Results in the treatment of bacterial endophthalmitis

Fifteen cases of confirmed and clinically suspected bacterial endophthalmitis seen at the Vitreous Clinic of Sydney Eye Hospital in the three-year period from July 1981 to July 1984 are reviewed. The predisposing factors are summarized; two cases followed secondary implantation of an intraocular lens and one case followed removal of sutures from a cataract section. All but one of the patients had been given topical, subconjunctival or systemic antibiotics prior to surgery. All but two of the patients had vitreous biopsies performed, and all of these patients in turn received intravitreal antibiotics, usually gentamicin and cephalothin. Positive cultures were obtained in nine cases (69%), including the two cases who had not received antibiotics prior to vitreous biopsy. Final visual acuities ranged from 6/6 to no perception of light (NPL). Delay of more than 36 hours between the onset of severe symptoms and intravitreal antibiotic treatment was associated with a poor visual outcome.     

Antibiotic prophylaxis of postoperative endophthalmitis.

Nonconcurrent analysis of 45,954 cataract operations performed by a single surgeon indicates that periocular injection of penicillin combined with multiple preoperative applications of topical chloramphenicol-sulphadimidine reduced the incidence of postoperative endophthalmitis by 72%. Periocular penicillin alone was ineffective. A concurrent masked randomized study of 6,618 cataract operations confirms the efficacy of combined prophylaxis and demonstrates that the topical regimen, by itself, is as ineffective as isolated penicillin prophylaxis.     

The treatment of bacterial endophthalmitis.

Restoration of good visual acuity following bacterial endophthalmitis is dependent on prompt diagnosis, immediate treatment, proper selection of antibiotics, high-dose parenteral and periocular antibiotic therapy, and systemic and periocular corticosteroids. Antibiotic selection should be based on the statistical incidence of pathogens rather than on the result of a Gram stain from the aqueous or vitreous humor. Recent experimental studies in the primate eye suggest that there is little to choose between the subconjunctival and retrobulbar routes of antibiotic administration. The role of intravitreal injection of antibiotic, although promising, requires further definition.     

Results of the treatment of infectious endophthalmitis by vitrectomy

Infective endophthalmitis is a severe ophthalmological condition and may occur as a consequence of a perforating injury or of a surgical procedure. The paper presents personal results of treatment of this disease with the use of vitrectomy and application of intraocular antibiotics. The visual acuity after completion of the treatment was 6/6 to 6/8 in 35.7% of cases. Besides--contemporary opinions on the treatment of infective endophthalmitis are presented on the basis of experience and data from the literature.     

Chronic postoperative endophthalmitis due to pseudomonas oryzihabitans

PURPOSE: To report a case of chronic postoperative endophthalmitis caused by the gram-negative bacterium Pseudomonas oryzihabitans.DESIGN: Interventional case report.METHODS: A 77-year-old man was referred to our service for nonpainful uveitis in the right eye accompanied by increased intraocular pressure of 2 years' duration with onset 4 months after uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens implantation. The uveitis partially responded to topical corticosteroid therapy but was recurrent with tapering of steroids. An anterior chamber tap and vitreous biopsies sent for cultures were negative. Owing to the persistence of inflammation despite intraocular vancomycin injection, the lens implant and capsule were removed and culture of the latter revealed the bacterium P. oryzihabitans.RESULTS: There was no recurrence of inflammation after removal of the lens implant and capsule.CONCLUSIONS: Unlike other gram-negative organisms, which are associated with poor outcomes, P. oryzihabitans may masquerade as chronic uveitis because of its low virulence.     

Etiology and diagnosis of bacterial postoperative endophthalmitis.

It is necessary to determine if postoperative endophthalmitis is of infectious or sterile etiology. Intraocular contents should be cultured and were positive in 50% of 58 eyes tested at our institute with suspected postoperative endophthalmitis. The vitreous aspirate is more sensitive than the anterior chamber aspirate in making a diagnosis. The use of a membrane filter to concentrate vitreous samples obtained at vitrectomy increases diagnostic yield. Fifty percent of culture-positive eyes yielded gram-positive organisms. Stained smears were consistent with the cultured organism in half of the cases.     

Chronic postoperative endophthalmitis caused by Propionibacterium acnes.

Persistent intraocular inflammation after cataract surgery with intraocular lens implantation is acquiring importance. Frequently, chronic uveitis or the "toxic lens syndrome" have to be differentiated from bacterial infection. This report describes five cases with chronic postoperative endophthalmitis where the anaerobic bacterium Propionibacterium acnes was found to be the causative organism. Adequate anaerobic culture media and proper sampling from the area around the lens haptics are the most important requirements for the detection of P. acnes.     

Delayed-onset postoperative endophthalmitis caused by Hafnia alvei.

PURPOSE: To identify Hafnia alvei as an etiological factor of delayed-onset endophthalmitis. CASE REPORT: A 68-year-old woman had uneventful cataract extraction by phacoemulsification with foldable posterior chamber intraocular lens implantation under topical anesthesia in the left eye. Four weeks later, the patient presented anterior uveitis treated by topical corticosteroids. Seven weeks later a posterior uveitis with retinal vasculitis appeared. The patient was treated by systemic and intravitreal corticosteroids without result. Due to the poor course pars plana vitrectomy was done, and a vitreous sample was taken. Microbiologic examination disclosed Hafnia alvei, gram-negative bacteria rarely isolated from human specimens. CONCLUSIONS: Hafnia alvei should be considered in the etiology of delayed-onset endophthalmitis.     

Acute postoperative endophthalmitis caused by Actinomyces neuii.

PURPOSE: To describe a case of acute postoperative endophthalmitis caused by Actinomyces neuii after uncomplicated phacoemulsification with posterior chamber intraocular lens implant. METHODS: Interventional case report. A 58-year-old male underwent phacoemulsification, right eye, with posterior chamber intraocular lens implant. On postoperative day 6, he presented with pain, redness, and decreased visual acuity, right eye, and was found to have endophthalmitis. RESULTS: Vitreous cultures revealed the gram-positive, anaerobe Actinomyces neuii. After appropriate intraocular, periocular, topical, and systemic therapy, the infection cleared, but the vision of the patient never improved as a result of a central vein occlusion. CONCLUSION: Actinomyces species can rarely cause postoperative endophthalmitis, and it should be considered in cases of severe postoperative intraocular inflammation.     

Management of purulent postoperative endophthalmitis

In 1985, postoperative purulent endophthalmitis (PPE) was diagnosed in 8 eyes (severe in 5 and presumed in 3 eyes). All were treated with paraocular injections of cefotaxime, gentamicin and triamcinolone with or without the same antibiotics by intraocular and/or systemic route with or without systemic corticosteroids. The suspect causative organisms were Staphylococcus epidermidis in 2 cases, Staphylococcus aureus in 3 cases, streptococcus in 1 case, in 2 cases the cause remained unknown. Pars plana vitrectomy and anterior chamber lavage were performed on 5 eyes, and anterior chamber and vitreous tap on 1 eye. The intraocular lens implants were not removed at vitrectomy. A useful vision ranging from 0.15 to 0.6 was obtained in all cases. Our present regime for the management of purulent postoperative or posttraumatic endophthalmitis is given.     

Role of intravitreal triamcinolone acetonide in the treatment of postoperative endophthalmitis

PURPOSE: To report the use of commercially available triamcinolone acetonide as adjunct treatment for acute-onset endophthalmitis after intraocular procedures. METHODS: Charts of 14 patients who received intravitreal triamcinolone in combination with intravitreal antibiotics for treatment of acute endophthalmitis were reviewed. Patients were included if they presented with pain, vision loss, and severe anterior chamber reaction or hypopyon. Visual acuities, intraocular pressures, anterior chamber reaction, and view of fundus details were recorded at baseline, 1 day, 1 week, 1 month, and 3 months to 5 months. RESULTS: Culture-positive results were found for 57% (8/14) of patients. Isolated species included Staphylococcus epidermidis, viridans streptococcus, group D Streptococcus (nonenterococcus), Propionibacterium acnes, and diphtheroid bacilli. Visual acuities improved an average of 7.5 Snellen lines. Preendophthalmitis level visual acuities were recovered in 78.6% patients (11/14), with 64% (9/14) of patients achieving visual acuity of 20/40 or better regardless of presenting vision. Resolution of anterior chamber reaction and view of fundus details were consistent with visual acuities. CONCLUSIONS: Intravitreal triamcinolone combined with intravitreal antibiotics appears to have a safety profile similar to current modalities with a favorable effect on visual recovery and function in the setting of acute postoperative endophthalmitis.