Clinical presentations and comparative outcomes of primary versus deferred intraocular lens explantation in delayed-onset endophthalmitis.

Purpose: To describe clinical presentations and comparative outcomes of primary versus deferred intraocular lens (IOL) explantation in delayed-onset endophthalmitis. Methods: In this retrospective study, a total of 77 eyes of 77 patients that were diagnosed clinically as delayed-onset endophthalmitis and underwent IOL explantation from January 1990 to January 2018 were included undiluted vitreous biopsy and IOL were subjected to microbiologic evaluation. Duration of symptoms, presenting visual acuity, organisms isolated, time to IOL explantation, time to endophthalmitis, resolution after explantation, number of repeat intravitreal injections, and final visual acuity were compared in the primary and the deferred IOL explantation groups. Results: There were primary and deferred IOL explantations. Interval between inciting event and endophthalmitis, between onset of symptoms to presentation, total follow-up, complication rate, and final visual acuity was comparable between the two groups. Median time to IOL explantation in the deferred group was 70 days. Between the primary and deferred IOL explantation groups the number of repeat intravitreal injections was 0.58 ± 0.86 and 2.62 ± 1.78 respectively, (P < 0.0001, 95% confidence interval, CI 2.00-2.22); the number of days to resolution after IOL explantation was 35.16 ± 14.26 and 55.5 ± 8.24 respectively, (P < 0.0001, 95% CI 15.22-25.45). Conclusion: Early IOL explantation in delayed-onset endophthalmitis causes faster clinical resolution and reduces the number of repeat intravitreal injections. Final visual improvement, however, may be unaffected.

Analysis of Intraocular Lens Biofilms and Fluids After Long-Term Uncomplicated Cataract Surgery.

PURPOSE: Postoperative endophthalmitis is a potentially sight-threatening complication of cataract surgery. However, the pathophysiological mechanisms are not completely understood. We sought to study and evaluate the intraocular environment (aqueous and vitreous humors), the capsular tissue, and the intraocular lens (IOL) surfaces of normal eyes after long-term uncomplicated cataract surgery. DESIGN: Experimental laboratory investigation. METHODS: We studied 69 eyes donated for transplantation that had previously undergone cataract surgery with posterior chamber IOL implantation and that had no recorded clinical history of postoperative inflammation. We assessed the intraocular environment (DNA traces and biofilm formation) by microbiological evaluation of intraocular fluids using conventional microbiology and molecular techniques, including assessment for the presence of microbes (biofilm formation) on the IOL surface by scanning electron microscopy and ultrastructural capsular remnants by transmission electron microscopy. RESULTS: Isolated or aggregated cocci were probable in 18.8% of IOL optic surfaces (n = 13) studied by scanning electron microscopy, suggesting the presence of bacterial biofilm. In 3 intraocular fluid samples for IOLs with biofilm, we identified 16S rDNA by polymerase chain reaction and sequencing. No microbial contamination was found in intraocular fluids by conventional microbiological methods. CONCLUSIONS: Our data suggest the possibility of bacterial biofilm formation on the optic surface of IOLs in normal eyes after long-term uncomplicated cataract surgery even in the absence of clinical or subclinical symptoms.

Moxifloxacin superior to cefuroxime in reducing bacterial adhesion of Staphylococcus epidermidis on hydrophobic intraocular lenses.

PURPOSE: To compare the anti-adhesive effect of cefuroxime and moxifloxacin on the primary attachment phase of Staphylococcus epidermidis on hydrophobic acrylic intraocular lenses (IOLs). METHODS: Forty hydrophobic acrylic IOLs were used. Two groups of IOLs were soaked in a moxifloxacin (Mox-T1: 0.5 mg/0.1 ml) or a cefuroxime (Cef-T1: cefuroxime 1 mg/0.1 ml) solution before incubation in a S. epidermidis bacterial suspension. Two other groups were incubated in the bacterial suspension before antibiotics (Cef-T2 and Mox-T2) were added. The control group (Ctrl) consisted of IOLs incubated in the bacterial suspension. After incubation, IOLs were sonicated and vortexed. The resultant suspension was spread over a nutritive agar plate. Bacterial colonies were counted after 24 hr of incubation. RESULTS: Mean number of colony-forming units per IOL was Cef-T1: 184 × 10(3) (SE: 5.24; SD: 28.21), Cef-T2: 117 × 10(3) (SE: 5.74; SD: 30.37), Mox-T1: 1.27 × 10(3) (SE: 0.12; SD: 0.61), Mox-T2: 25 × 10(3) (SE:1.98; SD: 9.72) and Ctrl: 361 × 10(3) (SE: 26.9; SD: 107.6). The number of adhering bacteria did not vary whether cefuroxime was added before or after IOL incubation in the bacterial suspension (p = 0.132). Moxifloxacin was more effective in reducing the number of adhering bacteria when used before IOL incubation (p < 0.001). Overall for T1 and T2, moxifloxacin was more effective than cefuroxime in reducing bacterial adhesion on IOLs (p < 0.001). CONCLUSION: Moxifloxacin and cefuroxime significantly reduced S. epidermidis adhesion on hydrophobic acrylic IOLs. The anti-adhesive effect was superior with moxifloxacin.

In vitro biofilm distribution on the intraocular lens surface of different biomaterials.

PURPOSE: To study the disposition of bacterial adhesion to intraocular lens (IOL) biomaterials depending on the material and region of the optic IOL surface: center or peripheral edge. SETTING: School of Medicine, University of Barcelona, Barcelona, Spain. DESIGN: Experimental study. METHODS: For the in vivo study, IOLs were explanted from donor ocular globes without clinical symptoms of endophthalmitis. Biofilm formation was qualitatively studied by scanning electron microscopy (SEM). For the in vitro study, 5 IOL biomaterials (hydrophilic acrylic, hydrophobic acrylic, poly[methyl methacrylate] [PMMA], heparinized PMMA, and silicone) were contaminated with a biofilm-producing strain of Staphylococcus epidermidis. Bacterial densities were quantitatively (colony-forming units per area) compared by SEM and direct counting of viable adherent bacteria, according to the biomaterial, region of the IOL optic surface, and time of incubation. For SEM, bacterial adhesion was also qualitatively classified according to the characteristics of biofilm observed: structure, cocci per cluster, homogeneity of cluster distribution, and extracellular matrix production. RESULTS: At 3 hours of incubation, bacterial counts for hydrophilic acrylic and PMMA IOLs were significantly lower, but at 72 hours there were no statistically significant differences among biomaterials. A higher density of bacteria was observed at the periphery of the IOL's optic of assayed biomaterials for in vitro and in vivo studies. Biofilm formation and the presence of extracellular matrix were predominantly restricted to the edges of IOL optic surface. CONCLUSION: Bacterial adhesion and biofilm development on the IOL optic surface depended on the region and biomaterial of the IOL. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Propionibacterium acnes, an emerging pathogen: from acne to implant-infections, from phylotype to resistance.

Propionibacterium acnes colonizes the lipid-rich sebaceous glands of the skin. This preferential anaerobic bacterium is easily identified if cultures are prolonged. It is involved in the inflammation process of acne, but until recently, it was neglected in other clinical presentations. Despite a reported low virulence, the new genomic, transcriptomic, and phylogenetic studies have allowed better understanding of this pathogen's importance that causes many chronic and recurrent infections, including orthopedic and cardiac prosthetic, and breast or eye implant-infections. These infections, facilitated by the ability of P. acnes to produce a biofilm, require using anti-biofilm active antibiotics such as rifampicin. The antibiogram of P. acnes is not systematically performed in microbiology laboratories because of its susceptibility to a wide range of antibiotics. However, in the last 10 years, the rate of antibiotic-resistant bacteria has increased, especially for macrolides and tetracyclines. Recently, rpoB gene mutations conferring resistance to rifampicin have been also reported. Thus in case of a biofilm growth mode, the therapeutic strategy should be discussed, according to the resistance phylotype and phenotype so as to optimize the treatment of these severe infections.

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.

Staphylococcus epidermidis biofilm formation and structural organization on different types of intraocular lenses under in vitro flow conditions.

AIM: To compare the adherence and structural organization of Staphylococcus epidermidis biofilm on intraocular lenses (IOLs). METHODS: IOLs made of 3 different biomaterials [polymethyl methacrylate (PMMA), hydrophilic acrylic or hydrophobic acrylic] were incubated into an S. epidermidis bacterial solution. Scanning electron microscopy was used to count the bound bacteria and to analyze the structural biofilm architecture. RESULTS: After 4-6 h of incubation, adherence was statistically weakest on the hydrophilic acrylic polymer. On the hydrophobic acrylic material, the bacterial cells tended to cover the substratum in a horizontal spread in a continuous monolayer. On the hydrophilic acrylic material or on the PMMA material bacterial cells tended to form only few, small scattered cell clusters. CONCLUSIONS: The data suggest that the pattern of S. epidermidis adhesion varies with the IOL biomaterial. Hydrophobic IOLs seem to be more permissive to S. epidermidis adhesion.

Antifouling foldable acrylic IOLs loaded with norfloxacin by aqueous soaking and by supercritical carbon dioxide technology.

Cataracts treatment usually involves the extraction of the opaque crystalline lens and its replacement by an intraocular lens (IOL). A serious complication is the occurrence of endophthalmitis, a post-surgery infection mainly caused by Staphylococcus epidermidis, Staphylococcus aureus, and Pseudomonas aeruginosa. IOLs having the ability to load and to release norfloxacin in a controlled way and at efficient therapeutic levels may help to overcome these issues. In this work, acrylic hydrogels combining 2-hydroxyethyl methacrylate (HEMA) and 2-butoxyethyl methacrylate (BEM) at various ratios were prepared to attain biocompatible networks that can be foldable even in the dry state and thus insertable through minor ocular incision, and that load therapeutic amounts of norfloxacin. Acrylamide (AAm) and methacrylic acid (MAAc) were also incorporated as functional comonomers in small proportions. Water sorption, contact angle, protein adsorption, and optical properties of the networks were characterized. BEM notably decreased the T(g) of the networks, but also the loading by immersion in aqueous solution (presoaking). Then, a scCO(2)-based impregnation/deposition (SSI) method was implemented to improve the uptake of the drug. Loading capacities were discussed in terms of the comonomers composition and the employed method and operational conditions. The networks prepared with HEMA/BEM 20:80 vol/vol and processed with supercritical fluids combine adequate mechanical properties, biocompatibility and norfloxacin loading/release, and seem to be suitable for developing norfloxacin-eluting IOLs.

Surface localisation of photosensitisers on intraocular lens biomaterials for prevention of infectious endophthalmitis and retinal protection.

Cataract surgery is one of the most commonly-practiced surgical procedures in Western medicine, and, while complications are rare, the most serious is infectious postoperative endophthalmitis. Bacteria may adhere to the implanted intraocular lens (IOL) and subsequent biofilm formation can lead to a chronic, difficult to treat infection. To date, no method to reduce the incidence of infectious endophthalmitis through bacterial elimination, while retaining optical transparency, has been reported. In this study we report a method to optimise the localisation of a cationic porphyrin at the surface of suitable acrylate copolymers, which is the first point of contact with potential pathogens. The porphyrin catalytically generates short-lived singlet oxygen, in the presence of visible light, which kills adherent bacteria indiscriminately. By restricting the photosensitiser to the surface of the biomaterial, reduction in optical transparency is minimised without affecting efficacy of singlet oxygen production. Hydrogel IOL biomaterials incorporating either methacrylic acid (MAA) or methyl methacrylate (MMA) co-monomers allow tuning of the hydrophobic and anionic properties to optimise the localisation of porphyrin. Physiochemical and antimicrobial properties of the materials have been characterised, giving candidate materials with self-generating, persistent anti-infective character against Gram-positive and Gram-negative organisms. Importantly, incorporation of porphyrin can also serve to protect the retina by filtering damaging shortwave visible light, due to the Soret absorption (λmax 430 nm).

An outbreak of acute post-cataract surgery Pseudomonas sp. endophthalmitis caused by contaminated hydrophilic intraocular lens solution.

OBJECTIVE: To report the investigation for the source of infection and the clinical course and treatment response of 11 cases of acute post-cataract surgery endophthalmitis that developed during an outbreak. DESIGN: Retrospective, consecutive, interventional case series. PARTICIPANTS: Eleven patients who developed acute postoperative endophthalmitis after an uneventful cataract surgery with intraocular lens implantation from September 6 to 29, 2010, at a tertiary eye care center in South India. METHODS: Aqueous aspirates, vitreous aspirates, and environmental surveillance specimens were sampled. All specimens were subjected to smear and culture. Positive cultures were subjected to antibiotic susceptibility. Genotypic diversity was determined by polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus (ERIC) primers of each strain and was used to establish the clonal relationship between clinical and environmental isolates. The clinical patterns were analyzed. MAIN OUTCOME MEASURES: Positive microbiology, molecular diagnostic similarity among the culture positive endophthalmitis cases, and surveillance specimens. RESULTS: Aqueous and vitreous samples showed gram-negative bacilli in the smears of 8 of 11 eyes, and cultures grew Pseudomonas aeruginosa in 5 of 11 eyes. Among the samples from various surveillance specimens cultured, only the hydrophilic acrylic intraocular lenses and their solution grew P. aeruginosa, with antibiotic susceptibility pattern identical to the clinical isolates. The isolates from the patients and the intraocular lens solution revealed matching patterns similar to an American Type Culture Collection (ATCC) strain of P. aeruginosa on ERIC-PCR. The intraocular lenses of the same make were discontinued at our hospital, and the endophthalmitis did not recur. The final visual acuity improved to ≥ 20/50 in 8 of 11 patients (72.7%). One patient developed retinal detachment, but was treated successfully, and 2 other patients progressed to phthisis bulbi. CONCLUSIONS: Positive microbiology and the ERIC-PCR results proved that contamination of hydrophilic intraocular lenses and the preservative solution was the source of infection in this outbreak. Early detection and a planned approach during the outbreak helped us to achieve good visual and anatomic outcomes, even though the offending organism was identified as P. aeruginosa.

Recurrent enterococcal endophthalmitis seeded by an intraocular lens biofilm.

A case of endophthalmitis following uneventful phacoemulsification and posterior chamber intraocular lens (IOL) implantation in a 77-year-old diabetic man was culture-positive for Enterococcus faecalis. After successful treatment with intravitreal, topical, and systemic antibiotic agents, the infection seemed to clear and the patient achieved a corrected visual acuity of 20/25. Four months after the initial presentation, the patient again developed signs and symptoms of endophthalmitis, with regrowth of E faecalis. The antibiotic therapy was repeated. One month later, the IOL was removed surgically and found to harbor a biofilm of the strain demonstrated by DNA analysis. The microbiologic and DNA analyses support that a biofilm on an IOL could be a vector for a cause of recurrent endophthalmitis. Intraocular lens exchange in cases of postoperative endophthalmitis caused by E faecalis may be considered to decrease the risk for recurrent infection.

[Intraocular lens and bacterial adhesion: influence of the environmental factors, the characteristics of the bacteria, and the target material surface]. / Implant intraoculaire et adhésion bactérienne : influence des conditions environnementales, des propriétés bactériennes et des caractéristiques du biomatériau.

Adhesion of bacteria to intraocular lenses is an important step in the pathogenesis of postoperative endophthalmitis. It can be described as a two-phase process including an initial, instantaneous, and reversible phase followed by a time-dependant and irreversible molecular and cellular phase. The binding of bacteria is affected by many factors including environmental factors such as medium composition, presence of proteins and flow conditions, the bacterial cell surface characteristics, and the material's surface properties. This article reviews all these factors affecting the adhesion of bacteria to intraocular lenses. A better understanding of these mechanisms would make it possible to reduce the bacterial adhesion process and thus could help decrease the incidence of postoperative endophthalmitis.

Experimental intracameral injection of vancomycin microparticles in rabbits.

PURPOSE: To evaluate the in vivo toxicity and efficacy of previously developed poly-(lactide-co-glycolide)-vancomycin-based microparticles (V-MPLs) for eventual use for endophthalmitis prophylaxis during cataract surgery. METHODS: The intraocular vancomycin concentration profile was evaluated after V-MPL injection into the anterior chamber of rabbit eyes. The toxicology of V-MPLs versus MPLs alone was tested by corneal cellular counting and retinal histology. The prophylactic efficacy of the V-MPLs was evaluated by bacterial counts after introducing contaminated intraocular lenses (IOLs) together with the V-MPLs into one anterior chamber of phakic rabbit eyes or without V-MPLs in control rabbit eyes. RESULTS: Intraocular V-MPLs produced effective vancomycin concentrations over at least 6 hours. Corneal counts revealed no significant increase in dead cells. Retinal toxicity manifested as inflammation 3 hours after injection, reaching its maximum between 12 hours and 24 hours, decreasing by 48 hours, and completely disappearing at 72 hours. Inflammation was similar between V-MPLs and MPLs. Untreated eyes implanted with highly infected IOLs showed severe, reproducible endophthalmitis. No sign of infection was observed with infected IOLs and concomitant V-MPL treatment, supported by bacterial counts showing a significant decrease in colony-forming Staphylococcus epidermidis units in the anterior chamber and on the implant surfaces within 6 hours. CONCLUSIONS: The present study demonstrated the release and toxicologic properties of the authors' newly developed V-MPLs in vivo. In addition, the rabbit model shows that V-MPLs are effective in reducing the risk of experimental endophthalmitis.

Effect of cefuroxime and moxifloxacin on Staphylococcus epidermidis adherence to intraocular lenses.

OBJECTIVE: To investigate and compare the effect of cefuroxime and moxifloxacin on adhesion of Staphylococcus epidermidis to intraocular lenses (IOLs). DESIGN: Experimental study. METHODS: The 3-pieced hydrophobic acrylic lenses were contaminated with S. epidermidis (American Type Culture Collection 35983) solutions containing 108 colony-forming units. IOLs were inoculated into test tubes containing tryptic soy broth after being held in antibiotic solutions for 15 minutes. Sonication and vortex procedures were performed in order to remove all the remaining bacteria. From each tube 10 microL and 100 microL was taken and inoculated into sheep blood agar. The colonies were counted overnight. The statistical analyses were made using one-way ANOVA, Turkey Honestly Significant Differences test (HSD) and independent t tests, and a p value less than 0.05 was considered statistically significant. RESULTS: Overall, the mean numbers of colony-forming units on the lenses that were held in control, cefuroxime, moxifloxacin 0.5 mg/0.1 mL and moxifloxacin 0.1 mg/0.1 mL solutions were 1398 (SE 10.01 x 10(3)), 29.9 (SE 1.16 x 10(3)), 0.23 (SD 0.04 x 10(3)), and 0.41 (SD 0.05 x 10(3)), respectively. The evaluation using one-way ANOVA and Turkey HSD tests revealed significant statistical differences among the groups (p = 0.000). The evaluation using independent t tests revealed significant statistical differences between the 2 moxifloxacin groups (p < 0.05). CONCLUSION: Our results suggest that moxifloxacin and cefuroxime significantly inhibit bacterial adherence to IOLs. The effect of moxifloxacin on inhibition of bacterial adherence was significantly greater than that of cefuroxime. For this reason moxifloxacin might be considered as a better prophylactic agent.

Foldable antibacterial acrylic intraocular lenses of high refractive index.

Hydrophilic copolymers with high refractive index and bactericide properties based on quaternary ammonium salts monomers and methacrylates bearing benzothiazole moieties have been developed for application as foldable intraocular lenses. Composition of the systems was adjusted to get materials with optimized flexibility, wettability, and refractive properties. All the materials have been characterized in terms of optical properties, glass transition temperature, water content, and wettability. Water contact values oscillated between 37 and 15% and refractive index values in the wet state between 1.49 and 1.53, depending on composition. Glass transition temperature interval was 63-77 degrees C. Values of surface free energy of the solid ranged from 49 to 54 mN/m, characteristic of IOL hydrogel materials. Bactericide properties of the quaternary ammonium salts methacrylates were higher than that of the benzothiazole derivative, showing inhibition halos as high as 23-25 mm in antibiogram tests against S. epidermidis and P. aeruginosa , strains found in the ocular cavity and responsible for most postsurgical endolphthalmitis. Biocompatibility of the systems was evaluated in cell cultures using human fibroblasts. Cellular viability was higher than 90%, and close to 100% in many cases, for the extracts of selected formulations collected at different periods of time.

Detection of pyrogens adsorbed to intraocular lenses: evaluation of limulus amoebocyte lysate and in vitro pyrogen tests.

PURPOSE: To determine the ability of the limulus amoebocyte lysate (LAL) assay and the in vitro pyrogen test (IPT) to detect pyrogens adsorbed to intraocular lenses (IOLs). SETTING: Berlin Eye Research Institute, Berlin, Germany. METHODS: Fifteen of each of the following IOLs were used: MicroSil MS 612 ASP, AcrySof SA60AT, Superflex, Sensar, XACT, and LS-106 IOLs. The challenge organism suspensions were 10(3) CFU/mL and 10(4) CFU/mL Escherichia coli, 10(3) CFU/mL and 10(4) CFU/mL Pseudomonas putida, and 10(5) CFU/mL and 10(6) CFU/mL Staphylococcus epidermidis. Two IOLs of each model were incubated at room temperature for at least 2 days in 0.6 mL of 1 of the suspensions. They were then gamma sterilized. The extract of 1 IOL was tested with the LAL assay; the other IOL was tested with the IPT. RESULTS: The LAL was negative for all incubated IOLs. The IPT was positive for all IOLs incubated in E coli and P putida suspensions, with the MicroSil MS 612 ASP, AcrySof SA60AT, XACT, and LS-106 IOLs showing a severe reaction. The Superflex and Sensar IOLs had a slight to moderate response for lower bacterial concentrations and a moderate to severe response for higher concentrations. For S epidermidis, all IOLs showed a slight IPT response except XACT IOLs, which showed a nonpyrogenic response. CONCLUSIONS: Results indicate that the LAL test may fail to detect pyrogens adsorbed to IOLs and the IPT reliably detects pyrogens with a dose-dependent response. This has relevance in the investigation of toxic anterior segment syndrome outbreaks.

Impact of slime dispersants and anti-adhesives on in vitro biofilm formation of Staphylococcus epidermidis on intraocular lenses and on antibiotic activities.

OBJECTIVES: Infectious endophthalmitis has occurred despite the use of antibiotics in irrigating solutions during implantation of intraocular lenses (IOLs). This infection is generally resistant to antibiotic therapy and, therefore, removal of the implant is necessary before eradication of the infection. This study was designed to assess the role of chosen dispersants and anti-adhesives in inhibiting Staphylococcus epidermidis hydrophobicity, adhesion, slime production and subsequently biofilm formation on IOLs. METHODS: The relative activity of several potential slime dispersants and anti-adhesives on slime production, hydrophobicity and the adherence of S. epidermidis to IOLs and the degrees to which their effects enhance antibiotic activities were investigated. RESULTS AND CONCLUSIONS: The MBCs of antibiotics against S. epidermidis strains in a biofilm increased 10-16 times compared with those against bacterial strains in suspension. Addition of slime dispersants or anti-adhesives reversed the susceptibility of the strains in a biofilm to that of bacteria in suspension. Slime production by S. epidermidis strains was significantly diminished by dispersants. Anti-adhesives, hyaluronan, heparin and carpobol 934 exerted less effects on slime production than dispersants. Addition of slime dispersants or anti-adhesives to cell cultures resulted in a significant reduction in bacterial surface hydrophobicity compared with control untreated cultures (at P < 0.001). Reduction of slime production and bacterial surface hydrophobicity led to a marked decrease in the adherence of S. epidermidis to IOLs. Slime dispersants were more effective at reducing bacterial adherence than anti-adhesives. Simultaneous use of antibiotics with slime dispersants or anti-adhesives will exert a more beneficial effect during IOL implantation.