Post-cataract surgery endophthalmitis: Difference between revisions

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**''[[Staphylococcus aureus]]''  
**''[[Staphylococcus aureus]]''  
**''[[Streptococcus]]''  
**''[[Streptococcus]]''  
**''[[Enterococcus]]'' and mixed bacteria
**''[[Enterococcus]]''  
*[[Gram-negative bacilli]]  
*[[Gram-negative bacilli]]  
**''[[Proteus|Proteus spp]]''
**''[[Proteus|Proteus spp]]''

Revision as of 23:21, 8 August 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Acute post-cataract endophthalmitis is an ocular inflammation resulting from the introduction of an infectious agent, most commonly coagulase-negative staphylococci, into the posterior segment of the eye. Nearly every type of ocular surgery may be able to disturb the eye globe integrity and contaminate the aqueous humor and/or vitreous. Cataract surgery accounts for approximately 90% of all cases of post-operative enndophthalmitis.

Historical Perspective

Classification

Based on the latancy of onset, post-cataract endophthalmitis may be classified into:

  • Acute post-catarct endophthalmitis
  • Delayed post-cataract endophthalmitis

Additionally, post-cataract enophthalmitis may be classified according to causative organisms into 2 subtypes: bacterial or fungal.

Pathophysiology

Pathogenesis

Acute post-cataract endophthalmitis is an ocular inflammation, which may occur within hours to few days after cataract surgery. Acute post-cataract endophthalmitis is mainly caused by the introduction of an infectious agent, most commonly coagulase-negative staphylococci, into the posterior segment of the eye. Nearly every type of ocular surgery may be able to disturb the eye globe integrity and contaminate the aqueous humor and/or vitreous. Cataract surgery accounts for approximately 90% of all cases of post-operative enndophthalmitis. Preoperative topical antimicrobial agents can decrease colony counts in the tear film, but they do not sterilize the area. The exact low rate of clinical infection following eye surgery (despite the relatively high prevalence of microorganisms in the eye) is not fully understood. It is thought that low rate of clinical infection following surgical procedure is explained by combination of low inoculum levels, low pathogenicity, and the innate ocular defenses against infection.[1][2][3]

Post-operative endophthalmitis may also occur weeks to years following surgery. It presents as a low-grade inflammation in the anterior chamber. The exact pathogenesis of delayed postoperative bacterial endophthalmitis is not fully understood. It is thought that delayed post-operative bacterial endophthalmitis is caused by either sequestration of low-virulence organisms introduced at the time of surgery or delayed inoculation of organisms to the eye through wound abnormalities, suture tracks, or filtering blebs. Propionibacterium acnes is the most common microorganism encountered in delayed post-operative bacterial endophthalmitis. [1][2]

Gross Pathology

On gross pathology, eyelid swelling, eyelid erythema, injected conjunctiva and sclera, hypopyon, chemosis, and mucoprulunt dischage are characteristic findings of post-cataract endophthalmitis.

Microscopic histopathological analysis

On microscopic histopathological analysis, infiltration of polymorphonuclear leukocytes or chronic inflammatory cells (depending on the duration of the inflammation) and destruction of ocular structures are characteristic findings of post cataract bacterial endophthalmitis.

Causes

Post-operative Endophthalmitis

Post-operative endophthalmitis has been reported following nearly every type of ocular surgery. Common causes of post-operative endophthalmitis include:[1][2]

Delayed Post-operative Bacterial Endophthalmitis

Common causes of delayed post-operative bacterial endophthalmitis include:[1][2]

Common causes of delayed post-operative fungal endophthalmitis include:

Differentiating Post-cataract Surgery Endophthalmitis from Other Diseases

Acute post-cataract endophthalmitis must be differentiated from:

  • Phacoanaphylactic endophthalmitis
  • Aseptic endophthalmitis (a severe sterile uveitis)This condition usually resolves with topical steroid treatment

Delayed post-cataract endophthalmitis must be differentiated from:

  • Pre-existing uveitis
  • Sterile inflammation attributed to reaction to contaminants on the intraocular lens (IOL)
  • Rebound inflammation related to abrupt discontinuation of steroid drops

Epidemiology and Demographics

  • In 1910, the incidence of post-cataract endophthalmitis was estimated 10,000 cases per 100,000 individuals with cataract surgery.
  • In developed country between 1970-1990, the incidence of post-cataract endophthalmitis was estimated to range from 72 to 120 cases per 100,000 individuals with cataract surgery.
  • Since the introduction of phacoemulsification and clear cornea incision, the incidence of post-cataract endophthalmitis was estimated to range from 300 to 500 cases per 100,000 individuals with cataract surgery.[4][5]

Geographical disterbution

In tropical regions such as India, 10–20% of all cases of acute post-cataract endophthalmitis are caused by fungi.

Developed Country

  • In the USA and Europe, nearly all cases of acute post-cataract endophthalmitis are caused by bacteria,

Risk Factors

Common risk factors in the development of post-operative bacterial endophthalmitis include:[2][6][7][8][9][10]

Screening

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

Diagnosis

Diagnostic Criteria

History

Symptoms

  • Acute post-cataract endophthalmitis may occur within hours to few days after cataract surgery in 75% of cases.
  • Delayed post-operative endophthalmitis may occur several weeks or month after surgery and often include less virulent bacteria.

Symptoms of post-cataratc endophthalmitis may include the following:

  • Deep pain
  • Decreased vision (with intraocular lens implantation (IOL) it can be the initial symptom)
  • Lid swelling
  • Red eye
  • Photophobia
  • Eye discharge

Physical Examination

A thorough physical and eye examination from the patient is necessary. Common ophthalmoscope examination findings of exogenous bacterial endophthalmitis include:[1][2]


Laboratory Findings

Imaging Findings

X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References

  1. 1.0 1.1 1.2 1.3 1.4 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
  3. Keay L, Gower EW, Cassard SD, Tielsch JM, Schein OD (2012). "Postcataract surgery endophthalmitis in the United States: analysis of the complete 2003 to 2004 Medicare database of cataract surgeries". Ophthalmology. 119 (5): 914–22. doi:10.1016/j.ophtha.2011.11.023. PMC 3343208. PMID 22297029.
  4. Koc, F., et al. "Factors influencing treatment results in pseudophakic endophthalmitis." European journal of ophthalmology 12.1 (2001): 34-39.
  5. Kattan, H. M., Flynn, H. W. Jr., Pflugfelder, S. C., Robertson, C., Forster, R. K.: Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery. Ophthalmology 98, 1991, 227 - 238
  6. Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM; et al. (2005). "Acute endophthalmitis following cataract surgery: a systematic review of the literature". Arch Ophthalmol. 123 (5): 613–20. doi:10.1001/archopht.123.5.613. PMID 15883279.
  7. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons (2007). "Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors". J Cataract Refract Surg. 33 (6): 978–88. doi:10.1016/j.jcrs.2007.02.032. PMID 17531690.
  8. Krall EM, Arlt EM, Jell G, Strohmaier C, Bachernegg A, Emesz M; et al. (2014). "Intraindividual aqueous flare comparison after implantation of hydrophobic intraocular lenses with or without a heparin-coated surface". J Cataract Refract Surg. 40 (8): 1363–70. doi:10.1016/j.jcrs.2013.11.043. PMID 25088637.
  9. Cooper BA, Holekamp NM, Bohigian G, Thompson PA: Case-control study of endophthalmitis after cataract surgery comparing scleral tunnel and clear corneal wounds. Am J Ophthalmol 2003; 137:598–599.
  10. Menikoff JA, Speaker MG, Marmor M, Raskin EM: A case-control study of risk factors for post-operative endophthalmitis. Ophthalmology 1991; 98:1761–1768.


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