Delayed- Versus Acute-Onset Endophthalmitis After Cataract Surgery




Purpose


To report a large consecutive case series of patients who developed delayed-onset and acute-onset endophthalmitis after cataract surgery.


Design


Retrospective consecutive case series.


Methods


The current study is a retrospective consecutive case series of patients treated between January 2000 and December 2009 for culture-proven endophthalmitis after cataract surgery. The study defined 2 groups after cataract surgery: acute-onset endophthalmitis (≤6 weeks after surgery) and delayed-onset endophthalmitis (>6 weeks after surgery).


Results


A total of 118 patients met study criteria; cases included 26 delayed-onset cases and 92 acute-onset cases. The following clinical features and outcomes occurred in delayed- vs acute-onset cases: 1) the presenting visual acuity was ≤5/200 in 31% vs 89%; 2) hypopyon was found in 46% vs 80%; 3) the most frequent isolate was Propionibacterium acnes (11/26) vs coagulase-negative Staphylococcus (57/92); and 4) patients with the most frequent isolate achieved a visual outcome of ≥20/100 in 91% vs 56%. In delayed-onset cases, the intraocular lens was removed or exchanged in 19 of 26 cases (73%). Of these 19 cases, 13 achieved a visual outcome of ≥20/100.


Conclusions


Patients with delayed-onset endophthalmitis generally presented with better initial visual acuities, had a lower frequency of hypopyon, and had better visual outcomes compared to acute-onset patients. Propionibacterium acnes and coagulase-negative Staphylococcus species were the most common organisms cultured in delayed- and acute-onset categories, respectively, and were associated with the best visual acuity outcomes in each group.


Endophthalmitis is a serious sight-threatening condition that can be classified into 2 broad categories: acute-onset and delayed-onset. As used in the Endophthalmitis Vitrectomy Study, acute-onset postoperative endophthalmitis was defined as infections within 6 weeks of surgery. By contrast, delayed-onset postoperative endophthalmitis has been defined as greater than 6 weeks after the surgery. These 2 categories may differ in their incidence, clinical features, microbiology, and visual acuity outcomes.


The reported incidence of acute-onset endophthalmitis after cataract surgery ranges from 0.03% to 0.15%. Since the mid-1990s, cataract surgical techniques have evolved to clear corneal, sutureless techniques. In spite of this change in technique, the nature of acute-onset endophthalmitis in both settings is virtually identical. Acute-onset postoperative endophthalmitis is characterized by a rapid onset of visual loss and marked intraocular inflammation and is frequently caused by coagulase-negative Staphylococcus .


In 1 single-center study, the reported rate of delayed-onset endophthalmitis following cataract surgery was 0.017%. In delayed-onset postoperative endophthalmitis, the onset is frequently insidious and the inflammation is often low grade, and is caused by less virulent bacteria and fungi. Propionibacterium acnes has been reported to be a common organism isolated in published series.


The purpose of the current study was to compare the clinical features, causative organisms, and visual acuity outcomes associated with delayed-onset vs acute-onset endophthalmitis after cataract surgery in a contemporary series from a university referral center.


Methods


The clinical and microbiology records were reviewed for all patients treated at Bascom Palmer Eye Institute between January 1, 2000 and December 31, 2009 for clinically diagnosed, culture-positive endophthalmitis following cataract surgery. The study included patients who were operated elsewhere and referred for care, as well as patients who underwent cataract surgery at Bascom Palmer Eye Institute. Patients were excluded from the study if the endophthalmitis was not associated with cataract surgery or if consequent to combined procedures (glaucoma and cataract surgery). Patients with preexisting macular degeneration, diabetic retinopathy, or glaucoma were not excluded from the study.


Intraocular fluid specimens were plated directly on chocolate agar, 5% sheep blood agar, CDC anaerobic blood agar, Sabouraud agar, and thioglycolate medium. Chocolate and blood agar plates and thioglycolate broth were incubated for up to 2 weeks at 35 C in 5% CO 2 . Anaerobic plates were incubated in an anaerobic jar in non-CO 2 for up to 2 weeks. Sabouraud agar was incubated at 35 C for 72 hours and then at 25 C for up to 2 weeks. To be considered a positive culture, a specimen must have demonstrated growth of the same organism on 2 or more solid culture media or growth on a single medium after identification on an initial smear.


Because the current study was a retrospective case series, there was no rigid protocol for managing these patients, although the practice algorithm is fairly consistent for all investigators. Intravitreal antibiotics were injected at the time of initial treatment in all patients. The use of vitrectomy was at the discretion of the treating physician, although the guidelines of the Endophthalmitis Vitrectomy Study (EVS) were generally followed for acute-onset cases. Recorded data included clinical features, visual acuity at diagnosis, cultured organisms, and visual acuity at follow-up.




Results


Between January 1, 2000 and December 31, 2009, 118 patients met study criteria. Of these 118 patients, 26 (22%) had delayed-onset postoperative endophthalmitis and 92 (78%) had acute-onset postoperative endophthalmitis ( Tables 1 and 2 ). In this study, 71 of the 118 cases (60%) were from male patients and 47 (40%) were from female patients. The mean age at presentation was 74 years (range 52–87, SD 9) in the delayed-onset group and 76 years (range 48–90, SD 9) in the acute-onset group.



TABLE 1

Presenting Clinical Features of Patients With Endophthalmitis Following Cataract Surgery



















Total n = 118 VA ≤ 5/200 Hypopyon Mean Days to Diagnosis
Delayed-onset (n = 26) 8 (31%) 12 (46%) 343 (median: 230, range: 48–1840)
Acute-onset (n = 92) 82 (89%) 74 (80%) 9 (median: 7, range: 1–39)

VA = visual acuity.


TABLE 2

Visual Acuity Outcomes by Category of Endophthalmitis






















Total n = 118 ≥20/40 ≥20/100 ≤5/200 NLP
Delayed-onset (n = 26) 50% 65% 27% 12%
Acute-onset (n = 92) 27% 41% 35% 4%

NLP = no light perception.


Delayed-Onset Postoperative Endophthalmitis


The mean time between surgery and the diagnosis of endophthalmitis was 343 days (range 48–1840, SD 379). Intraocular cultures became positive on days 2 to 7 after obtaining the specimen (mean time to culture positivity: 3.5 days). The average follow-up time after initial treatment was 804 days (range 61–3069, SD 774). A presenting visual acuity of ≤5/200 was noted in 8 of 26 patients (31%). Hypopyon was present in 12 of 26 patients (46%), and keratic precipitates were present in 19 of 26 patients (73%) ( Figure 1 ) . A white plaque associated with the capsular bag was noted in 17 of 26 patients (65%) ( Figures 2 and 3 ) . In the 26 delayed-onset cases, the following organisms were isolated: Propionibacterium acnes in 11 (42%), fungal species in 7 (27%), gram-negative species in 3 (12%), gram-positive species in 3 (12%), and Mycobacterium chelonae in 2 (8%).




FIGURE 1


Hypopyon and granulomatous keratic precipitates associated with Propionibacterium acnes endophthalmitis. (Top) Initial presentation of Patient 2; visual acuity 5/200. (Bottom) After pars plana vitrectomy with total capsulectomy and intraocular lens removal; visual acuity was 20/20 with aphakic contact lens correction.



FIGURE 2


White plaque within the capsular bag associated with Propionibacterium acnes endophthalmitis. (Top) Initial presentation of Patient 22; visual acuity was 20/40. (Bottom) After pars plana vitrectomy with partial capsulectomy; visual acuity was 20/25.



FIGURE 3


White plaque within the capsular bag associated with Acremonium strictum endophthalmitis. (Top) Initial presentation of Patient 12; visual acuity was 20/200. (Middle) Recurrence of infection with hypopyon after pars plana vitrectomy; visual acuity was hand motions. (Bottom) After pars plana vitrectomy with total capsulectomy and intraocular lens removal; visual acuity was 20/30 with aphakic contact lens correction.


Initial treatment consisted of 3 different strategies: 1) vitreous tap and injection of intraocular antibiotics; 2) 3-port pars plana vitrectomy (PPV) with injection of intraocular antibiotics; and 3) 3-port pars plana vitrectomy with partial posterior capsulectomy and injection of intraocular antibiotics. No patients underwent initial treatment with total capsulectomy, intraocular lens (IOL) exchange, or IOL removal. However, 19 of 26 delayed-onset patients (73%) subsequently underwent combinations of these procedures because of recurrence of inflammation ( Figure 4 ) .




FIGURE 4


Surgical procedures in delayed-onset endophthalmitis patients who had intraocular lens implant (IOL) removal. Procedures were intraocular antibiotics (IOAB), pars plana vitrectomy (PPV), partial capsulectomy (PC), total capsulectomy (TC), IOL removal (noIOL), penetrating keratoplasty (PKP), and IOL exchange (IOLx). Of the 7 patients with delayed-onset endophthalmitis who did not undergo IOL removal, initial treatment was PPV/PC/IOAB (4 patients), PPV/IOAB (2 patients), and IOAB (1 patient). None of these 7 patients had recurrences or further interventions. TAP = vitreous tap.


Of these 19 patients who underwent exchange or removal of the IOL, initial treatment included injection of intraocular antibiotics in 2, PPV with intraocular antibiotics in 8, and PPV with partial capsulectomy and intraocular antibiotics in 9. Seventeen of 19 patients (89%) underwent PPV with total capsulectomy and IOL removal or exchange as a secondary procedure. Only 2 of these 17 patients (12%) developed recurrence, which was managed by PPV with IOL removal in 1 patient and penetrating keratoplasty for keratitis in the other patient. Two patients who underwent PPV as a secondary procedure developed recurrence, which was treated with PPV, total capsulectomy, and IOL removal. In patients without recurrence, removal or exchange of the IOL was often the last procedure used to eliminate the infection.


Seven of 26 patients (27%) did not undergo exchange or removal of the IOL. Initial treatment in these patients included injection of intraocular antibiotics in 1, PPV with intraocular antibiotics in 2, and PPV with partial capsulectomy and intraocular antibiotics in 4. None of these patients had further recurrences or interventions after initial treatment.


Visual outcomes were ≥20/100 in 17 of 26 (65%) and ≤5/200 in 7 of 26 (27%) of delayed-onset patients. The distribution of visual outcomes according to the various isolates is displayed in Table 3 . Clinical features, presenting visual acuity, and visual outcomes of delayed-onset patients classified by those who underwent IOL exchange or removal are shown in Table 4 and Figure 4 .



TABLE 3

Visual Acuity Outcomes by Cultured Organism in Delayed-Onset and Acute-Onset Endophthalmitis










































Delayed-Onset Endophthalmitis
Total n = 26 ≥20/40 ≥20/100 ≤5/200 NLP
Propionibacterium acnes (n = 11) 55% 91% 9% 0
Fungal species a (n = 7) 57% 57% 29% 0
Mycobacterium chelonae (n = 2) 50% 50% 50% 50%
Gram-negative species (n = 3) 0 0 67% 33%
Other gram-positive species (n = 3) 67% 67% 33% 33%




































Acute-Onset Endophthalmitis
Total n = 92 ≥20/40 ≥20/100 ≤5/200 NLP
Coagulase-negative Staphylococcus (n = 57) 38% 56% 13% 0
S. aureus (n = 11) 0 0 100% 0
Streptococcus species (n = 8) 0 0 67% 33%
Other b (n = 16) 11% 22% 67% 11%

NLP = no light perception.

a Fungal species include Candida parapsilosis (3), Aspergillus fumigatus , Penicillum citrinum , Paecilomyces variotti , Acremonium strictum .


b Other cultured organisms include gram-negative species.



TABLE 4

Clinical and Microbiologic Features of Delayed-Onset Endophthalmitis Patients Who Had Intraocular Lens Implant Removal vs Those Who Did Not Have Implant Removal



























































































































































































































































Patient Eye Days to Diagnosis Organism Visual Acuity at Diagnosis Hypopyon Keratic Precipitates Visual Outcome
Delayed Onset Endophthalmitis With IOL Removal
1 a OD 278 Propionibacterium acnes 20/60 Y Y 20/25
2 OD 256 Propionibacterium acnes 5/200 Y Y 20/20
3 a OD 476 Propionibacterium acnes 20/100 N N 20/30
4 OD 735 Propionibacterium acnes 20/150 N Y 20/80
5 a OD 127 Propionibacterium acnes 20/30 N Y 20/40
6 a OS 808 Propionibacterium acnes 20/80 N Y 20/60
7 OS 714 Propionibacterium acnes 20/40 N Y LP c
8 a OD 210 Propionibacterium acnes 20/40 N Y 20/70
9 OS 331 Candida parapsilosis 20/200 N Y 20/400
10 OS 125 Candida parapsilosis CF N Y 5/200
11 OD 133 Candida parapsilosis 20/200 N Y 20/25
12 OD 250 Acremonium strictum 20/200 N Y 20/30
13 OS 125 Aspergillus fumigatus 20/60 Y Y 20/20
14 OD 716 Paecilomyces variotti CF Y N 5/200
15 b OD 154 Mycobacterium chelonae 20/30 Y Y 20/25
16 OS 57 Mycobacterium chelonae 20/400 Y Y NLP d
17 OD 276 Agrobacterium radiobacter HM Y Y LP
18 a OD 202 Staphylococcus epidermidis 5/200 Y Y 20/15
19 OS 104 Staphylococcus epidermidis 2/200 Y N 20/40
Delayed Onset Endophthalmitis Without IOL Removal
20 OS 126 Propionibacterium acnes 20/50 N Y 20/25
21 OD 111 Propionibacterium acnes 20/50 N Y 20/100
22 OS 381 Propionibacterium acnes 20/40 N N 20/25
23 OD 258 Penicillum citrinum 20/60 N Y 20/30
24 OD 73 Ewingella americana 20/400 Y N 20/300
25 OS 1840 Haemophilus influenzae LP Y N NLP
26 OD 48 Streptococcus intermedius LP Y N NLP

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Jan 12, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Delayed- Versus Acute-Onset Endophthalmitis After Cataract Surgery

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