Post-cataract surgery endophthalmitis: Difference between revisions

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__NOTOC__
__NOTOC__
{{SI}}
{{SI}}
{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{SaraM}}


==Overview==
==Overview==
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''[[Propionibacterium acnes]]'' is the most common microorganism encountered in delayed post-operative bacterial endophthalmitis. <ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
''[[Propionibacterium acnes]]'' is the most common microorganism encountered in delayed post-operative bacterial endophthalmitis. <ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
====Gross Pathology====
====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.  
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====
====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.
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.
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*''Xanthomonas maltophilia''
*''Xanthomonas maltophilia''
*''Alcaligenes xylosoxidans''
*''Alcaligenes xylosoxidans''
'''Fungal'''<ref name="pmid12831144">{{cite journal| author=Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P et al.| title=Spectrum and clinical profile of post cataract surgery endophthalmitis in north India. | journal=Indian J Ophthalmol | year= 2003 | volume= 51 | issue= 2 | pages= 139-45 | pmid=12831144 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12831144  }} </ref><ref> Frahmy JA. Endophthalmitis following cataract extraction: A study of 24 cases in 4498 operations. Acta Ophthalmol 1975;53:522-36.  Back to cited text no.</ref><ref>Theodore FH. Symposium: Postoperative endophthalmitis. Etiology and diagnosis of fungal endophthalmitis. Trans Am Acad Ophthalmol Otolaryngol 1978;85;327-29 </ref>
'''Fungal'''<ref name="pmid12831144">{{cite journal| author=Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P et al.| title=Spectrum and clinical profile of post cataract surgery endophthalmitis in north India. | journal=Indian J Ophthalmol | year= 2003 | volume= 51 | issue= 2 | pages= 139-45 | pmid=12831144 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12831144  }} </ref><ref> Frahmy JA. Endophthalmitis following cataract extraction: A study of 24 cases in 4498 operations. Acta Ophthalmol 1975;53:522-36.  Back to cited text no.</ref><ref>Theodore FH. Symposium: Postoperative endophthalmitis. Etiology and diagnosis of fungal endophthalmitis. Trans Am Acad Ophthalmol Otolaryngol 1978;85;327-29 </ref><ref name="pmid26124631">{{cite journal| author=Jindal A, Pathengay A, Jalali S, Mathai A, Pappuru RR, Narayanan R et al.| title=Microbiologic spectrum and susceptibility of isolates in delayed post-cataract surgery endophthalmitis. | journal=Clin Ophthalmol | year= 2015 | volume= 9 | issue=  | pages= 1077-9 | pmid=26124631 | doi=10.2147/OPTH.S82852 | pmc=4476472 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26124631  }} </ref>
*''[[Candida|Candida spp]]
*''[[Candida|Candida spp]]
*''[[Aspergillus|Aspergillus spp]]''
*''[[Aspergillus|Aspergillus spp]]''
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*[[Toxic anterior segment syndrome|Toxic anterior segment syndrome (TASS)]]
*[[Toxic anterior segment syndrome|Toxic anterior segment syndrome (TASS)]]


Delayed post-cataract endophthalmitis must be differentiated from:<ref name="pmid26124631">{{cite journal| author=Jindal A, Pathengay A, Jalali S, Mathai A, Pappuru RR, Narayanan R et al.| title=Microbiologic spectrum and susceptibility of isolates in delayed post-cataract surgery endophthalmitis. | journal=Clin Ophthalmol | year= 2015 | volume= 9 | issue= | pages= 1077-9 | pmid=26124631 | doi=10.2147/OPTH.S82852 | pmc=4476472 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26124631 }} </ref><ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028 }} </ref>
Delayed post-cataract endophthalmitis must be differentiated from:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028 }} </ref><ref name="pmid26124631">{{cite journal| author=Jindal A, Pathengay A, Jalali S, Mathai A, Pappuru RR, Narayanan R et al.| title=Microbiologic spectrum and susceptibility of isolates in delayed post-cataract surgery endophthalmitis. | journal=Clin Ophthalmol | year= 2015 | volume= 9 | issue= | pages= 1077-9 | pmid=26124631 | doi=10.2147/OPTH.S82852 | pmc=4476472 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26124631 }} </ref>
*[[Uveitis]]
*[[Uveitis]]
*Sterile inflammation
*Sterile inflammation
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==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence and Incidence===
*In 1910, the incidence of post-cataract endophthalmitis was estimated 10,000 cases per 100,000 individuals with cataract surgery.
*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.
*Between 1970 to 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.<ref> Koc, F., et al. "Factors influencing treatment results in pseudophakic endophthalmitis." European journal of ophthalmology 12.1 (2001): 34-39.</ref><ref> 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</ref>
*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.<ref> Koc, F., et al. "Factors influencing treatment results in pseudophakic endophthalmitis." European journal of ophthalmology 12.1 (2001): 34-39.</ref><ref> 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</ref>
 
===Age===
*Post-operative endophthalmitis (following cataract surgery) commonly affects patients older than 85 years.<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
===Gender===
*Post-operative endophthalmitis affects men and women equally.<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
===Geographical Distribution===
===Geographical Distribution===
In tropical regions such as India, 10–20% of all cases of acute post-cataract endophthalmitis are caused by fungi.<ref name="pmid12831144">{{cite journal| author=Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P et al.| title=Spectrum and clinical profile of post cataract surgery endophthalmitis in north India. | journal=Indian J Ophthalmol | year= 2003 | volume= 51 | issue= 2 | pages= 139-45 | pmid=12831144 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12831144  }} </ref>
In tropical regions such as India, 10–20% of all cases of acute post-cataract endophthalmitis are caused by fungi.<ref name="pmid12831144">{{cite journal| author=Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P et al.| title=Spectrum and clinical profile of post cataract surgery endophthalmitis in north India. | journal=Indian J Ophthalmol | year= 2003 | volume= 51 | issue= 2 | pages= 139-45 | pmid=12831144 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12831144  }} </ref>
===Developed Country===
*In the United States, post-cataract endophthalmitis is the most common form of bacterial endophthalmitis.
*In the United States, the incidence of cataract endophthalmitis was estimated to range from 80 to 360 cases per 100,00 individuals with ocular surgery.<ref name="pmid9627649">{{cite journal| author=Aaberg TM, Flynn HW, Schiffman J, Newton J| title=Nosocomial acute-onset postoperative endophthalmitis survey. A 10-year review of incidence and outcomes. | journal=Ophthalmology | year= 1998 | volume= 105 | issue= 6 | pages= 1004-10 | pmid=9627649 | doi=10.1016/S0161-6420(98)96000-6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9627649  }} </ref>
*In the  United States and Europe, nearly all cases of acute post-cataract endophthalmitis are caused by bacteria.
*In the United States, the incidence of culture-proven postoperative endophthalmitis caused by cataract surgery with or without intraocular lens (IOL) was estimated to be 80 cases per 100,000 individuals.
*In the United States, the incidence of culture-proven postoperative endophthalmitis caused by secondary IOL placement was estimated to be 360 cases per 100,000 individuals.


===Developed Country===
*In the USA and Europe, nearly all cases of acute post-cataract endophthalmitis are caused by bacteria,
==Risk Factors==
==Risk Factors==
Common risk factors in the development of post-catarct endophthalmitis include:<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid15883279">{{cite journal| author=Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM et al.| title=Acute endophthalmitis following cataract surgery: a systematic review of the literature. | journal=Arch Ophthalmol | year= 2005 | volume= 123 | issue= 5 | pages= 613-20 | pmid=15883279 | doi=10.1001/archopht.123.5.613 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15883279  }} </ref><ref name="pmid17531690">{{cite journal| author=Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons| title=Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. | journal=J Cataract Refract Surg | year= 2007 | volume= 33 | issue= 6 | pages= 978-88 | pmid=17531690 | doi=10.1016/j.jcrs.2007.02.032 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17531690  }} </ref><ref name="pmid25088637">{{cite journal| author=Krall EM, Arlt EM, Jell G, Strohmaier C, Bachernegg A, Emesz M et al.| title=Intraindividual aqueous flare comparison after implantation of hydrophobic intraocular lenses with or without a heparin-coated surface. | journal=J Cataract Refract Surg | year= 2014 | volume= 40 | issue= 8 | pages= 1363-70 | pmid=25088637 | doi=10.1016/j.jcrs.2013.11.043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25088637  }} </ref><ref>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. </ref><ref>Menikoff JA, Speaker MG, Marmor M, Raskin EM: A case-control study of risk factors for post-operative endophthalmitis. Ophthalmology 1991; 98:1761–1768. </ref>
Common risk factors in the development of post-catarct endophthalmitis include:<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid15883279">{{cite journal| author=Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM et al.| title=Acute endophthalmitis following cataract surgery: a systematic review of the literature. | journal=Arch Ophthalmol | year= 2005 | volume= 123 | issue= 5 | pages= 613-20 | pmid=15883279 | doi=10.1001/archopht.123.5.613 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15883279  }} </ref><ref name="pmid17531690">{{cite journal| author=Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons| title=Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. | journal=J Cataract Refract Surg | year= 2007 | volume= 33 | issue= 6 | pages= 978-88 | pmid=17531690 | doi=10.1016/j.jcrs.2007.02.032 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17531690  }} </ref><ref name="pmid25088637">{{cite journal| author=Krall EM, Arlt EM, Jell G, Strohmaier C, Bachernegg A, Emesz M et al.| title=Intraindividual aqueous flare comparison after implantation of hydrophobic intraocular lenses with or without a heparin-coated surface. | journal=J Cataract Refract Surg | year= 2014 | volume= 40 | issue= 8 | pages= 1363-70 | pmid=25088637 | doi=10.1016/j.jcrs.2013.11.043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25088637  }} </ref><ref>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. </ref><ref>Menikoff JA, Speaker MG, Marmor M, Raskin EM: A case-control study of risk factors for post-operative endophthalmitis. Ophthalmology 1991; 98:1761–1768. </ref>
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==Screening==
==Screening==
Screening for post cataract surgery endophthalmitis is not recommended.<ref name=post-traumatic>US Preventivre Services Task Force http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=endophthalmitis Accessed on August 5, 2016 </ref>


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
===Natural History===
===Natural History===
 
Post-cataract endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal infiltration, corneal perforation, and ultimately permanent [[vision loss]].
===Complications===
===Complications===
 
Common complications of post-catarsct endophthalmitis include:
*Panophthalmitis
*Decrease or loss of vision
*[[Chronic pain]]
*[[Cataract]] development
*[[Retinal detachment]]
*[[Vitreous hemorrhage]]
*[[Hypotony]] and [[phthisis bulbi]]
===Prognosis===
===Prognosis===
Early diagnosis and treatment with antimicrobial therapy are fundamental to optimize visual outcome.<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid11978440">{{cite journal| author=Mamalis N| title=Endophthalmitis. | journal=J Cataract Refract Surg | year= 2002 | volume= 28 | issue= 5 | pages= 729-30 | pmid=11978440 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11978440  }} </ref>
Overall, 50% of eyes with post-cataract endophthalmitis obtain a final [[visual acuity]] 20/40 vision, and 10% obtain a final [[visual acuity]] of 20/400.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref>
The visual outcome of post cataract endophthalmitis is highly correlated with the bacteriology.
*Post-operative endophthalmitis caused by any type of [[streptococci]] is associated with very poor visual outcome.
*Post-operative endophthalmitis caused by [[staphylococcus|coagulase-negative staphylococcus]] (cause milder endophthalmitis) is associated with better visual outcome than strepcocci.
*Delayed post-operative endophthalmitis is associated with particularly good prognosis with treatment.<ref> Zambrano, William, et al. "Management options for Propionibacterium acnes endophthalmitis." Ophthalmology 96.7 (1989): 1100-1105. </ref>


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
===Diagnostic Criteria===
Endophthalmitis is a clinical diagnosis, supported by culture of intra-ocular fluids.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>


===History===
===History===
A detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient with post-cataract surgery endophthalmitis include:
*History of previous [[cataract|cataract surgery]]
*History of [[chronic]], recurrent, steroid responsive [[uveitis|idiopathic uveitis]] (most patients with delayed post-operative endophthalmitis are characterized by this presentation)
===Symptoms===
===Symptoms===
*'''Acute post-cataract endophthalmitis''' may occur within hours to few days after  cataract surgery in 75% of cases.  
*'''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.  
*'''Delayed post-operative endophthalmitis''' may occur several weeks or month after surgery and often include less virulent bacteria and only of the patients may present with eye pain.
Symptoms of post-cataratc endophthalmitis may include the following:
Symptoms of post-cataratc endophthalmitis may include the following:<ref name="pmid18067969">{{cite journal| author=Lalwani GA, Flynn HW, Scott IU, Quinn CM, Berrocal AM, Davis JL et al.| title=Acute-onset endophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features, causative organisms, and visual acuity outcomes. | journal=Ophthalmology | year= 2008 | volume= 115 | issue= 3 | pages= 473-6 | pmid=18067969 | doi=10.1016/j.ophtha.2007.06.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18067969  }} </ref><ref name="pmid15883279">{{cite journal| author=Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM et al.| title=Acute endophthalmitis following cataract surgery: a systematic review of the literature. | journal=Arch Ophthalmol | year= 2005 | volume= 123 | issue= 5 | pages= 613-20 | pmid=15883279 | doi=10.1001/archopht.123.5.613 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15883279  }} </ref>
*Deep pain
*Deep pain
*Decreased vision (with intraocular lens implantation (IOL) it can be the initial symptom)
*Decreased vision
*Lid swelling
*Lid swelling
*Red eye
*Red eye
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===Physical Examination===
===Physical Examination===
A thorough physical and eye examination from the patient is necessary.  
A thorough physical and eye examination from the patient is necessary.  
Common ophthalmoscope examination findings of '''exogenous bacterial endophthalmitis''' include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
Common ophthalmoscope examination findings of post-operative endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
*Visual acuity less than 5/200
*Visual acuity less than 5/200
*Light perception
*No retinal vessel visible by indirect ophthalmoscopy
*[[Conjunctival injection]]
*[[Conjunctival injection]]
*[[eyelid edema]]
*[[eyelid edema]]
*[[Hypopyon]]
*Clumps of [[exudate]] in the anterior chamber (around the pupillary margin)
*[[Cloudy cornea]]
*Decreased [[red reflex]]
*Decreased [[red reflex]]
*[[Anterior chamber]] and [[vitreous]] inflammatory reactions
*[[Retinitis]]


===Laboratory Findings===
Laboratory studies consistent with the diagnosis of post-cataract endophthalmitis include:<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref><ref name="pmid18721702">{{cite journal| author=Seal D, Reischl U, Behr A, Ferrer C, Alió J, Koerner RJ et al.| title=Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract & Refractive Surgeons multicenter study and susceptibility testing. | journal=J Cataract Refract Surg | year= 2008 | volume= 34 | issue= 9 | pages= 1439-50 | pmid=18721702 | doi=10.1016/j.jcrs.2008.05.043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18721702  }} </ref>
*Culture and gram stain of [[aqueous humor]] as well as the [[vitreous humor]] (not often sensitive)
*[[polymerase chain reaction|Polymerase chain reaction (PCR)]]  of [[aqueous humor]] as well as the [[vitreous humor]] (much more sensitive than culture (70% vs. 9%)
*Conjunctival and eyelid cultures in patients with [[blepharitis]] and wound dehiscence may indicated


 
[[Vitreous]] cultures are more likely to be positive after [[vitrectomy]] than vitreous aspirate (90% vs. 75%), and [[aqueous]] cultures are positive in 40% of all cases with endophthalmitis.
===Laboratory Findings===


===Imaging Findings===
===Imaging Findings===
====X Ray====
====X Ray====
There are no diagnostic x ray findings associated with post-cataract endophthalmitis.


====CT====
====CT====
 
There are no diagnostic CT scan findings associated with post-cataract endophthalmitis.
====MRI====
====MRI====
 
There are no diagnostic MRI findings associated with post-cataract endophthalmitis.
====Ultrasound====
====Ultrasound====
 
On ocular ultrasonography, endophthalmitis may characterized by anterior vitreous [[haze echoes]] and retinochoroidal thickening.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref>
====Other Imaging Findings====
====Other Imaging Findings====
Orbital echography is helpful for assessment of vitreous opacification, status of the posterior hyaloid face, and retinal detachment in a patient with post-operative.<ref name="pmid20390032">{{cite journal| author=Kernt M, Kampik A| title=Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives. | journal=Clin Ophthalmol | year= 2010 | volume= 4 | issue=  | pages= 121-35 | pmid=20390032 | doi= | pmc=2850824 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20390032  }} </ref><ref name="pmid3495766">{{cite journal| author=Affeldt JC, Flynn HW, Forster RK, Mandelbaum S, Clarkson JG, Jarus GD| title=Microbial endophthalmitis resulting from ocular trauma. | journal=Ophthalmology | year= 1987 | volume= 94 | issue= 4 | pages= 407-13 | pmid=3495766 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3495766  }} </ref>


===Other Diagnostic Studies===
===Other Diagnostic Studies===
====Slit lamp finding====
*Hypopyon ( >80% of cases)
*[[Anterior chamber]] and [[vitreous]] inflammation
*Cloudy cornea
*Clumps of [[exudate]] in the anterior chamber (around the pupillary margin)
*[[Cloudy cornea]]
*Decreased [[red reflex]]
<gallery>
Image:Anterior_chamber_inflammation.gif|[[Anterior chamber]] inflammation, mild corneal edema, and [[hypopyon]] in bacterial endophthalmitis
Image:Exogenous_fungal_endophthalmitis.gif|Exogenous fungal endophthalmitis with corneal ulcer
Image:Endophthalmitis.gif|[[Hypopyon]]
Image:Clinical_slit-lamp_photograph.jpg|(A) Severe conjunctival injection, subconjunctival hemorrhage, corneal stromal edema, and hypopyon (B) Fundus photograph shows a mild pale color of optic disc & macular degeneration<ref name="pmid18323709">{{cite journal| author=Seo SW, Chung IY, Kim E, Park JM| title=A case of postoperative Sphingomonas paucimobilis endophthalmitis after cataract extraction. | journal=Korean J Ophthalmol | year= 2008 | volume= 22 | issue= 1 | pages= 63-5 | pmid=18323709 | doi=10.3341/kjo.2008.22.1.63 | pmc=2629956 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18323709  }} </ref>
Image:IndianJOphthalmol-55-464-g001.gif|Corneal edema and severe [[anterior chamber]] exudation<ref name="pmid22606461">{{cite journal| author=Jaru-Ampornpan P, Agarwal A, Midha NK, Kim SJ| title=Traumatic Endophthalmitis due to Cellulosimicrobium cellulans. | journal=Case Rep Ophthalmol Med | year= 2011 | volume= 2011 | issue=  | pages= 469607 | pmid=22606461 | doi=10.1155/2011/469607 | pmc=3350247 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22606461  }} </ref>
</gallery>


==Treatment==
==Treatment==
*The patient needs urgent examination by an expert [[ophthalmologist]] and/or vitreo-retina specialist who will usually decide for urgent intervention to provide [[intravitreal injection]] of potent antibiotics and also prepare for an urgent pars plana [[vitrectomy]] as needed.  [[Enucleation]] may be required to remove a blind and painful eye.
The patient needs urgent examination by an expert [[ophthalmologist]] and/or vitreo-retina specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics and also prepare for an urgent pars plana [[vitrectomy]] as needed.  [[Enucleation]] may be required to remove a blind and painful eye.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref>
*Endogenous endophthalmitis is caused by the hematologic dissemination of an infection to the eyes. Systemic antibiotics are recommended in endogenous bacterial endophthalmitis because the source of the infection is distant from the eye.
*Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
*Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
*Immediate [[vitrectomy]] is often necessary
*In addition to intravitreal antibiotic therapy, immediate vitrectomy is often necessary
*Repeat antimicrobial regimen in 2 days post-vitrectomy is necessary
*Systemic antibiotics are not recommended, but may be considered in severe cases, especially with orbital involvement.
*In delayed post-operative endophthalmitis, treatment should include vitrectomy with posterior capsulectomy and intravitreal injection.


===Antimicrobial Regimens===
===Antimicrobial Regimens===
*'''Infectious endophthalmitis'''<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=PMC3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref>
'''Infectious endophthalmitis'''<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=PMC3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref>
:*'''1. Causative pathogens'''
:*'''1. Causative pathogens'''
::*''[[Staphylococcus epidermidis]]''
::*''[[Staphylococcus epidermidis]]''
Line 193: Line 238:
:::* Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
:::* Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
::*'''3.3 Gram-negative bacteria'''
::*'''3.3 Gram-negative bacteria'''
:::*Preferred regimen: [[Ceftazidime]] 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Ceftazidime]] 1 g IV bid for 2 weeks
:::*Preferred regimen: [[Ceftazidime]] 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Ceftazidime]] 1 g IV bid for 2 weeks {{or}} [[Amikacin]] 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
:::* Note: Intravitreal amikacin is associated with the development of retinal microvasculitis
:::* Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
:::* Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
::*'''3.4 Candida spp.'''
::*'''3.4 Candida spp.'''
Line 202: Line 248:
:::* Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
:::* Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
:::* Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy
:::* Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy
:*'''4. Special Considerations'''
::*'''4.3 Post-operative endophthalmitis'''
:::*'''4.3.1 Empiric antimicrobial therapy'''
::::* Preferred regimen: [[Vancomycin]] 1 mg per 0.1 mL normal saline intravitreal injection, single dose {{and}} [[Ceftazidime]] 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose
::::*Note (1): In addition to intravitreal antibiotic therapy, vitrectomy is necessary
::::*Note (2): If there is no improvement in 48 h, a repeat intravitreal injection may be administered
::::*Note (3): Late post-operative endophthalmitis is often caused by Propionibacterium acnes (several years post-op)
:::*'''4.3.2 Pathogen-directed antimicrobial therapy'''
::::*'''4.3.2.1 Gram-positive bacteria'''
:::::* Preferred regimen: [[Vancomycin]] 1 mg per 0.1 mL normal saline intravitreal injection, single dose
::::*'''4.3.2.2 Gram-negative bacteria'''
:::::* Preferred regimen: [[Amikacin]] 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
:::::* Note: Intravitreal amikacin is associated with the development of retinal microvasculitis
::*'''4.4 Post-traumatic endophthalmitis'''


===Surgery===
===Surgery===
====Vitrectomy====
[[Vitrectomy]] surgically debrides the [[vitreous humor]], similarly to draining an abscess, and is the fastest way of clearing infection in eyes with fulminant endophthalmitis.<ref name="pmid23438028">{{cite journal| author=Durand ML| title=Endophthalmitis. | journal=Clin Microbiol Infect | year= 2013 | volume= 19 | issue= 3 | pages= 227-34 | pmid=23438028 | doi=10.1111/1469-0691.12118 | pmc=3638360 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23438028  }} </ref><ref name="pmid9298055">{{cite journal| author=Barza M, Pavan PR, Doft BH, Wisniewski SR, Wilson LA, Han DP et al.| title=Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. | journal=Arch Ophthalmol | year= 1997 | volume= 115 | issue= 9 | pages= 1142-50 | pmid=9298055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9298055  }} </ref><ref name="pmid7487614">{{cite journal| author=| title=Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. | journal=Arch Ophthalmol | year= 1995 | volume= 113 | issue= 12 | pages= 1479-96 | pmid=7487614 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7487614  }} </ref>
*Vitrectomy is recommended for all patients who develop post cataract endophthalmitis
*A vitrectomy is almost always indicated in all patients with delayed post-operative endophthalmitis
The benefits of vitrectomy include:
*Better vitreous sample
*Rapid and complete sterilization of the vitreous
*Removal of toxic bacterial products
*Enhancement of systemic antimicrobial penetration in to the eye


===Prevention===
===Prevention===
====Primary prevention====
Effective measures for the primary prevention of post-cataract surgery endophthalmitis include:<ref name="pmid18711270">{{cite journal| author=Kelkar A, Kelkar J, Amuaku W, Kelkar U, Shaikh A| title=How to prevent endophthalmitis in cataract surgeries? | journal=Indian J Ophthalmol | year= 2008 | volume= 56 | issue= 5 | pages= 403-7 | pmid=18711270 | doi= | pmc=2636140 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18711270  }} </ref><ref>Isenberg, Sherwin J., et al. "Efficacy of topical povidone-iodine during the first week after ophthalmic surgery." American journal of ophthalmology 124.1 (1997): 31-35.</ref><ref>Classen, David C., et al. "The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection." New England Journal of Medicine 326.5 (1992): 281-286.</ref><ref>Barry, Peter, et al. "ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study." Journal of Cataract & Refractive Surgery 32.3 (2006): 407-410.</ref>
*Proper sterile preparation of the surgical site
*Sterile preparation of the skin surrounding the surgical eye with Povidone-Iodine 10%
*Povidone-Iodine 5% onto the ocular surface (3-5 minutes prior to surgery)
*preoperative antibiotic propylaxis (timing, routs of delivery, and antibiotic choice in not clear)
*Proper construction of wound, injectable intraocular lenses
*Preoperative clinical assessment of the patient before proceeding for surgery
====Secondary prevention====
There are no secondary preventive measures available for post-operative endophthalmiatis. Post-operative endophthalmiatis is a medical emergency.


==References==
==References==
Line 228: Line 276:


[[Category:Ophthalmology]]
[[Category:Ophthalmology]]
[[Category:Infectious disease]]
 




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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

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 post-operative endophthalmitis is not fully understood. It is thought that delayed post-operative 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

Acute Post-operative Endophthalmitis

Post-operative endophthalmitis has been reported following nearly every type of ocular surgery. Common causes of acute post-cataract endophthalmitis include:

Bacterial[1][2]

Fungal[4][5][6]

Delayed Post-operative Endophthalmitis

Common causes of delayed post-operative endophthalmitis include:

Bacterial[1][2]

Fungal[4][7][8][9]

Differentiating Post-cataract Surgery Endophthalmitis from Other Diseases

Acute post-cataract endophthalmitis must be differentiated from:[1][10][11]

Delayed post-cataract endophthalmitis must be differentiated from:[1][9]

  • Uveitis
  • Sterile inflammation
  • Rebound inflammation (related to abrupt discontinuation of steroid drops)
  • Iris or vitreous incarceration in the wound (low-grade inflammation)
  • Uveitis-glaucoma-hyphema syndrome
  • Fungal endophthalmitis

Epidemiology and Demographics

Prevalence and Incidence

  • In 1910, the incidence of post-cataract endophthalmitis was estimated 10,000 cases per 100,000 individuals with cataract surgery.
  • Between 1970 to 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.[12][13]

Age

  • Post-operative endophthalmitis (following cataract surgery) commonly affects patients older than 85 years.[2]

Gender

  • Post-operative endophthalmitis affects men and women equally.[2]

Geographical Distribution

In tropical regions such as India, 10–20% of all cases of acute post-cataract endophthalmitis are caused by fungi.[4]

Developed Country

  • In the United States, post-cataract endophthalmitis is the most common form of bacterial endophthalmitis.
  • In the United States, the incidence of cataract endophthalmitis was estimated to range from 80 to 360 cases per 100,00 individuals with ocular surgery.[14]
  • In the United States and Europe, nearly all cases of acute post-cataract endophthalmitis are caused by bacteria.
  • In the United States, the incidence of culture-proven postoperative endophthalmitis caused by cataract surgery with or without intraocular lens (IOL) was estimated to be 80 cases per 100,000 individuals.
  • In the United States, the incidence of culture-proven postoperative endophthalmitis caused by secondary IOL placement was estimated to be 360 cases per 100,000 individuals.

Risk Factors

Common risk factors in the development of post-catarct endophthalmitis include:[2][15][16][17][18][19]

Screening

Screening for post cataract surgery endophthalmitis is not recommended.[20]

Natural History, Complications, and Prognosis

Natural History

Post-cataract endophthalmitis is a medical emergency. If left untreated, It may lead to panophthalmitis, corneal infiltration, corneal perforation, and ultimately permanent vision loss.

Complications

Common complications of post-catarsct endophthalmitis include:

Prognosis

Early diagnosis and treatment with antimicrobial therapy are fundamental to optimize visual outcome.[2][21] Overall, 50% of eyes with post-cataract endophthalmitis obtain a final visual acuity 20/40 vision, and 10% obtain a final visual acuity of 20/400.[1] The visual outcome of post cataract endophthalmitis is highly correlated with the bacteriology.

  • Post-operative endophthalmitis caused by any type of streptococci is associated with very poor visual outcome.
  • Post-operative endophthalmitis caused by coagulase-negative staphylococcus (cause milder endophthalmitis) is associated with better visual outcome than strepcocci.
  • Delayed post-operative endophthalmitis is associated with particularly good prognosis with treatment.[22]

Diagnosis

Diagnostic Criteria

Endophthalmitis is a clinical diagnosis, supported by culture of intra-ocular fluids.[1][2]

History

A detailed and thorough history from the patient is necessary. Specific areas of focus when obtaining a history from the patient with post-cataract surgery endophthalmitis include:

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 and only of the patients may present with eye pain.

Symptoms of post-cataratc endophthalmitis may include the following:[23][15]

  • Deep pain
  • Decreased vision
  • 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 post-operative endophthalmitis include:[1][2]

Laboratory Findings

Laboratory studies consistent with the diagnosis of post-cataract endophthalmitis include:[1][24][25]

Vitreous cultures are more likely to be positive after vitrectomy than vitreous aspirate (90% vs. 75%), and aqueous cultures are positive in 40% of all cases with endophthalmitis.

Imaging Findings

X Ray

There are no diagnostic x ray findings associated with post-cataract endophthalmitis.

CT

There are no diagnostic CT scan findings associated with post-cataract endophthalmitis.

MRI

There are no diagnostic MRI findings associated with post-cataract endophthalmitis.

Ultrasound

On ocular ultrasonography, endophthalmitis may characterized by anterior vitreous haze echoes and retinochoroidal thickening.[1][2]

Other Imaging Findings

Orbital echography is helpful for assessment of vitreous opacification, status of the posterior hyaloid face, and retinal detachment in a patient with post-operative.[2][26]

Other Diagnostic Studies

Slit lamp finding

Treatment

The patient needs urgent examination by an expert ophthalmologist and/or vitreo-retina specialist who will usually decide for urgent intervention to provide intravitreal injection of potent antibiotics and also prepare for an urgent pars plana vitrectomy as needed. Enucleation may be required to remove a blind and painful eye.[1][24]

  • Bacterial and fungal cultures from vitreous samples are necessary in the management of endophthalmitis
  • In addition to intravitreal antibiotic therapy, immediate vitrectomy is often necessary
  • Repeat antimicrobial regimen in 2 days post-vitrectomy is necessary
  • Systemic antibiotics are not recommended, but may be considered in severe cases, especially with orbital involvement.
  • In delayed post-operative endophthalmitis, treatment should include vitrectomy with posterior capsulectomy and intravitreal injection.

Antimicrobial Regimens

Infectious endophthalmitis[1]

  • 1. Causative pathogens
  • 2. Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note (1): Re-injection should be considered if the infection does not improve beyond 48 hours of the first injection. Re-injection significantly increases the risk of retinal toxicity.
  • Note (2): In addition to intravitreal and systemic antibiotic therapy, vitrectomy is usually necessary
  • Note (3): Intravitreal and intravenous Amphotericin B may be added to the regimen if fungal endophthalmitis is suspected
  • 3. Pathogen-directed antimicrobial therapy
  • 3.1 Bacillus spp.
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks AND Clindamycin 600-1200 mg IV bid to qid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.2 Non-Bacillus gram-positive bacteria
  • Preferred regimen: Vancomycin 1 mg per 0.1 mL normal saline intravitreal injection, single dose AND Vancomycin 1 g IV bid for 2 weeks
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.3 Gram-negative bacteria
  • Preferred regimen: Ceftazidime 2.25 mg per 0.1 mL normal saline intravitreal injection, single dose AND Ceftazidime 1 g IV bid for 2 weeks OR Amikacin 0.4 mg per 0.1 mL normal saline intravitreal injection, single dose
  • Note: Intravitreal amikacin is associated with the development of retinal microvasculitis
  • Note: In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.4 Candida spp.
  • Preferred regimen: (Fluconazole 400-800 mg IV/PO qd for 6-12 weeks OR Voriconazole 400 mg IV/PO bid for 2 doses followed by 200-300 mg IV/PO bid for 6-12 weeks OR Amphotericin B 0.7-1.0 mg/kg IV qd for 6-12 weeks) AND Amphotericin B 5-10 microgram in 0.1 mL in normal saline intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • 3.5 Aspergillus spp.
  • Preferred regimen: Amphotericin B 5-10 microgram in 0.1 mL normal saline intravitreal injection, single dose AND Dexamethasone 400 microgram intravitreal injection, single dose
  • Note (1): In addition to antimicrobial therapy, vitrectomy is usually necessary
  • Note (2): Repeat antimicrobial regimen in 2 days post-vitrectomy

Surgery

Vitrectomy

Vitrectomy surgically debrides the vitreous humor, similarly to draining an abscess, and is the fastest way of clearing infection in eyes with fulminant endophthalmitis.[1][24][29]

  • Vitrectomy is recommended for all patients who develop post cataract endophthalmitis
  • A vitrectomy is almost always indicated in all patients with delayed post-operative endophthalmitis

The benefits of vitrectomy include:

  • Better vitreous sample
  • Rapid and complete sterilization of the vitreous
  • Removal of toxic bacterial products
  • Enhancement of systemic antimicrobial penetration in to the eye

Prevention

Primary prevention

Effective measures for the primary prevention of post-cataract surgery endophthalmitis include:[30][31][32][33]

  • Proper sterile preparation of the surgical site
  • Sterile preparation of the skin surrounding the surgical eye with Povidone-Iodine 10%
  • Povidone-Iodine 5% onto the ocular surface (3-5 minutes prior to surgery)
  • preoperative antibiotic propylaxis (timing, routs of delivery, and antibiotic choice in not clear)
  • Proper construction of wound, injectable intraocular lenses
  • Preoperative clinical assessment of the patient before proceeding for surgery

Secondary prevention

There are no secondary preventive measures available for post-operative endophthalmiatis. Post-operative endophthalmiatis is a medical emergency.

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Kernt M, Kampik A (2010). "Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives". Clin Ophthalmol. 4: 121–35. PMC 2850824. PMID 20390032.
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