Author
Period
Aetiology
Location
No.
Organism
Kenchappa et al. [11]
Jun 2003
Phacoprobe and internal tubings of phacoemulsification machine
Hyderabad,
South India
9 Eyes
Pseudomonas aeruginosa
Malhotra et al. [12]
Feb 2005–Feb 2006
Not known (three different clusters)
Raipur, Chhattisgarh,
Central India
24 Eyes
Pseudomonas aeruginosa
Korah et al. [13]
2006
Not known
Vellore,
South India
19 Eyes
Enterobacter amnigenus
Pinna et al. [7]
Feb–Apr 2008
Phacoemulsifier’s internal tubes, the povidone-iodine solution and the operating theatre air conditioning system
Tiruchirappalli,
South India
20 Eyes
Pseudomonas aeruginosa
Ramappa et al. [8]
Sep 2010
Hydrophilic acrylic intraocular lenses and their solution
Hyderabad,
South India
11 Eyes
Pseudomonas aeruginosa
NPCB report [14]
Sep 2010
Not known
Mandala, MP,
Central India
38 Eyes
Not known
NPCB report [14]
Dec 2010
Water used for scrubbing was contaminated
Indore, MP,
Central India
18 Eyes
Klebsiella sp.
NPCB report [14]
Sept 2011
Contaminated OT trolley and table
Balod, Chhattisgarh,
Central India
46 Eyes
Pseudomonas aeruginosa
Lalitha et al. [15]
Dec 2011–Mar 2012
Local anaesthetic eye drops
Madurai,
South India
13 Eyes
Burkholderia cepacia
Isolated cases of acute postoperative endophthalmitis cases are usually believed to arise from the patient’s own commensal bacteria and are mainly gram-positive cocci. In contrast, gram-negative organisms have been found to be commonly associated with epidemics of cluster outbreaks of acute-onset postoperative endophthalmitis after cataract surgery. Pseudomonas aeruginosa is the most common gram-negative organism. It is often associated with nosocomial infections affecting the skin, urinary tract, lungs and heart [10]. Outbreaks of P. aeruginosa endophthalmitis are most likely to have an exogenous origin as they are not part of the normal conjunctival flora.
Cluster endophthalmitis has also occurred after the use of anti-VEGF agents, more commonly bevacizumab (Avastin®, Genentech, Inc.), and the outbreak has usually been because of a contaminated batch. Postinjection endophthalmitis is discussed in another chapter in this book.
Management Principles
The aim of management in cases of an outbreak should be:
Prompt and effective treatment of the endophthalmitis cases
Reporting to the concerned authorities
Analysis and identification of the cause
Implementation of practices to reduce future outbreaks
Continuous audit of complications, procedures and practice patterns
The medical management of cluster endophthalmitis is no different than the postoperative endophthalmitis and invariably follows the recommendations of the Endophthalmitis Vitrectomy Study (EVS) [16] except that more often these eyes need vitreous surgery.
The management of cluster endophthalmitis does not end with the clinical management of the eyes. It is necessary to probe the cause of such infection and take measures to prevent future recurrences. This process begins with the reporting incident to the hospital infection control committee (HICC). Depending on the number of cases, green/amber/red alert is sounded as follows (Table 13.2).
Table 13.2
Alerts in cluster endophthalmitis
An amber or red alert may necessitate closure of the operating rooms in order to investigate for the cause of the outbreak.
Tracking Cluster Endophthalmitis
The Royal College of Ophthalmology provides guidelines for investigating and managing outbreaks of endophthalmitis [17].
In general the following protocols and procedures should be adhered to:
Alert colleagues and make them aware of the cases thus far and recall the patients operated on the same day or in the same operating room(s).
Inquire about the incidence of any other case(s), and ensure that other patient(s) are fully aware of postoperative danger symptoms.
The incident forms should be filled and documentation should be done (A sample incident form is attached at the end of this chapter—Annexe 1 and 2)
If receiving multiple cases from another hospital, then their clinical heads and concerned ophthalmologists and hospital administrators should be informed.
Constitute an investigating team involving the hospital consultant microbiologist, ophthalmologists and hospital infection team including the operating room nursing staff, clinical risk managers and hospital managers.
The main areas of investigation as recommended by Anderson et al. [2] are:
- 1.
Operating room environment
- 2.
Pre-, peri- and postoperative practices
- 3.
Instrument cleaning and sterilisation
- 4.
Equipment maintenance
- 5.
Documentation of cases and the irrigating fluids used and other factors
Microbiological Surveillance
Checklist for Investigation of Suspected Outbreak of Postoperative Endophthalmitis
CSSD-(Central Sterile Supply Department) Related Issues
Autoclave function, its pressure and temperature gauges.
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