), diabetes mellitus is recognized as an important risk factor for exogenous endophthalmitis [14]. Sometimes, cases of clustering of the endophthalmitis are seen, suggesting contaminated materials/solutions or problems with instrument sterilization as responsible [15,16]. Bacterial infections are the most common cause of post-operative endophthalmitis, and Gram-positive isolates account for the majority of these cases [2]. ...
Bacterial Endophthalmitis
Chapter
  • Dec 2016
Various toxins and enzymes are produced and secreted by the invading organisms causing destruction of protective mechanisms in the eye in case of fulminant infection in eye. B. cereus produces a number of cytolysins and enzymes that could contribute to the rapid course and severity of endophthalmitis, including haemolysins, lipases, enterotoxins and proteases [30]. E. faecalis strains frequently harbour conjugative plasmids that encode a cytolysin which effectively lyses both eukaryotic and prokaryotic cells [44]. Cytolysin causes destructive changes in retinal architecture and vitreal structures. Adhesin, aggregation substance, produced by enterococci is a virulence-enhancing factor and helps them to attach to membranous vitreous structures. S. aureus secretes cell wall-associated products and adhesions (e.g. clumping factor, fibronectin-binding protein and protein A) and extracellular virulence factors (e.g. toxins such as alpha-toxin, beta-toxin, gamma-toxin and leukocidin, proteases and lipases) which are responsible for high virulence of this organism in endophthalmitis. These virulence factors are controlled by quorum-sensing systems namely, agr (accessory gene regulator) and sar (staphylococcal accessory regulator) [45]. Hence, therapeutics designed to inactivate global regulation of S. aureus during the early stages of infection may be more effective in arresting tissue damage than targeting individual toxins.
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... Recent news of cluster infection from more than one part of the country have raised a question mark on our preventive measures. [8,9] The present article tries to give a brief overview of the practices needed to prevent the infection during ocular surgeries. Several guidelines are available to help the readers -National Programme for Control of Blindness in India, [10] All India Ophthalmological Society, [11] vision 2020, [12] European Society for Cataract and Refractive Surgery (ESCRS), [13] American Academy of Ophthalmology, [14] International Council of Opthalmology, etc., to name a few. ...
Prevention of operative infection in ophthalmic surgery
Article
Full-text available
  • Jan 2016
Prevention of infection in ocular surgery is based on the science of asepsis and antisepsis not only depends on what we do pre-, intra-, and post-operatively but also depends on how we prepare our patient and personnel. Practicing no touch technique is extremely important in preventing sporadic infections, whereas breach in sterility many times is the cause of cluster infection - whether it is the presterile product purchased from the market, or items sterilized in the operation theater (OT) protocols (such as standard operating practices) play a key role in ensuring all these. There are several guidelines available to guide us. Many activities are done in the absence of the surgeon inside the OT such as cleaning and sterilization by our staff. Their understanding of the science of asepsis and antisepsis pertaining to the tasks performed by them is very important. All these needs to be monitored and continuous medical education need to be organized for our staff also. Written protocols help in achieving this. Everybody should be aware of the protocol and this should be strictly followed. No compromise at any cost should be accepted inside the OT.
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Risk factors for acute endophthalmitis after cataract surgery
Article
Full-text available
  • Mar 2018
A bibliographic review of the main risk factors for developing an acute endophthalmitis after cataract surgery was achieved. Aspects such as the infection source and mechanism of production, predisposing factors to develop an intraocular infection from a contaminated anterior chamber, pathogenicity and virulence of the infectious agent, bacterial resistance and host susceptibility were updated. It is concluded that although several risk factors are associated with the appearance of an acute post-surgical endophthalmitis, the entry of germs inside the eye through the surgical incision during the trans or post-operative moment is a necessary but not determinant condition for the onset of infection. The size of the inoculum linked to the virulence of the germ, bacterial resistance and individual susceptibility of the patient could determine the development of an acute endophthalmitis after cataract surgery.
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Infections Caused by Antimicrobial Drug-Resistant Saprophytic Gram-Negative Bacteria in the Environment
Article
Full-text available
  • Oct 2017
Background Drug-resistance genes found in human bacterial pathogens are increasingly recognized in saprophytic Gram-negative bacteria (GNB) from environmental sources. The clinical implication of such environmental GNBs is unknown.Objectives We conducted a systematic review to determine how often such saprophytic GNBs cause human infections.Methods We queried PubMed for articles published in English, Spanish, and French between January 2006 and July 2014 for 20 common environmental saprophytic GNB species, using search terms “infections,” “human infections,” “hospital infection.” We analyzed 251 of 1,275 non-duplicate publications that satisfied our selection criteria. Saprophytes implicated in blood stream infection (BSI), urinary tract infection (UTI), skin and soft tissue infection (SSTI), post-surgical infection (PSI), osteomyelitis (Osteo), and pneumonia (PNA) were quantitatively assessed.ResultsThirteen of the 20 queried GNB saprophytic species were implicated in 674 distinct infection episodes from 45 countries. The most common species included Enterobacter aerogenes, Pantoea agglomerans, and Pseudomonas putida. Of these infections, 443 (66%) had BSI, 48 (7%) had SSTI, 36 (5%) had UTI, 28 (4%) had PSI, 21 (3%) had PNA, 16 (3%) had Osteo, and 82 (12%) had other infections. Nearly all infections occurred in subjects with comorbidities. Resistant strains harbored extended-spectrum beta-lactamase (ESBL), carbapenemase, and metallo-β-lactamase genes recognized in human pathogens.Conclusion These observations show that saprophytic GNB organisms that harbor recognized drug-resistance genes cause a wide spectrum of infections, especially as opportunistic pathogens. Such GNB saprophytes may become increasingly more common in healthcare settings, as has already been observed with other environmental GNBs such as Acinetobacter baumannii and Pseudomonas aeruginosa.
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Cluster Endophthalmitis
Chapter
  • Jan 2018
Endophthalmitis is one of the most serious and dreaded complications of intraocular surgeries, and although the incidence is low, the ocular morbidity of postsurgical endophthalmitis is significant. The incidence of postoperative endophthalmitis has been reported to be 0.14–0.16% or 1 case per 625–730 cataract extractions in one of the reports [1]. Isolated cases of endophthalmitis are not uncommon when large volumes of surgeries are done. These are dealt with in another chapter. However, a cluster of cases requires a more detailed evaluation and understanding. There is a paucity in ophthalmic literature about the incidence of cluster cases. This chapter describes a systematic approach to evaluation, management and outcomes of cluster endophthalmitis.
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Outcomes of high volume cataract surgeries in a developing country
Article
Full-text available
  • Sep 2005
To analyse the outcome of high volume cataract surgery in a developing country, community based, high volume eye hospital. In a non-comparative interventional case series, the authors reviewed the surgical outcomes of 593 patients with cataract operated upon by three high volume surgeons on six randomly selected days. There were 318 female (54%) and 275 male (46%) patients. Their mean age was 59.57 (SD 10.13) years. The majority of the patients underwent manual small incision cataract surgery (manual SICS). Extracapsular cataract extraction with posterior chamber intraocular lens (ECCE-PCIOL) and intracapsular cataract extraction (ICCE) were also done on a few patients as clinically indicated. Best corrected visual acuity of >or=6/18 was achieved in 94% of the 520 patients who could be followed up on the 40th postoperative day (88% follow up rate). Intraoperative and immediate postoperative complications as defined by OCTET occurred in 11 (1.9%) and 75 (12.6%) patients, respectively. Average surgical time of 3.75 minutes per case (16-18 cases per hour) was achieved. Statistically significant risk factors for outcomes were found to be age >60, sex, and surgeon. High volume surgery using appropriate techniques and standardised protocols does not compromise quality of outcomes.
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Results of the Endophthalmitis Vitrectomy Study: A Randomized Trial of Immediate Vitrectomy and of Intravenous Antibiotics for the Treatment of Postoperative Bacterial Endophthalmitis
Article
  • Dec 1995
  • Arch Ophthalmol
Objective: To determine the roles of immediate pars plana vitrectomy (VIT) and systemic antibiotic treatment in the management of postoperative endophthalmitis. Design: Investigator-initiated, multicenter, randomized clinical trial. Setting: Private and university-based retina-vitreous practices. Patients: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation. Interventions: Random assignment according to a 2 x 2 factorial design to treatment with VIT or vitreous tap or biopsy (TAP) and to treatment with or without systemic antibiotics (cefiazidime and amikacin). Main Outcome Measures: A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically. Results: There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed. However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP. In this group of patients, the difference between VIT and TAP was statistically significant (P<.001, log rank test for cumulative visual at-airy scores) over the entire range of vision. Conclusions: Omission of systemic antibiotic treatment can reduce toxic effects, costs, and length of hospital stay. Routine immediate VIT is not necessary in patients with better than light perception vision at presentation but is of substantial benefit for those who have light perception-only vision.
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Experimental Aspects and Their Clinical Application
Article
  • May 1978
  • OPHTHALMOLOGY
After laboratory evaluation of nontoxic doses of intravitreal antibiotics, 26 cases of bacterial and fungal endophthalmitis were treated by intravitreal antibiotic or vitrectomy. In 46% of all cases, visual acuity was better than 20/100, whereas 27% had light perception to 20/300 visual acuity, 4% had no light perception, and 23% of the cases were enucleated or eviscerated. Best results have been achieved when the treatment began within 36 hours after symptomatic onset of infection and when the organism involved was not to virulent. We advocate intravitreal antibiotics immediately after intracameral and vitreous tap for culture, to be followed by vitrectomy 24 hours later if the culture is positive. In bacterial endophthalamitis when the vitreous is severely involved and in cases of fungal endophthalmitis, we advocate vitrectomy plus intravitreal antibiotics as the primary procedure.
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Endophthalmitis caused by gram-negative organisms
Article
  • Nov 1992
  • ARCH OPHTHALMOL-CHIC
The medical records of 52 patients (53 eyes) with culture-proven gram-negative endophthalmitis between January 1982 and December 1990 were reviewed. Pseudomonas aeruginosa (23% [12/53]) and Haemophilus influenzae (19% [10/53]) were the most frequent isolates in this series. Overall, 26 (49%) of 53 treated patients achieved 20/400 or better visual acuity. Fifty-two (98%) of the original 53 gram-negative isolates were sensitive to the aminoglycoside antibiotics. To determine their sensitivity to recently developed antibiotics, 35 of the isolates were again grown on culture media and their sensitivities to ceftazidime, ciprofloxacin, and imipenem were obtained. Only ceftazidime demonstrated in vitro efficacy for all the organisms tested.
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Postoperative endophthalmitis caused by an Enterobacter species
Article
  • Apr 1994
  • J HOSP INFECT
Six patients (aged 8 to 75 years) who were operated upon during the same day developed bacterial endophthalmitis on the following day; seven eyes were affected. Two patients had intracapsular cataract extraction, one extracapsular lens extraction, two extracapsular cataract extraction with intraocular lens implantation and one repair of bilateral scleral or corneoscleral perforations. Vitreous cultures taken from six eyes were positive for an Enterobacter sp. Despite antibiotic treatment systemically, subconjunctivally and intravitreally, four eyes had to be eviscerated, while two eyes showed evidence of shrinkage (phthisis); only one eye retained useful vision (9/10). Cotton swabs used during surgery, prepared manually from cotton wool moistened with saline, were identified as the source of infection; the batch had not been subjected to the prescribed autoclaving process. The importance of proper sterile procedures in association with surgery is emphasized.
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Endophthalmitis caused by Enterobacter cloacae
Article
  • Sep 1993
  • Ann Ophthalmol
Cataract extraction with placement of intraocular lenses is the most common intraocular procedure done today, with endophthalmitis as its most devastating complication. To our knowledge, this is only the third reported case of postoperative endophthalmitis caused by the gram-negative bacillus, Enterobacter cloacae. The course of infection, the treatment, and the laboratory identification of this organism are presented. It is important to add this proven case of gram-negative endophthalmitis to our growing knowledge of causes of this disease because, despite aggressive treatment with vitrectomy and intravitreal antibiotics, the infection was so virulent that it led to eventual phthisis bulbi.
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Enterobacter cloacae Endophthalmitis: Report of Four Cases
Article
  • Feb 1998
Members of the genus Enterobacter are commensal organisms of the gastrointestinal tract and are considered pathogenic only for patients with lowered resistance to infection (e.g., chronic infection, cancer, or diabetes mellitus) or those with impaired immunity (congenital, acquired, or impaired immunity secondary to therapy). We report on four cases of endophthalmitis caused by Enterobacter cloacae: two in patients with acute postoperative endophthalmitis, one in a patient with delayed bleb-related endophthalmitis, and one in a patient presenting with presumed posttraumatic endophthalmitis. Each patient presented with severe disease many days after the onset of ocular symptoms, and two patients had systemic risk factors accounting for a reduced resistance to infection. Endophthalmitis caused by gram-negative bacilli is characterized by acute onset, rapid progression, and poor final visual outcome. Each of these patients was treated by a standard protocol with intravitreal, systemic, and topical antibiotics and systemic steroids. Despite treatment, the final visual outcomes for three of these patients was no perception of light, and that for one patient remained perception of hand movements only. In common with endophthalmitis caused by other gram-negative organisms, intraocular infection secondary to Enterobacter cloacae infection is a devastating disease which, despite treatment, results in extensive ocular damage and severe visual loss. Since 1966, only four cases of endophthalmitis secondary to infection with members of this genus have been reported. This report presents four cases which occurred over a period of 14 months and, to the best of our knowledge, the first case of bleb-related endophthalmitis secondary to E. cloacae infection.
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Microbiologic spectrum and susceptibility of isolates: Part I. Postoperative endophthalmitis. Endophthalmitis Research Group
Article
  • Sep 1999
  • AM J OPHTHALMOL
To present the microbial spectrum and susceptibilities of isolates in posttraumatic endophthalmitis. Isolates from 182 eyes of 182 patients who underwent vitrectomy for posttraumatic endophthalmitis were examined. One hundred thirteen (62.1%) of 182 vitreous samples were culture-positive, and 23 (20.4%) of 113 culture-positive cases were polymicrobial, including three (2.7%) trimicrobial cases, yielding a total of 139 isolates. Isolates included 63 (45.3%) gram-positive cocci, 24 (17.3%) gram-positive bacilli, 25 (18.0%) gram-negative organisms, seven (5.0%) Actinomycetes-related organisms, and 20 (14.4%) fungi. Susceptibilities to amikacin, ceftazidime, chloramphenicol, cefazolin, ciprofloxacin, gentamicin, and vancomycin are reported. This study represents a large series on microbial spectrum and susceptibilities in posttraumatic endophthalmitis. We report a high prevalence of gram-positive bacilli species and polymicrobial infections containing gram-negative species, underscoring the importance of broad-spectrum, combination antibiotics in the empiric treatment of posttraumatic endophthalmitis.
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Post operative endophthalmitis: Experimental aspects and their applications
  • Nov 1977
  • 374-85
  • GA Peyman
  • DW Vastine
  • M Raichand
  • GA Peyman
  • DW Vastine
  • M Raichand