Endophthalmitis (post-operative) (Exogenous Slit lamp exam showed fine keratic precipitates (KP) and 1+ AC cell OD; the left eye was unremarkable. Am J Ophthalmol 2020;217:325-334. LP vision or worse: same as above but also perform pars plana vitrectomy. found the rate of endophthalmitis in post-ICL patients to be approximately 1 in 6000 (0.017%).10. Date:7/8/2022 concluded this increase coincided with rising rates of clear corneal sutureless wound closure.5 The incidence of C. acnes endophthalmitis is not known; however, rates of delayed-onset endophthalmitis are estimated to be 0.017%.3, C. acnes is a commensal bacterium that makes up the normal flora of the conjunctiva and skin and commonly causes acne vulgaris.6 While rare, it is a known cause of exogenous endophthalmitis that typically presents with a more delayed presentation than common causal organisms of endophthalmitis.4 This is because C. acnes is an anaerobic organism resistant to monocyte and neutrophil mechanisms for killing - allowing the organism to survive after phagocytosis. Chronic post-operative iris prosthesis endophthalmitis in a Significant media opacity often requires ultrasonography to grossly examine the posterior segment (Figure 2). Some findings suggestive of a chronic PCE include granulomatous precipitates on the cornea and intraocular lens without an obvious hypopyon, as well as the presence of white intracapsular plaques.5, Risk factors can be divided into preoperative and intraoperative risk factors. Incidence, clinical features, causative organisms, and visual outcomes of delayed-onset pseudophakic endophthalmitis. Due to suspicion for chronic endophthalmitis, the patient was taken to surgery for pars plana vitrectomy, vitreous biopsy, posterior capsulotomy and intravitreal injection of vancomycin, ceftazidime, and voriconazole. Chronic post-operative endophthalmitis is characterized by decreased visual acuity, mild pain, and low-grade uveitis several weeks or months after intraocular surgery which may be responsive to corticosteroids, but recur JCRS Online Case Reports 2019;7:1:3-5. 14. Disclaimer. When PCE is suspected, prompt treatment with broad-spectrum intravitreal antibiotics (vancomycin and ceftazidime, with amikacin being used for patients with a suspected penicillin/cephalosporin allergy) is critical. Produced by the Moran Eye Center in partnership with the Eccles Library, Home /Intraocular Inflammation and Uveitis / Endophthalmitis, Title: Chronic Postoperative Endophthalmitis The relative risk of improvement of visual outcomes between the two groups was shown to be 1.04, indicating the viability of both treatments.29 However, surgeons in the included studies may have performed PPV on more severe cases, biasing the results. In a 36 patient study, 50% of patients retained vision better than or equal to 20/40 following surgical treatment6. Intraoperative risk factors include prolonged surgery, secondary IOL implantation, posterior capsular rupture, vitreous loss, iris prolapse, contaminated irrigating solutions or IOLs, and a slightly inferotemporal clear corneal incision. Careers, Unable to load your collection due to an error. Safety of intracameral moxifloxacin for prophylaxis of endophthalmitis after cataract surgery. A report by the American academy of Ophthalmology. 2022 Nov;70(11):4004-4009. doi: 10.4103/ijo.IJO_1938_22. Post Chronic post-operative endophthalmitis is characterized by decreased visual acuity, mild pain, and low-grade uveitis several weeks or months after intraocular surgery which may be responsive to Bacterial and fungal endophthalmitis. Treatment of Propionibacterium acnes endophthalmitis. Multiple intravitreal and intracameral injections with topical steroids were required to maintain a stable VA at 20/30; however, inflammation persisted and removal of the ICL and his native lens was ultimately required. FOIA The most common causative organisms in PCE are well-described, and their detection is facilitated with traditional microbial cultures, PCR and new methodologies, including whole-genome sequencing. Chronic Postoperative Endophthalmitis: A Review of Clinical Characteristics, Microbiology, Treatment Strategies, and Outcomes Europe PMC Chronic postoperative endophthalmitis: a review of clinical characteristics, microbiology, treatment strategies, Please enable it to take advantage of the complete set of features! Robbins C.C., Sobrin L., Ma K.K., Brouillette K.M., Moore J.K. Culture-negative C acnes endophthalmitis following implantation of a phakic implantable collamer lens. Polymerase chain reaction testing of samples may improve diagnostic yield. By definition, acute post-cataract endophthalmitis occurs within six weeks of surgery, typically within a few days, while cases that occur more than six weeks after surgery are deemed chronic endophthalmitis.3,4 Most patients present with symptoms including blurred vision (93.1 percent of cases), redness (80.6 percent), pain (75.4 percent), and eyelid swelling (33.1 percent).4 On examination, eyes often have a conjunctival injection. It is commonly observed in patients after surgery (exogenous) and trauma and is reported rarely by hematogenous dissemination (endogenous) [ 1 ]. Would you like email updates of new search results? The EVS evaluated the microbiological spectrum and susceptibilities of infecting organisms in acute postoperative endophthalmitis after cataract surgery. The former occurs within days of surgery, presents with acute inflammation, and is often caused by S. aureus, streptococci, or enterococci. 1. Federal government websites often end in .gov or .mil. This review will focus on the clinical featu Endophthalmitis Vitrectomy Study Group. The Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Rahmani S, Eliott D. Postoperative endophthalmitis: A review of risk factors, prophylaxis, incidence, microbiology, treatment, and outcomes. External bacterial flora probably enters the anterior chamber through the surgical wound; in fact, contamination of the anterior chamber at the end of surgery has been noted to be as high as 5.721.1%. J Cataract Refract Surg 2008;34:7:1114-1120.. 24. An anterior chamber tap is often easy to obtain but has a lower yield rate. 14 months prior to presentation, the patient had cataract surgery in the right eye followed by the same in the left eye one week later. The findings provided a basis for choosing initial empiric antibiotic therapy and for evaluating subsequent changes in microbiological spectrum in this disease. In this specific group, early vitrectomy resulted in a three-fold increase in the proportion of eyes recovering to 20/40 or better acuity (33 vs 11 percent), a two-fold increase of achieving 20/100 or better (56 vs 30 percent), and a 50-percent decrease in rates of severe vision loss (20 vs 47 percent) compared to those receiving primary tap and inject.7 Some smaller studies suggest that there may be a benefit to early vitrectomy. CONTACT US. In: Clark WL, Kaiser PK, Flynn HW Jr, Belfort A, Miller D, Meisler DM. official website and that any information you provide is encrypted Optical coherence tomography (OCT) of the macula was notable for mild vitreous cell OD, but no cystoid macular edema (Fig. Postoperative Endophthalmitis - an overview | ScienceDirect To our knowledge, this is the first reported case of chronic, post-operative Although the technical procedures used in cataract surgery are improving, the incidence of endophthalmitis has not changed and may be increasing. Intravenous administration of Penicillin results in therapeutic intravitreal levels in chronic postoperative endophthalmitis - PMC Journal List J Ophthalmic Inflamm Infect v.11; 2021 PMC7820044 As a library, NLM provides access to scientific literature. Background: Post-operative endophthalmitis is a serious complication of intraocular surgery which may present acutely or chronically. The diagnosis of delayed post-operative endophthalmitis by polymerase chain reaction of bacterial DNA in vitreous samples. Journal of Medical Microbiology. 1994;40(6):408415. [PubMed] [Google Scholar] 50. Mandelbaum S, Meisler DM. Postoperative chronic microbial endophthalmitis. Accessibility official website and that any information you provide is encrypted Fungal cases have less specific findings, and the diagnosis is often made by Gram stain, Giemsa stain, and culture. Mr. Im is a medical student at the Sidney Kimmel Medical College at Thomas Jefferson University. J Cataract Refract Surg 2013;39:1:8-14. WGS also provides a distinct advantage in that, unlike PCR, it doesnt require a pre-existing list of potential pathogen genomes to detect the presence of foreign DNA. Dense vitritis, and a hazy posterior view were noted(figure 3). Examination of his right anterior chamber was significant for a 2.5mm hypopyon and 4+ cell and fibrin, neovascularization of the iris, a PCIOL, and in his vitreous 2+ cell, condensation, and 4+ haze with no view for a fundus exam (figure 1). Endophthalmitis is a potential sight-threatening condition that leads to blindness. Sensitivity, specificity and predictive values of anterior chamber tap in cases of bacterial endophthalmitis. Postoperative Endophthalmitis - Medscape Endophthalmitis, pronounced end-opf-THAL-mi-tis, is the term used to Arch Ophthalmol 1995;113:12:1479-1496. Additionally, this case illustrates the importance of anaerobic vitreous culture to confirm diagnosis. 28. Both intraoperative intracameral antibiotic injection and perioperative topical povidone-iodine have been shown to be effective prophylactic interventions that reduce the risk of PCE. However, sometimes you cant obtain a vitreous tap. One-month post-operatively the patient complained of floaters with associated blurry vision, redness, and ocular pain OD. WebBACKGROUND: Post-operative endophthalmitis is a serious complication of intraocular surgery which may present acutely or chronically. Chronic Postoperative Endophthalmitis: A Review of Clinical Currently, ICLs are only used to treat myopia in the United States. sharing sensitive information, make sure youre on a federal Review of systems was positive for essential tremor made worse on prednisone, easy bruising on prednisone, and urinary urgency with Diamox. Recommended antimicrobial therapy includes vancomycin for P. acnes and intraocular amphotericin for fungi; imidazoles, including ketoconazole, fluconazole, or voriconazole may be of benefit.15,16,140, Andrew C. Westfall, Matthew S. Benz, in Ocular Trauma, 2007. During surgery, the ICL is placed anterior to the natural lens, without disturbing the natural lens. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. Taban M., Behrens A., Newcomb R.L., et al. While this method is currently limited by access, labor and costs, WGS may help detect pathogens that can impact patient prognosis. Arch Ophthalmol. Staphylococcus epidermis is the most commonly isolated organism in the acute post-operative setting. With WGS, its possible to screen for all non-human DNA in the sample, making it a powerful tool for identifying causative organisms in PCE. While a rare occurrence, post-cataract endophthalmitis occurs in a few thousand people each year in the United States and is a significant source of visual morbidity. The incidence of endophthalmitis following intravitreal injection can be reduced with a standardized protocol for aseptic injections, including the use of a sterile eyelid speculum and povidone-iodine.27 For example, in the VISION study, most endophthalmitis cases occurred in the setting of a protocol deviation.15 Prophylactic topical antibiotics are commonly used, although their efficacy is unproven.28, Travis A. Meredith, in Retina (Fourth Edition), 2006. Ophthalmology 2000;107:7:1274-1282. Intravenous administration of Penicillin results Mohan N. Iyer MD, Eric R. Holz MD, in Roy and Fraunfelder's Current Ocular Therapy (Sixth Edition), 2008. Endophthalmitis after cataract surgery in the United States: A report from the Intelligent Research in Sight registry, 2013-2017. Chronic postoperative endophthalmitis: a review of clinical characteristics, microbiology, treatment strategies, and outcomes. eCollection 2021 May-Jun. She has extensively traveled outside the US and lived in France as a child. His vitreous biopsy was negative. The EVS is still the only large, multicenter, randomized clinical trial that investigated the visual outcomes of immediate pars plana vitrectomy versus tap and injection, both with and without systemic antibiotics.7 For eyes that had hand-motion vision or better there was no advantage to prompt vitrectomy over tap and inject alone. Intravitreal injection-related endophthalmitis: Pseudo-endophthalmitis,' or non-infectious endophthalmitis, seen after intravitreal triamcinolone injection, presumably as a result of toxic or inflammatory reaction to the drug, the vehicle in which the drug is suspended, or a contaminant in the preparation. The Endophthalmitis Vitrectomy Study found that approximately one-third of cases were culture negative. B scan showed a lens capsule without deposits, fluffy material attached to the temporal ciliary body suspicious for vegetation, and anterior vitreous hemorrhage (figure 2). A portion of the vitreous sample was sent to the University of Washington for multiplex PCR. Clipboard, Search History, and several other advanced features are temporarily unavailable. Careers. Treatment includes vancomycin and, often times, vitrectomy. As seen in this case, removal of the native lens was also required. The patient presented to uveitis clinic on prednisolone 1% QID, as well as brimonidine tartrate 0.2%/timolol maleate 0.5% BID OD for a history of steroid response up to the 50s. Seal D, Reischl U, Behr A, et al. Postoperative endophthalmitis most often follows cataract extraction but can be associated with any form of intraocular procedure or extraocular operations, such as strabismus repair (in which organisms presumably are introduced into the globe by inadvertent needle perforation of the sclera).1114 The rate of endophthalmitis after pediatric intraocular surgery is similar to that found in adults, approximately 1 in 1000 cases.12 A recent trend in cataract surgery toward use of unsutured self-sealing incisions through temporal clear cornea (as opposed to the superior limbus) has been associated with a small but substantial increase in the frequency of postoperative endophthalmitis. Acute postoperative endophthalmitis usually occurs within 2 weeks of surgery, whereas the presentation of infection after penetrating trauma will often be more rapid. Bethesda, MD 20894, Web Policies Preoperative: povidone-iodine on the ocular surface, barrier draping the eyelashes. Intravitreal steroids were not evaluated, and systemic antibiotics were not found to be beneficial. Intravitreal dexamethasone in exogenous bacterial endophthalmitis: Results of a prospective randomised study. Chronic We use cookies to help provide and enhance our service and tailor content and ads. Copyright 2023 Elsevier B.V. or its licensors or contributors. Moran CORE | Chronic Postoperative Endophthalmitis An official website of the United States government. Far PM, Yeung SC, Farimani PL, et al. All received 500 mg of oral The leading causes of postoperative endophthalmitis include staphylococci, streptococci, Enterococcus faecalis, and Propionibacterium acnes. Endophthalmitis (which means inflammation inside the eye) can also occasionally be caused by retained surgical material (e.g. cotton fibres). It is called acute if it occurs within the first week after surgery and chronic if it occurs up to a month after surgery. The .gov means its official. government site. On the other hand, there was no statistical difference in the rates of endophthalmitis with or without the application of levofloxacin. An official website of the United States government. Slit lamp exam was notable for 0.5+ AC cell with more consolidation of whitish opacities and debris on the anterior lens capsule (Fig. Bookshelf Occlusion of AquaPORT Flow in a Case of Toxic Anterior Segment Syndrome Following Implantable Collamer Lens Surgery Causing Severe Pupillary Block. Bacterial Endophthalmitis - Where We Stand Ocular medications included Durezol and prednisolone in the right eye. Pain and progressive vision loss are not characteristic. government site. He reported intermittent achy ocular pain status post ICL placement and blurry vision. A) Implantable collamer lens (ICL) with white round deposits between the ICL and the native lens OD. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 30. There is less redness, pain, and anterior chamber reaction than in endophthalmitis. 6 months later, the patient presented again with recurrent episodes of inflammation. Achromobacter species-associated endophthalmitis is rare and may present as either acute or chronic postoperative endophthalmitis. The use of intracameral vancomycin also carries the risk of the rare but potentially devastating hemorrhagic occlusive retinal vasculitis, as reported in some retrospective case series.25, 26 HORV can appear one to 21 days after surgery. doi: 10.1016/S0161-6420(97)30326-1. Neil J. Friedman MD, Peter K. Kaiser MD, in Case Reviews in Ophthalmology (Second Edition), 2018. 29. Treatment of Post-operative Endophthalmitis Ophthalmology 2020;127:2:151-158. A 75 year old female with a history of glaucoma requiring trabeculectomy in the right eye 2 years ago as well as bilateral cataract surgery 6 years ago, and rosacea was referred for evaluation of chronic anterior chamber inflammation in the right eye. Diagnosis: Chronic Postoperative Endophthalmitis. However, the efficacy of topical antibiotics remains controversial. 1B). P. acnes often produces a granulomatous inflammation, usually beginning 48 weeks after surgery. estoring vision through cataract surgery remains a gift ophthalmologists provide patients, and the outcomes continue to improve. Whitish condensations in plaques on the posterior capsule suggest the diagnosis and over several months the vitreous becomes inflamed. Patients with diabetes have the propensity for retinal spread of K. pneumoniae from hepatic abscesses and of E. coli from a urinary tract infection. sharing sensitive information, make sure youre on a federal The European Society for Cataract & Refractive Surgeons. All rights reserved. One study compared traditional culture to PCR and a WGS method called Biome Representational in silico Karyotyping (BriSK).10 The study found that traditional culture remained the gold standard, and a number of presumed endophthalmitis cases didnt have detectable bacterial DNA. 2021 Jan 7;12(1):1-10. doi: 10.1159/000510208. 2020 Nov 4;5(3):258-260. doi: 10.1177/2474126420968402. J Refract Surg. Douglas R. Fredrick, in Principles and Practice of Pediatric Infectious Diseases (Sixth Edition), 2023. Unable to load your collection due to an error, Unable to load your delegates due to an error. Reproduction in whole or in part without permission is prohibited. A number of prognostic factors have been proposed, the most important of which is probably the virulence of the infecting organism, as demonstrated in the EVS. In the posterior segment, vitritis often obscures the fundus, and sometimes retinal hemorrhages occur. Federal government websites often end in .gov or .mil. Treatment is prolonged because of the slow replication of the microorganisms involved. Eur J Ophthalmol. Br J Ophthalmol 1999;83:9:1050-1055. Findings often include AC cells and posterior, white plaque on the ocular implant as seen in our patient. MEDIA KIT| Fowler BJ, Miller D, Yan X, Yannuzzi NA, Flynn HW Jr. Case Rep Ophthalmol. If you have any questions, you can email OnLine@Ingrams.com, or call 816.268.6402. -, Al-Mezaine H.S., Al-Assiri A., Al-Rajhi A.A. TAP and inject versus pars plana vitrectomy for postprocedural endophthalmitis: A meta-analysis. Diagnosis is aided by aqueous or vitreous aspiration sent for anaerobic culture, or polymerase chain reaction (PCR). Lee AY, Akileswaran L, Tibbetts MD, Garg SJ, Van Gelder RN. His other laboratory testing was unremarkable except for WBC elevated at 13.18 (ref range 4.3-11.3) felt to be consistent with neutrophilia from systemic glucocorticoid dosing. doi: 10.1128/CMR.00113-16. This site needs JavaScript to work properly. PCR of vitreous or aqueous contents is frequently used to aid in diagnosis of CPE and can be more sensitive than culture and microscopy7. While the data favor intraoperative intracameral antibiotic prophylaxis, some uncertainty remains regarding what antibiotic agent is best. Several patient characteristics and intraoperative factors have been identified as potential risks for PCE. Diagnosis of CPE is often delayed due to resemblance of sterile post-operative inflammation initially as well as initial improvement of inflammation on steroids6. Given concern for chronic post-operative endophthalmitis OD, a vitreous tap and injection of vancomycin 1 mg/0.1 mL and ceftazidime 2 mg/0.1 mL was performed. Documented complications of ICL implantation include infection, inflammation, glaucoma, endothelial cell loss, iris abnormalities, and retinal detachment.9 Allan et al. A 45-year-old male presented three months after ICL implantation of the right eye with blurry vision, redness, and ocular pain in the setting of prolonged post-operative anterior chamber (AC) cell. 9. Post-traumatic MANAGEMENT OF POST-OPERATIVE INFECTIOUS Its cause and incidence vary geographically. In cases of traumatic endophthalmitis, the authors typically recommend vitrectomy if a safe view of the posterior segment is at all possible, as most patients with traumatic endophthalmitis will eventually require vitrectomy for visual rehabilitation. Given persistent deposits on the anterior lens capsule, repeat intravitreal and intracameral injection of vancomycin 1 mg/0.1 mL (dose divided) was performed two more times over the subsequent weeks. Endophthalmitis Chronic post-operative iris prosthesis endophthalmitis in a All authors attest that they meet the current ICMJE criteria for Authorship. Also treat with subconjunctival (vancomycin and cetfazidime or gentamicin) and topical (fortified vancomycin and ceftazidime) antibiotics and steroids, and a topical cycloplegic. Postoperative hemorrhagic occlusive retinal vasculitis: Expanding the clinical spectrum and possible association with vancomycin. 259 Acute post-operative endophthalmitis is defined as that occurring within the 6 weeks following surgery. B) Native lens opacity shown at higher magnification and C) retro illumination. Robbins CC, Sobrin L, Ma KK, Brouillette KM, Moore JK. Bethesda, MD 20894, Web Policies The outcome of treatment for postoperative endophthalmitis began to improve dramatically during the 1980s. Incidence of endophthalmitis after corneal transplant or cataract surgery in a medicare population. Granulomatous KPs are seen in 31-81% of eyes4. While PCR has these distinct advantages over culture, there are two main drawbacks to PCR. When Pseudomonas aeruginosa or Bacillus organisms are the infecting microbes, salvage of useful vision is almost never reported.12,13,21,88 Delay of therapy for more than 36 h after onset of symptoms has been reported to be associated with poor visual outcome in one series, whereas delay of greater than 24 h after onset of symptoms in eyes in which vitrectomy was performed was associated with a worse outcome in others.96,188 In animal experiments, administration of antibiotics in a model of Pseudomonas endophthalmitis 24 h after bacterial injection produced sterilization of the vitreous cavity, whereas later injection did not.171, Visual acuity at initial manifestation has also been correlated with outcome.
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