, Nidhi Relhan Batra1, Stephen G. Schwartz2 and Andrzej Grzybowski3, 4
(1)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
(2)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Naples, Florida, USA
(3)
Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland
(4)
Institute for Research in Ophthalmology, Poznan, Poland
Treatment outcomes are highly variable and are related to the infecting organism as well as the time to diagnosis and treatment. Prompt treatment is more important than any other consideration, including the decision between TAP and PPV. Treatment outcomes may be substantially worse in certain categories of endophthalmitis, such as post-traumatic and post-PPV, due to preexisting or concomitant posterior segment disease.
Treatment Outcomes of Acute-Onset Postoperative Endophthalmitis Following Cataract Surgery
Treatment outcomes are discussed as reported by following studies:
- (a)
The EVS
- (b)
Lalwani et al. (Ophthalmology, 1998)
- (c)
Yannuzzi et al. (AJO 2017)
Outcomes as Reported by the EVS
The multicenter, randomized clinical trial enrolled 420 patients with clinical evidence of endophthalmitis within 6 weeks of cataract surgery or secondary intraocular lens (IOL) implantation. The EVS determined the roles of immediate pars plana vitrectomy and systemic antibiotic treatment in the management of acute-onset postoperative endophthalmitis. Reported outcomes were as follows:
53% of patients had final visual acuity of 20/40 or better
15% of patients had final visual acuity of 20/200 or worse
Coagulase-negative Staphylococci associated with best outcomes
Lalwani et al. 2008
Retrospective case series of 73 eyes of 73 patients, with endophthalmitis treated at a single medical center between January 1, 1996, and December 31, 2005, for clinically diagnosed, culture-positive endophthalmitis occurring within 6 weeks of clear corneal cataract surgery. Reported outcomes were as follows:
Hypopyon was present in 60 of 73 (82.2%) eyes. The initial treatment included intravitreal vancomycin, ceftazidime, and dexamethasone. A vitreous tap and intravitreal injection were performed in 54 of 73 (74.0%) eyes and pars plana vitrectomy in 19 of 73 (26.0%) eyes.
Coagulase-negative Staphylococcus was isolated in 50 of 73 (68.4%) eyes. Other isolates included Staphylococcus aureus in 5/73 (6.8%) and Streptococcus species in 6 of 73 (8.2%).
A visual acuity of 20/40 or better was achieved in 36 of 73 patients (49.3%) at final follow-up.
The features and outcomes of endophthalmitis associated with clear corneal cataract surgery were similar to those reported in the EVS, which are associated with scleral incisions, but time to diagnosis was later with clear corneal incisions.
Yannuzzi et al. 2016
Retrospective case series of 63 eyes of 63 patients (clinical and microbiology records) with culture-positive endophthalmitis occurring within 6 weeks of clear corneal cataract surgery who presented to a tertiary referral center between 2006 and 2015 were analyzed. Reported outcomes were as follows:
Coagulase-negative Staphylococcus was isolated in 39 of 63 (62%) eyes, Staphylococcus aureus in 7 of 63 (11%) eyes, and Streptococcus species in 7 of 63 (11%) eyes.
A VA of 20/40 or better was achieved in 24 of 63 (38%) eyes.
A number of isolates were resistant to cephalosporins and fluoroquinolones.
Comparison of Yannuzzi et al. (2016) vs. Lalwani et al. (2008). Both studies were reported from the same medical center
The number of patients presenting with 5/200 or better was similar in both studies, but mean time to presentation was reported to be shorter in Yannuzzi et al. (8 vs. 13 days).
The overall distribution of organisms was similar between the two studies with coagulase-negative Staphylococcus comprising most cases.
While 19 (26%) of 73 eyes were treated with PPV as the initial treatment in Lalwani et al., only 6 (10%) of 73 eyes were treated with PPV as the initial treatment in Yannuzzi et al. (p = 0.013).
Final visual outcomes were slightly more favorable in Lalwani et al. with a larger proportion of patients achieving 20/40 and 20/100 or better, although these differences were not statistically significant (p = 0.189 and p = 0.058, respectively). There was, however, a statistically significant difference in the percentage of eyes ending with 5/200 or better (63 of 73 eyes, 86%, in Lalwani et al. vs. 45 of 63 eyes, 71%, in Yannuzzi et al. (p = 0.032).
Of the eyes with coagulase-negative Staphylococcus, 31 (62%) of 52 eyes achieved 20/40 or better in Lalwani et al. in comparison to 20 (51%) of 39 in Yannuzzi et al. p = 0.310.
Both patients treated with tap and inject as the initial treatment and those treated with PPV and inject as the upfront treatment in Yannuzzi et al. study fared slightly worse than Lalwani et al. with fewer achieving 20/40 or 20/100 or better.
References: Treatment Outcomes Acute-Onset Endophthalmitis
Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995;113(12):1479–96.
Lalwani GA, Flynn HW, Jr., Scott IU, Quinn CM, Berrocal AM, Davis JL, et al. Acute-onset endophthalmitis after clear corneal cataract surgery (1996–2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology. 2008;115(3):473–6.
Sridhar J, Yonekawa Y, Kuriyan AE, Joseph A, Thomas BJ, Liang MC, et al. Microbiologic spectrum and visual outcomes of acute-onset endophthalmitis undergoing therapeutic pars plana vitrectomy. Retina. 2017;37(7):1246–51.
Thomas BJ, Mehta N, Yonekawa Y, Sridhar J, Kuriyan AE, Relhan N, et al. Pars plana vitrectomy for late vitreoretinal sequelae of infectious endophthalmitis: surgical management and outcomes. Retina. 2017;37(4):651–6.
Yannuzzi NA, Si N, Relhan N, Kuriyan AE, Albini TA, Berrocal AM, et al. Endophthalmitis after clear corneal cataract surgery: outcomes over two decades. Am J Ophthalmol. 2017;174:155–9.
Treatment Outcomes of Delayed-Onset Postoperative Endophthalmitis Following Cataract Surgery
Visual outcomes are discussed as reported by following two studies:
- (a)
Clarke et al. (1999)
- (b)
Shirodkar et al. (2012)
Clark et al.
Clark et al. (1999) report the treatment strategies and visual acuity outcomes of chronic postoperative endophthalmitis caused by Propionibacterium acnes. In this retrospective noncomparative case series of 36 patients treated at two institutions from 1974 to 1996, the mean follow-up after the last treatment was 2.9 years. Patients underwent three different initial treatment strategies:
- 1.
Intraocular antibiotic injection alone (IOAB; n = 12)
- 2.
Pars plana vitrectomy and IOAB injection (PPV; n = 10)
- 3.
PPV with subtotal capsulectomy and IOAB injection (PPV-PC; n = 14)
The number of patients with recurrent or persistent inflammation after one of the three initial treatment strategies was as follows: (1) IOAB alone, 12 (100%); (2) PPV, 5 (50%); and (3) PPV-PC, 2 (14%).
None of the patients that underwent subsequent PPV, total capsular bag removal, IOAB injection, and either intraocular lens (IOL) exchange or removal had persistent or recurrent intraocular inflammation.
Overall, final visual acuity was 20/40 or better in 18 patients (50%), and a total of 28 patients (78%) retained 20/400 or better vision.
In this series of chronic P. acnes endophthalmitis, initial treatment with IOAB injection alone or vitrectomy without capsulectomy was associated with high rates of recurrent or persistent intraocular inflammation.
Pars plana vitrectomy, partial capsulectomy, and IOAB injection without IOL exchange were usually successful on long-term follow-up.
In patients with recurrent intraocular inflammation, pars plana vitrectomy, total capsular bag removal, IOAB injection, and IOL exchange or removal were a uniformly successful strategy.
The study recommended that in contrast to other types of postoperative endophthalmitis, IOL exchange can be considered in these patients after total capsular bag removal.
Shirodkar et al. (2012)
Shirodkar et al. (2012) reported a large retrospective consecutive case series of 118 patients with delayed-onset and acute-onset endophthalmitis (culture-proven) after cataract surgery, who were treated at the Bascom Palmer Eye Institute between January 2000 and December 2009. The study results were as follows (Table 9.1):
Table 9.1
Results of retrospective case series by Shirodkar et al. 2012
Acute-onset endophthalmitis (≤6 weeks after surgery) | Delayed-onset endophthalmitis (>6 weeks after surgery) | |
|---|---|---|
Number of cases | 92 | 26 |
Presenting visual acuity 5/200 or worse | 89% | 31% |
Hypopyon | 80% | 46% |
Most frequent isolate | Coagulase-negative Staphylococcus (57/92) | Propionibacterium acnes (11/26) |
Visual outcome of 20/100 or better in patients with most frequent isolate | 56% | 91% |
Intraocular lens removed or exchange | – | 19 of 26 cases (73%) Of these 19 cases, 13 achieved a visual outcome of 20/100 or better |
Visual Outcome
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.
Microbiology
In delayed-onset endophthalmitis group—Propionibacterium acnes was the most common organism cultured and was associated with the best visual acuity outcomes.
In the acute-onset endophthalmitis group, Coagulase-negative Staphylococcus was the most common organism cultured and was associated with the best visual acuity outcomes.
References: Treatment Outcomes Delayed-Onset Endophthalmitis
Clark WL, Kaiser PK, Flynn HW, Belfort A, Miller D, Meisler DM. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999;106(9):1665–70.
Shirodkar AR, Pathengay A, Flynn HW, Jr., Albini TA, Berrocal AM, Davis JL, et al. Delayed- versus acute-onset endophthalmitis after cataract surgery. Am J Ophthalmol. 2012;153(3):391–8 e2.
Treatment Outcomes of Endophthalmitis After Pars Plana Vitrectomy
Visual outcomes after treatment of post-PPV endophthalmitis are generally worse than after cataract surgery. Underlying retinal pathology could be the reason for poor visual potential. A review by Dave et al. of various series on endophthalmitis post vitrectomy is shown in Table 9.2.
Table 9.2
Review of literature on various series on endophthalmitis post pars plana vitrectomy
Paper | Diagnosis at time of PPV | Year | Cases | Visual outcome at last visit |
|---|---|---|---|---|
Cohen et al. | ERM, MH, PDR | 1995 | 18/12,216 | 3 EV, 6 NLP, 1 HM, 1 LP, 2 20/400, 1 20/50, 1 20/30, 1 20/25 and 2 20/20
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