The ocular surface bacterial contamination and its management in the prophylaxis of post cataract surgery endophthalmitis.

Objective: To investigate the recent pieces of evidence regarding the bacterial ocular surface contamination and its treatment in the prophylaxis of post-cataract surgery endophthalmitis. Methods: We conducted a literature research on the topic of interest and selected the most relevant data. Results: The studies reported a relatively high rate of positive conjunctival culture and the most frequently isolated organism was Coagulase negative Staphylococcus, which is also the most common etiological agent of the postoperative endophthalmitis. The bacterial ocular surface load is influenced by age, climate, associated diseases, topical and systemic medication. The use of povidone-iodine alone or in association with levofloxacin eyedrops as prophylactic method is effective in reducing the conjunctival bacterial contamination and consequently decreases the incidence of postoperative endophthalmitis. Conclusions: Based on the current pieces of evidence, adequate treatment of the bacterial ocular surface contamination prior to cataract surgery seems to be effective in preventing endophthalmitis after cataract surgery. Abbreviations: EU = European Union, Spp. = Species, HIV = Human Immunodeficiency Virus.

Pantoe Agglomerans Endophthalmitis after Phaco Surgery: The First Case in Literature.

Purpose: The aim of this study was to report endophthalmitis caused by pantoe agglomerans after phacoemulsification surgery for the first time in English literature.Material-method: A 44-year-old male patient was referred to Yeniyuzyil University Gaziosmanpasa Hospital because of sudden painful vision loss in his right eye.Result: Pantoea agglomerans was identified in the culture of humor from the anterior chamber and vitreous. Based on the antibiotic susceptibility test, P.Agglomerans species culture was sensitive to ciprofloxacin.Conclusion: This is the first reported case of endophthalmitis after cataract surgery.

Contaminación bacteriana de cámara anterior durante la cirugía de catarata / Anterior chamber bacterial contamination during cataract surgery

RESUMEN Objetivo: Determinar la existencia de contaminación bacteriana en cámara anterior durante la cirugía de catarata. Métodos: Se realizó un estudio transversal de serie de casos, en el cual participaron los pacientes sometidos a cirugía de catarata en el Servicio de Microcirugía Ocular del Instituto Cubano de Oftalmología Ramón Pando Ferrer, en el período comprendido de enero del año 2015 a diciembre 2016. Se relacionaron los antecedentes patológicos personales oculares y sistémicos, los factores de riesgo asociados y las complicaciones transoperatorias con la presencia de bacterias en la cámara anterior al final de la cirugía. Los pacientes fueron seleccionados aleatoriamente en el salón de cirugía. La muestra quedó constituida por 200 pacientes y divididos en tres grupos dependiendo de la experiencia de los cirujanos. Resultados: Al inicio del proceder quirúrgico, el 100 por ciento de los cultivos fueron negativos, mientras que al final de la cirugía se detectó crecimiento bacteriano en el 3 por ciento. Los gérmenes Gram positivos fueron los de mayor frecuencia (66,6 por ciento) donde el Staphylococcus epidermidis se aisló en un 50 por ciento de los casos. No existió relación significativa entre antecedentes patológicos personales oculares, sistémicos y los factores de riesgo asociados. La ruptura de la cápsula posterior fue la complicación transoperatoria más frecuente y al 4,7 por ciento se le detectó crecimiento bacteriano. Conclusión: Se detecta una baja frecuencia de contaminación de la cámara anterior al final de la cirugía de catarata y los gérmenes comúnmente encontrados están relacionados con la microbiota de la superficie ocular(AU)

ABSTRACT Objective: Determine the presence of anterior chamber bacterial contamination during cataract surgery. Methods: A cross-sectional case-series study was conducted of patients undergoing cataract surgery at the Ocular Microsurgery Service of Ramón Pando Ferrer Cuban Institute of Ophthalmology from January 2015 to December 2016. Personal ocular and systemic pathological antecedents, associated risk factors and perioperative complications, were related to the presence of anterior chamber bacterial contamination at the end of surgery. Patients were randomly selected in the operating room. The sample was composed of 200 patients, who were divided into three groups according to the surgeons' experience. Results: At the start of the surgical procedure, 100 percent of the cultures were negative, whereas at the end 3 percent bacterial growth was detected. Gram-positive germs were the most common (66.6 percent), with Staphylococcus epidermidis isolated in 50 percent of the cases. No significant relationship was found between personal ocular or systemic pathological antecedents and associated risk factors. Posterior capsule rupture was the most frequent intraoperative complication, with 4.7 percent bacterial growth detected. Conclusion: Low frequency of anterior chamber contamination was detected at the end of cataract surgery, and the germs commonly found are related to the ocular surface microbiota(AU)

Diagnosis, Clinical Presentations, and Outcomes of Nocardia Endophthalmitis.

PURPOSE: To describe the clinical presentations, diagnosis, and management outcomes of Nocardia endophthalmitis. DESIGN: Retrospective, interventional, multicenter case series. METHODS: The study was conducted in a multicentric institutional practice setup and included 25 eyes of 25 patients with culture-proven Nocardia endophthalmitis. Anterior chamber fluid and/or vitreous and/or intraocular lens were submitted for microbiological evaluation in all cases. Patients with non-Nocardia etiology and those that were culture negative were excluded. Case records were studied and data regarding demography, clinical presentations, interventions received, and final visual and anatomic outcomes were noted. The main outcome measures were final visual outcomes and factors determining them. RESULTS: The mean age of the patients was 54.7 ± 22.9 years. By the etiology of infection, 18 (75%) eyes were post-cataract surgery (operated elsewhere), 3 (12.5%) eyes were posttrauma, and 3 (12.5%) eyes were endogenous. The final follow-up was a mean of 14.25 ± 30.35 months, median 2 months. The odds of a favorable outcome were 42.5 (95% confidence interval [CI] 3.15 to 571.84, P = .0047) when the vision was more than hand motions at presentation, 9.42 (95% CI 0.92 to 95.89, P = .05) in male sex, 21 (95% CI 0.9 to 489.7, P = .05) when presentation was within 48 hours, and 2.5 (95% CI 0.23 to 26.48, P = .44) with primary vitrectomy instead of a biopsy. The in vitro susceptibility was poor for vancomycin and was best for amikacin. CONCLUSIONS: The visual outcome in Nocardia endophthalmitis is very guarded when presenting vision is poor. On diagnostic confirmation or high index of suspicion, intravitreal amikacin is preferred.

Klebsiella endophthalmitis as the herald of occult colorectal cancer.

A 67-year-old Chinese man presented with acute loss of vision and pain in the left eye with hypopyon in the anterior chamber. The patient was afebrile with no systemic symptoms at presentation. Diagnosis of endogenous endophthalmitis was made with vitreous tap yielding Klebsiella pneumoniae Pars plana vitrectomy was performed twice to clear the infection. Thorough investigations showed no septic foci. Whole body positron emission tomography CT revealed a rectal tumour and biopsy showed adenocarcinoma. He was treated with neoadjuvant chemoirradiation followed by surgery to resect the tumour. Vision in the left eye was hand movement at 12 months postoperatively. This case illustrates Klebsiella endogenous endophthalmitis might be a herald of occult colorectal cancer. Bacteria might gain access into bloodstream via mucosal defect in the tumour.

Molecular characterization and potential sources of aqueous humor bacterial contamination during phacoemulsification with intraocular lens implantation in dogs.

Bacterial contamination of the anterior chamber during cataract surgery is one of the main responsible for endophthalmitis postoperative. Phacoemulsification is a less invasive technique for cataract treatment, although it does not exclude the possibility of contamination. In this study, bacterial contaminants of aqueous humor collected pre- and post-phacoemulsification with intraocular lens implantation (IOL) of twenty dogs were identified. As the conjunctival microbiota constitute a significant source of anterior chamber contamination, bacterial isolates from aqueous humor were genetically compared with those present in the conjunctival surface of the patients. Three dogs presented bacterial growth in both aqueous humor and conjunctival surface samples. Bacterial isolates from these samples were grouped according to their genetic profiles by repetitive-element PCR (rep-PCR) and their representatives were identified by 16S rRNA sequencing. Isolates from conjunctival surface were identified as Enterobacter spp., Staphylococcus spp. and S. aureus; and from aqueous humor samples as Enterobacter spp., Pantoea spp., Streptococcus spp. and Staphylococcus spp., respectively in decreasing order of prevalence. According to the rep-PCR analysis, 16.6% of Enterobacter spp. isolates from conjunctival surface were genetically similar to those from aqueous humor. The rest of isolates encountered in aqueous humor were genetically distinct from those of conjunctival surface. The significant genetic diversity of bacterial isolates found in the aqueous humor samples after surgery denoted the possibility of anterior chamber contamination during phacoemulsification by bacteria not only from conjunctival surface but also from different sources related to surgical environment.

Extreme Surgical Maneuvers in Fungal Endophthalmitis.

PURPOSE: To present the different evolution of 2 cases of endophthalmitis caused by Fusarium solani, an aggressive filamentous fungus, depending on the medical and surgical treatment performed. METHODS: We present 2 cases of endophthalmitis caused by Fusarium solani. Topical, intrastromal, intravitreal, and systemic antifungal treatment (natamycin, voriconazole, amphotericin B) failed in both cases. Corneal perforation took place in one of them, being unsuccessfully treated with cyanoacrylate and several amniotic membrane transplants. It became necessary to perform a hot penetrating keratoplasty (PK) in both patients. The lenses were removed, and the microbiological analysis showed their colonization by Fusarium solani. In one of the cases, a second PK and a more aggressive pars plana vitrectomy (PPV) were performed after corneal recurrence detected by confocal microscopy, as well as the following therapeutic intra- and postoperative maneuvers: anterior chamber washing with povidone-iodine 5% for 1 min; iridectomy of the infiltrated regions; aspiration of the fungal colonies with vitrector; several air/fluid/amphotericin/voriconazole exchanges during PPV; endodiathermy and endophotocoagulation of the chorioretinitis foci; and intrascleral angle injections of voriconazole and amphotericin. RESULTS: These were the only cases of endophthalmitis caused by Fusarium attended to at our hospital during the last 10 years. In the case in which PPV was performed without those maneuvers, endophthalmitis rapidly recurred in a more aggressive way, so finally it became necessary to eviscerate the globe. On the other hand, in the patient who underwent PPV with the specific surgical maneuvers and postoperative procedures described above, we could preserve the eye and even a vision of hand motion without an intraocular lens. CONCLUSIONS: The main objectives of these surgical procedures are to control the fungal infection and to preserve the ocular globe. It is essential to eliminate all ocular structures (iris, lens, vitreous, etc.) affected by this strain of fungus in order to reduce the risk of recurrence. When indicated, early surgery with the appropriate maneuvers detailed above may make an evisceration unnecessary and even recover some visual acuity.

Reduced anterior chamber contamination by frequent surface irrigation with diluted iodine solutions during cataract surgery.

PURPOSE: To verify that ocular surface irrigation with 0.025% povidone-iodine (PI) or 0.0025% polyvinyl alcohol-iodine (PAI) during cataract surgery minimizes bacterial contamination of the anterior chamber. METHODS: The study was a prospective, interventional case series. First, the bactericidal effect of PI or PAI against Staphylococcus aureus was evaluated in vitro. Next, in 400 eyes undergoing cataract surgery, the ocular surface was irrigated every 20 seconds during surgery with balanced salt solution (BSS; 200 eyes) or BSS containing 0.025% PI (100 eyes) or 0.0025% PAI (100 eyes). At the completion of surgery, anterior chamber fluid was cultured bacteriologically. Visual acuity (VA) and corneal endothelial cell density were measured before and 7 days after surgery. RESULTS: A marked bactericidal effect was observed when S. aureus was directly exposed for 15 seconds to 0.01% PI or 0.001% PAI diluted in BSS. When the two solutions were stored at room temperature, bactericidal effect did not attenuate after 60 min. The bacterial detection rate at the completion of surgery was significantly reduced in 0.025% PI (0%, 0/100 eyes) or 0.0025% PAI group (0%, 0/100 eyes) compared to BSS group (5%, 10/200 eyes) (p = 0.0340). No differences in postoperative visual acuity and postoperative corneal endothelial cell density were observed between three groups. CONCLUSION: In cataract surgery, irrigation every 20 seconds of the operative field with 0.025% PI or 0.0025% PAI, both of which contain 0.0025% available iodine concentration, achieved a very low bacterial contamination rate in the anterior chamber.

Perioperative Antibiotics to Prevent Acute Endophthalmitis after Ophthalmic Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Post-operative endophthalmitis is a rare and dreaded complication in ophthalmic operations because it often induces irreparable vision loss. Although many ophthalmological studies aimed at reducing the rate of endophthalmitis have been performed around the world, controversy continues to surround some issues, including the choice of antimicrobials and their route of administration, duration and timing. The aim of this study is to investigate some of these unresolved issues. METHODS: A systematic review and meta-analysis of randomized controlled trials and observational studies was performed. The PubMed, EMBASE, Cochrane Library and Clinical Trials databases were searched to identify studies published until Feb. 2016. The relative risk (RR) for each clinical outcome data is presented with 95% confidence intervals (CIs). Pooled estimates of effects were calculated using random-effect models. RESULTS: Thirty-four studies from twenty-four reports involving 1264797 eyes were included in this analysis. Endophthalmitis occurred, on average, in one out of 6177 eyes when intracameral vancomycin/moxifloxacin were used and in one out of 1517 eyes when intracameral vancomycin/moxifloxacin were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.20 (0.10, 0.42) when intracameral antibiotics were used (p<0.0001). The subconjunctival injection of antibiotics was not superior to other administration routes included in this study (RR = 1.67, 95% CI (0.55, 5.05), p = 0.36). A statistically significant difference was found in the rate of endophthalmitis between the use and lack of use of topical antibiotics (RR = 0.65, 95% CI (0.43, 0.99), p = 0.04). However, no statistically significant difference was found in microbial isolation rates between these groups (RR = 0.77, 95% CI (0.34, 1.75), p = 0.53). When long-term and short-term use of topical antibiotics before surgery were compared, a statistically significant difference was found in microbial isolation rates (RR = 0.57, 95% CI (0.44, 0.74), p<0.0001). CONCLUSIONS: This meta-analysis concluded intracameral antibiotics are effective at preventing endophthalmitis in ocular surgery. A randomized controlled trial confirms the efficacy of cefuroxime but recent large cohort studies support the efficacy of vancomycin/moxifloxacin intracamerally. Intracameral antibitoics are superior to subconjunctival injections but that irrigation antibitoic data are not of enough quality to make a comparison. Different results were found in two clinical outcomes between the use or lack of use of topical antibiotic therapy, we did not find sufficient evidence to conclude that its use prevents endophthalmitis.

Conjunctival and intraocular swabs for the microbiological assessment of donor corneas.

PURPOSE: In this study, we investigated the associations between conjunctival (co) and intraocular (io) swabs and their implications for the contamination rates of organ-cultured corneas. METHODS: A total of 4177 swabs from 1054 corneas of 527 donors were acquired from the conjunctiva, after disinfection with 5% polyvinylpyrrolidone-iodine solution, and also from the anterior chamber after corneoscleral trepanation (io). Samples were incubated at 22.5 ± 2.5°C and 32.5 ± 2.5°C in thioglycollate broth for 14 days. Donor corneas were cultured in a closed system at 31°C. Microbial differentiation was performed for positive cultures. RESULTS: A higher temperature (32.5°C) and the intraocular swab retrieving localization led to significantly higher swab positive rates (32.5°C versus 22.5°C, odds 1.65, p < 0.0001; io versus co, odds 1,53, p < 0.0001). Death-to-collection time and laterality (left or right eye) had no significant influence on swab positivity. The cause of death significantly influenced the positive rates (p < 0.0001). Detection at 32.5°C occurred significantly earlier than at 22.5°C (p < 0.0001). The overall comparison of detected species showed no significant differences in the variety between intraocular and conjunctival swabs. During the study period, six contaminations of organ-cultured corneas occurred: four times Pseudomonas aeruginosa and once each Candida albicans and Staphylococcus hominis were found. Swap results and cornea contaminations were not significantly correlated. CONCLUSIONS: Co and io swabs show high microbial colonization rates, even after standard disinfection. Io swabs generally reproduce the co microbial range, most likely due to a mobilization and diversion of microorganisms during the trepanation procedure. Swab results do not yield a valuable tool to predict contaminations of organ-cultured corneas.

Anterior chamber paracentesis to improve diagnosis and treatment of infectious uveitis in South Africa.

Infectious uveitis is a significant cause of blindness in South Africa, especially among HIV-infected individuals. The visual outcome of uveitis depends on early clinical and laboratory diagnosis to guide therapeutic intervention. Analyses of aqueous humor, obtained by anterior chamber paracentesis, directs the differential diagnosis in infectious uveitis. However, although safe and potentially cost-effective, diagnostic anterior chamber paracentesis is not common practice in ophthalmic care across Africa. We seek to draw attention to this important procedure that could improve the diagnosis and prognosis of infectious uveitis.

Anterior chamber bacterial contamination in cataract surgery.

BACKGROUND: The incidence of postoperative endophthalmitis has reduced during last several years to <0.01%; however, its associated complications continue to be devastating. Several sources of infection, including contamination by air, solutions, surgical instruments, intraocular lens, and wound leakage have been identified. The objective of this study was to evaluate the surgical technique, antibiotics, and asepsis that are used to reduce the risk of infection during cataract surgery. METHODS: This was a transversal prospective study, in which 64 cataract surgeries were evaluated from 32 patients, with 1 month recovery time; and cultures from preoperative and postoperative aspirates were analyzed. Two groups were established based on whether preoperative antibiotics were given or not. The analysis employed descriptive statistics. RESULTS: Of the 32 patients whose aspirates were obtained, three (9.37%) and 10 (31.25%) yielded positive cultures preoperative and postoperatively respectively. Staphylococcus species was the most common contaminating bacteria. The isolation of Staphylococcus species may indicate its potential as exogenous contaminant at time of wound closure. The cultures obtained from patients using preoperative antibiotics were positive for S. aureus in 10% (n = 2) of cases, and positive in 8.33% (n = 1) of cases not using antibiotics. The mean transoperative time with positive growth was 67 ± 17.8 minutes, and with negative growth was 76.3 ± 25.2 minutes. Two surgical techniques were evaluated: phacoemulsification and extracapsular extraction. The extracapsular technique showed a contamination rate of 33.33% (n = 8) compared to phacoemulsification with a rate of 25% (n = 2) (RR = 1.33). CONCLUSIONS: Common contaminating microorganisms included the Staphylococcus species, which was isolated from the eyelids and ocular annexes at the time of wound closure. The isolation of microorganisms postoperatively could have been influenced by the surgical technique used, the surgical time, and the use of antibiotics.

Endophthalmitis caused by Klebsiella species.

PURPOSE: To report the clinical presentation, antibiotic sensitivities, treatment strategies, and visual outcomes associated with endophthalmitis caused by Klebsiella species. METHODS: A noncomparative consecutive case series. Microbiology database records were retrospectively reviewed for all patients with endophthalmitis caused by Klebsiella species from 1990 to 2012 at a large university referral center. The corresponding clinical records were then reviewed to evaluate the endophthalmitis clinical features and treatment outcomes. RESULTS: Seven patients were identified. Clinical settings included endogenous (n = 3), posttraumatic (n = 2), trabeculectomy bleb-associated (n = 1), and postpenetrating keratoplasty (n = 1). Five patients presented with hypopyon. Presenting visual acuity ranged from 20/60 to light perception in nonendogenous cases and 1/200 to light perception in endogenous cases. Klebsiella was sensitive to aminoglycosides, third-generation cephalosporins, and second- and third-generation fluoroquinolones in all cases. Initial treatment strategies were vitreous tap and injection (n = 4), pars plana vitrectomy with intravitreal antibiotics (n = 2), and anterior chamber tap and injection (n = 1). All three endogenous cases later underwent enucleation or evisceration. In nonendogenous cases, the final visual acuity was 20/70 or better in all 4 patients. CONCLUSION: Endophthalmitis caused by Klebsiella species is associated with poor visual outcomes. Endogenous cases had high rates of enucleation or evisceration.

Candida pelliculosa endophthalmitis after cataract surgery: a case report.

BACKGROUND: Here we report the first case of postoperative endophthalmitis due to Candida pelliculosa after cataract surgery. We describe the clinical management of this type of candida infection in the eye. CASE PRESENTATION: A 57-year-old Turk man was seen at our clinic at the end of the first postoperative month after cataract surgery. He presented with eye redness, pain and decreased visual acuity. His ophthalmologic examination revealed moderate tyndall and a mild flare in the anterior chamber. Hypopyon in the capsular bag posterior to the intraocular lens was seen in the second postoperative month. Despite topical and subconjunctival bacterial endophthalmitis treatment, there was no improvement in the clinical situation. Candida pelliculosa was isolated from a sample culture obtained from the anterior chamber. Oral fluconazole could not be administered because of increased liver enzyme levels and intravenous amphotericin B could not be administered because of an allergic reaction. Intraocular lens explantation, pars plana vitrectomy and anterior chamber lavage by rupturing the posterior wall of the microabscesses were performed. Intravitreal and intracameral amphotericin B injections were given four times in addition to surgical interventions. The patient has been followed for 2 years and his best-corrected visual acuity was 0.4 at the last visit. CONCLUSION: Nearly 1 month after cataract surgery, a patient presented with eye redness and blurred vision, with corneal endothelial deposits, hypopyon in the capsular bag and microabscesses on the incision sites and corneal endothelium. Candida pelliculosa should be considered in patients showing these symptoms. Multiple intraocular amphotericin B (5 µg) administrations can be used safely even in cases with high sensitivity to systemic use. Rupturing the posterior wall of the abscesses on the corneal endothelium surgically with intraocular lens explantation and pars plana vitrectomy are recommended.