Clinical profile, visual outcome and root cause analysis of post-operative cluster endophthalmitis due to Burkholderia cepacia complex

Purpose: To present varied clinical presentations, surveillance reports, and final visual outcomes of a rare outbreak of cluster endophthalmitis caused by gram?negative, opportunistic bacilli, Burkholderia cepacia complex (Bcc). Methods: Details of five patients who developed postoperative cluster endophthalmitis were collected. For each patient, an undiluted vitreous sample was collected during vitreous tap. Bacterial culture from the vitreous sample in each case had grown Bcc. Surveillance investigations for root cause analysis (RCA) were performed in the operating room (OR), admission, and day?care wards to localize the source. Results: Four patients had undergone phacoemulsification surgery, and one patient had undergone penetrating keratoplasty. Each patient received an initial dose of empiric intravitreal ceftazidime and vancomycin. The organism isolated in each case was sensitive to ceftazidime, cotrimoxazole, and meropenem and resistant to other antibiotics. Core vitrectomy was done after 48–60 hours in four patients along with intravitreal imipenem injection. One patient did not provide consent for core vitrectomy and subsequently developed phthisis bulbi. Three patients had subsequent recurrences. Two patients had a final BCVA of 20/60, two had BCVA better than 20/200, while one patient had no perception of light. None of the surveillance samples from the OR complex could isolate Burkholderia. Conclusion: Extensive OR surveillance should be done to identify the potential source of infection. However, the source may not be identifiable in few instances like in our case. Longer follow?up is recommended in cases of Bcc endophthalmitis due to the persistent nature of the infection

Postoperative endophthalmitis due to Pseudomonas luteola: First reported case of acute and virulent presentation from a tertiary eye care center in South India

A 60-year-old male presented with pain and decreased vision 3 weeks following uneventful intracapsular cataract extraction with anterior vitrectomy for subluxated cataract. A diagnosis of acute endophthalmitis was made based on clinical and ultrasound features. Patient improved only after undergoing pars plana vitrectomies twice and repeated intravitreal antibiotic-steroid injections. Vitreous aspirate revealed Gram-negative bacillus identified as Pseudomonas luteola on culture. Patient returned with a retinal detachment at first follow-up which was treated with vitrectomy, endolaser, and silicone oil tamponade. To the best of our knowledge, this is the first case of P. luteola causing acute onset, virulent endophthalmitis reported in literature.

Analysis of Referred 113 Patients with Endophthalmitis after Cataract Surgery and Associated Prognostic Factors

PURPOSE: To evaluate factors affecting final visual acuity by analyzing patients referred with infectious endophthalmitis after cataract surgery. METHODS: A retrospective investigation of clinical notes of 113 patients referred with endophthalmitis following cataract surgery was conducted from January 2008 to December 2013. To evaluate factors affecting final visual acuity, initial visual acuity, onset of endophthalmitis after the cataract surgery, types of treatment, presence of hypopyon and culture results were investigated. RESULTS: Of the 113 patients, visual acuities at presentation were hand motions or less in 75 patients (66.3%) and final visual acuities after treatments were 0.5 or better in 73 patients (64.6%). Cases with initial visual acuity of hand motions or better achieved favorable outcomes whereas cases with gram-negative infection or endophthalmitis occurring within 2 days postoperatively showed poor prognosis. Statistically, vitrectomy versus intraocular antibiotic injection as primary means of treatment showed no differences in final visual acuity in patients with initial visual acuity of hand motion or better. CONCLUSIONS: Visual acuities at presentation, type of cultured organism and onset of endophthalmitis after cataract surgery are significantly related to visual prognosis. Advantages of initial vitrectomy versus intraocular antibiotic injections were unclear and further investigations are necessary to clarify these issues.

A Case of Staphylococcus lugdunensis Endophthalmitis after Cataract Surgery

PURPOSE: To report a case of Staphylococcus lugdunensis endophthalmitis following cataract extraction and intraocular lens implantation. CASE SUMMARY: A 59-year-old woman presented with unilateral vision impairment and eyeball pain in her left eye, thirteen days after phacoemulsification and posterior chamber intraocular lens implantation. Best-corrected visual acuity of her left eye was 20/200. Slit lamp examination of her left eye revealed a severe conjunctival injection, severe chamber reactions with exudative membranes, hypopyon (about 1 mm) in the anterior chamber, and the fundus was not visible. Before the patient was admitted to the hospital, we cultured samples of aqueous fluid and performed an intravitreal antibiotics injection (vancomycin 1.0 mg/0.1 mL, ceftazidime 2.0 mg/0.1 mL). However, on the next day, because the inflammatory reactions of the anterior chamber and vitreous cavity were not improved and Gram positive cocci was confirmed, we performed a pars plana vitrectomy and an additional intravitreal antibiotics injection (vancomycin 1.0 mg/0.1 mL, dexamethasone 0.5 mg/0.1 mL). Seven days after the surgery, Staphylococcus lugdunensis was identified in the aqueous fluids culture. 11 days after the surgery, her inflammation and symptoms were improved and therefore, she could be discharged. Three months after the surgery, best-corrected visual acuity of her left eye was 20/20 and there was no evidence of recurrence of endophthalmitis and no abnormal findings in her fundus.

Pseudomonas aeruginosa endophthalmitis masquerading as chronic uveitis.

A 65-year-old male presented with decreased vision in the left eye of 15-day duration after having undergone an uneventful cataract surgery 10 months back. He had been previously treated with systemic steroids for recurrent uveitis postoperatively on three occasions in the same eye. B-scan ultrasonography showed multiple clumplike echoes suggestive of vitreous inflammation. Aqueous tap revealed Pseudomonas aeruginosa sensitive to ciprofloxacin. The patient was treated with intravitreal ciprofloxacin and vancomycin along with systemic ciprofloxacin with good clinical response. Even a virulent organism such as P.aeruginosa can present as a chronic uveitis, which, if missed, can lead to a delay in accurate diagnosis and appropriate management.

Factors Affecting Final Visual Acuity in Infectious Endophthalmitis Following Cataract Surgery

PURPOSE: To evaluate the factors affecting the clinical outcome and final visual acuity in patients with infectious endophthalmitis following cataract surgery. METHODS: In this study, 35 patients who were diagnosed with endophthalmitis following cataract surgery from 2003 to 2012 were retrospectively analyzed. To evaluate factors affecting final visual acuity, the following were investigated: initial visual acuity, presence of diabetes mellitus, onset of endophthalmitis after the cataract surgery, performance of vitrectomy, duration between diagnosis and vitrectomy, presence of culture and results of bacterial cultures, type of corneal incision, presence of suture on corneal incision, presence of posterior capsule rupture, and surgeon's experience in referred cases. RESULTS: Intravitreal antibiotic injection was given in all 35 cases, and vitrectomy was additionally performed in 30 of the cases. Statistically, none of the initially investigated factors affected final visual acuity. Coagulase-negative staphylococci including staphylococcus epidermidis were the most common organisms isolated during the study period. CONCLUSIONS: No single factor investigated significantly affected the final visual acuity in postoperative endophthalmitis following cataract surgery.

Two Different Cases of Stenotrophomonas Maltophilia Endophthalmitis after Cataract Surgery

PURPOSE: To report 2 different cases of postoperative endophthalmitis caused by Stenotrophomonas maltophilia after cataract surgery. CASE SUMMARY: A 73-year-old male with diabetes mellitus developed severe pain in the right eye 2 weeks after cataract surgery. The patient was hospitalized with a diagnosis of infectious endophthalmitis, and vitrectomy was performed. Cultures of aqueous humor and vitreous aspirate revealed S. maltophilia. On day 30 after vitrectomy, his visual acuity had improved to 20/20 and there were no recurrences. A 61-year-old female with no significant past medical history was referred for uveitis or delayed onset endophthalmitis 30 days after cataract surgery. An anterior chamber tapping and cultures were performed. S. maltophilia and Aspergillus fumigatus were isolated. The patient received antibiotics and antifungal agents and her visual acuity improved to 20/25. CONCLUSIONS: S. maltophilia has been considered a life-threatening systemic opportunistic infection; however, the organism has recently been reported as an exogenous pathogen of endophthalmitis following cataract surgery. Herein, 2 different cases of S. maltophilia endophthalmitis after cataract surgery are presented and compared with previous case reports.

A Randomized, Prospective Clinical Comparison of the Efficacy and Safety of Topical Fluoroquinolone Antibiotics in Ophthalmologic Microsurgery

PURPOSE: To report the results of a clinical comparison study of a prophylactic new generation fluoroquinolone (FQs; levofloxacin 0.5%, gatifloxacin 0.3% and moxifloxacin 0.5%) topical antibiotic regimen administered prior to intraocular microsurgery. METHODS: From May 2007 to April 2010, Trial 1, 214 eyes of 211 patients scheduled for intravitreal injection were randomized into one of three FQ-treated groups or the control (non-treated) group. Patients who were randomized into FQ-treated groups were treated with eye drops containing one of three FQ antibiotics (levofloxacin 0.5%, gatifloxacin 0.3% and moxifloxacin 0.5%) preoperatively four times a day for three days before surgery. The rate of positive bacterial cultures from conjunctival scrapings were assessed and compared. Trial 2, 159 eyes of 159 patients scheduled for cataract surgery were randomized into one of three FQ-treated groups, and treated with eye drops as same method in trial 1. The concentration of antibiotics in the anterior chamber of the eye were measured and compared. RESULTS: The positive bacterial culture rates of trial 1 were 48.9%, 38.3%, 23.4% in the levofloxacin-treated group, the gatifloxacin- group, and the moxifloxacin-treated group, respectively. These rates were all significantly lower than the 70.2% positivity rate observed in the control group. Average antibiotic residue concentrations in the aqueous humor measured in trial 2 were 0.37 +/- 0.49 microg/ml in the levofloxacin-treated group, 0.31 +/- 0.37 microg/ml in the gatifloxacin-treated group and 0.59 +/- 0.72 microg/ml in the moxifloxacin-treated group. These concentrations were not significantly different. There were no reported side effects during the study period. CONCLUSIONS: Eye drops containing new generation FQ antibiotics instilled three days before microscopic ophthalmic surgery can be used safely and effectively for the prevention of postoperative endophthalmitis.

The Clinical Outcomes of 23-Gauge Transconjunctival Sutureless Vitrectomy for Endophthalmitis after Cataract Surgery

PURPOSE: To report the clinical outcomes and utility of 23-gauge (G) transconjunctival sutureless vitrectomy (TSV) in patients with postoperative endophthalmitis following cataract surgery. METHODS: The medical records of 16 patients (17 eyes) who underwent 23-G TSV between January 2008 and December 2009 at Konyang University Hospital due to postoperative endophthalmitis following cataract surgery were retrospectively analyzed. The pre- and post-operative best-corrected visual acuities (BCVA), changes in intraocular pressure, the time from diagnosis to surgery, the intraoperative and postoperative complications, and the average duration of hospitalization were investigated. RESULTS: The mean BCVA significantly improved from log MAR 1.89 +/- 1.03 to log MAR 0.42 +/- 0.82 (p = 0.001), and the mean intraocular pressure changed from 16.1 +/- 4.1 mm Hg at baseline to 16.2 +/- 3.3 mm Hg on the first postoperative day without any significant difference (p = 0.955). In addition, none of the patients required sutures to treat wound leakage or showed hypotony on follow-up observation. The average operation time was 64.7 +/- 22.5 minutes, and the average duration of hospitalization was 5.4 +/- 4.5 days. CONCLUSIONS: The use of 23-G TSV in patients with postoperative endophthalmitis following cataract surgery may offer more convenience for the surgeon and more comfort for the patient. In addition, the patient may return to normal life earlier with a shortened duration of hospitalization.

Postoperative Endophthalmitis Following Cataract Surgery Over an Eight-Year Period

PURPOSE: To estimate the annual incidence rate, evaluate any changes, analyze the microbiologic spectrum of infecting organisms, antibiotic susceptibility, and factors associated with visual outcomes of postoperative endophthalmitis following cataract surgery over an 8-year period. METHODS: A retrospective investigation of direction, sex, age, culture results, interval duration, and initial visual acuity of 29 patients with endophthalmitis following cataract surgery was conducted from January 2000 to December 2007. The study was divided into two 4-year periods, with patients categorized into either Group 1 or 2. RESULTS: The incidence rate was 0.359%, the major infective organism was Staphylococcus epidermidis, and no significant change was observed during the 8-year period. Vancomycin retained efficacy in all cases, but increased resistance occurred with ciprofloxacin during the 8 years. Increased visual acuity after treatment was greater in Group 2 and the interval from onset of ocular symptoms to ophthalmic consultation was shorter in Group 2, although a statistical significance was not demonstrated. CONCLUSIONS: Vancomycin remains effective for patients with endophthalmitis following cataract surgery. Patients who initially had good visual acuity showed greater improvement. However, sex, age, or whether or not the patients had a vitrectomy operation, were not statistically significant factors in the improvement of visual acuity.

A Case of Postoperative Sphingomonas paucimobilis Endophthalmitis After Cataract Extraction

PURPOSE: To report a case of an acute onset of delayed postoperative endophthalmitis that was caused by Sphingomonas paucimobilis. METHODS: This case demonstrates an acute onset of delayed postoperative endophthalmitis at 3 months after uneventful cataract extraction and posterior chamber intraocular lens implantation. We performed vitrectomy, intraocular lens and capsular bag removal, and intravitreal antibiotics injection. On the smear stains from the aspirated vitreous humor, gram-negative bacilli were detected and S. paucimobilis was found in culture. RESULTS: At three months after vitrectomy, the best corrected visual acuity was 20/300. Fundus examination showed mild pale color of optic disc and macular degeneration. CONCLUSIONS: Vitrectomy with intravitreal ceftazidime injection had contributed to the favorable result in case of an acute onset of delayed postoperatire endophthalmitis caused by S. paucimobilis.

A Case of Postoperative Sphingomonas paucimobilis Endophthalmitis After Cataract Extraction

PURPOSE: To report a case of an acute onset of delayed postoperative endophthalmitis that was caused by Sphingomonas paucimobilis. METHODS: This case demonstrates an acute onset of delayed postoperative endophthalmitis at 3 months after uneventful cataract extraction and posterior chamber intraocular lens implantation. We performed vitrectomy, intraocular lens and capsular bag removal, and intravitreal antibiotics injection. On the smear stains from the aspirated vitreous humor, gram-negative bacilli were detected and S. paucimobilis was found in culture. RESULTS: At three months after vitrectomy, the best corrected visual acuity was 20/300. Fundus examination showed mild pale color of optic disc and macular degeneration. CONCLUSIONS: Vitrectomy with intravitreal ceftazidime injection had contributed to the favorable result in case of an acute onset of delayed postoperatire endophthalmitis caused by S. paucimobilis.

Factors Associated with Visual Outcomes of Postoperative Endophthalmitis Following Cataract Surgery

PURPOSE: The most serious complication related to cataract surgery is endophthalmitis. Although its incidence is decreasing, it remains the great threat to the outcome of visual acuity in patients who received cataract surgery. METHODS: Retrospective analysis was performed on 18 patients who were diagnosed with endophthalmitis. The following factors were investigated: method of cataract extraction, performance of anterior vitrectomy, presence of posterior capsule rupture, results of bacterial culture, existence of systemic disease, and the duration of time from initial cataract surgery to diagnosis of endophthalmitis and then to subsequent posterior vitrectomy. In addition, the differences in final visual acuity due to variations in these factors were analyzed. RESULTS: Patients who were diagnosed with endophthalmitis and had been commenced on systemic antibiotics within a week of the cataract operation, showed better outcomes in final visual acuity (P=0.043). CONCLUSION: Occurrence of endophthalmitis and subsequent usage of systemic antibiotics within a one-week time frame of cataract surgery, led to statistically significant improvement in final visual acuity compared to cases in which these events occurred one week later.

Factors Associated with Visual Outcomes of Postoperative Endophthalmitis Following Cataract Surgery

PURPOSE: The most serious complication related to cataract surgery is endophthalmitis. Although its incidence is decreasing, it remains the great threat to the outcome of visual acuity in patients who received cataract surgery. METHODS: Retrospective analysis was performed on 18 patients who were diagnosed with endophthalmitis. The following factors were investigated: method of cataract extraction, performance of anterior vitrectomy, presence of posterior capsule rupture, results of bacterial culture, existence of systemic disease, and the duration of time from initial cataract surgery to diagnosis of endophthalmitis and then to subsequent posterior vitrectomy. In addition, the differences in final visual acuity due to variations in these factors were analyzed. RESULTS: Patients who were diagnosed with endophthalmitis and had been commenced on systemic antibiotics within a week of the cataract operation, showed better outcomes in final visual acuity (P=0.043). CONCLUSION: Occurrence of endophthalmitis and subsequent usage of systemic antibiotics within a one-week time frame of cataract surgery, led to statistically significant improvement in final visual acuity compared to cases in which these events occurred one week later.

Bacterial Adherence to Intraocular Lenses

Bacterial adherence to intraocular lenses (IOLs)could be the cause of the endophthalmitis following cataract surgery and IOL implantation. In this study we investigated bacterial adherences to the four different IOLs. Clinical strains of Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa were used.Polymethylmethacrylate (PMMA), silicone, hydrophilic acrylate (Acrysof)and hydrogel IOLs were used in this study.Four types of lenses were suspended for 60 minutes in suspensions of each strain of bacteria and then these lenses were washed with sterile broth to remove the nonadherent bacteria.The adherent bacteria were removed from the lenses, diluted with sterile broth and inoculated onto the blood and chocolate agar plates.The plates were incubated for 24 hours, and the numbers of colony forming units were counted. The lenses with the adherence of S.aureus in order of decreasing magnitude were: Acrysof>silicone>hydrogel>PMMA; the adherence of S.epider-midis, silicone>Acrysof>PMMA>hydrogel;the adherence of P.aeruginosa, Acrysof>silicone>PMMA>hydrogel. The bacterial adherence was significantly lower in the hydrophilic IOL.This result suggests that the risk of postoperative endophthalmitis after cataract extraction and IOL implantation may be reduced with the use of hydrophilic IOL.