ORIGINAL STUDY
Endophthalmitis Trends and Outcomes Following Glaucoma Surgery at a Tertiary Eye Care Hospital in Saudi Arabia Saba Al Rashaed, MD,* Fernando Arevalo, MD, FACS,*w Sulaiman Al Sulaiman, MD,* Jelewy Masoud, MD,* Abdulaziz Rushood, MD,* Nasira Asghar, MS,* and Deepak P. Edward, MD*
Purpose: To compare the incidence, microbial profile, management and outcomes of endophthalmitis after glaucoma drainage implant (GDI), or trabeculectomy over 2 separate time periods before and after the year 2000. Methods: A chart review was performed for patients with endophthalmitis after trabeculectomy (trabeculectomy group) or GDI group between 1983 to 1999 (group 1) and 2000 to 2011 (group 2) at a tertiary care hospital. Data were compared between groups and time periods. Results: There were 56 cases of endophthalmitis after trabeculectomy in group 1 and 17 cases in group 2. After GDI, there were 10 cases of endophthalmitis in group 1 and 1 case in group 2. The incidence of endophthalmitis after GDI decreased significantly from 0.0105% to 0.00074% in groups 1 and 2, respectively (P < 0.05). The incidence of endophthalmitis decreased significantly after trabeculectomy from 0.007% in group 1 to 0.00197% in group 2 (P = 0.0004). There were 26 culture-positive cases in group 1 and 10 in group 2. The most common isolates were Streptococcus species in group 1 and Staphylococcus species in group 2. Indicators of morbidity were lower in group 2. The final visual outcome in either group was not correlated to the type of surgery, microbes, or initial management. Conclusions: There was a greater incidence of endophthalmitis after trabeculectomy compared with GDI. The incidence of endophthalmitis decreased from 2001 to 2011 compared with 1983 to 1999, which is likely due to advances in surgical technique. However, significant visual morbidity does occur despite prompt treatment. Key Words: endophthalmitis, trabeculectomy, glaucoma drainage implant
(J Glaucoma 2016;25:e70–e75)
G
laucoma-filtering procedures and implantation of drainage devices are common intraocular procedures performed in cases that are poor responders or unresponsive to conservative treatment of glaucoma. However,
Received for publication April 24, 2014; accepted March 25, 2015. From the *Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia; and wRetina Division, Wilmer Eye Institute, Johns Hopkins University, School of Medicine, Baltimore, MD. Disclosure: The authors declare no conflict of interest. Reprints: Saba Al Rashaed, MD, Vitreoretinal Division, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Kingdom of Saudi Arabia (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000261
postoperative endophthalmitis can occur as a rare complication resulting in permanent visual loss. The incidence of bleb-related endophthalmitis ranges between 0.2% and 9.6%.1–7 A recent study8 suggested that changes in surgical technique may have contributed to a 4.5% decrease in the incidence of endophthalmitis over 2 time periods (1993 to 1997 and 1999 to 2005). Visual acuity after treatment of bleb-associated endophthalmitis (BAE) is typically poor.9 Only 22% to 67% of eyes with BAE achieve visual acuity of 20/400 or better.9 The most frequent causative organisms include Streptococcus species and gram-negative microbes.9 Endophthalmitis after glaucoma drainage implant (GDI) is rare with several retrospective studies reporting only a single case or a few cases. The incidence of endophthalmitis after GDI ranges between 0.8% and 6.3%.10,11 This study compares the incidence, causative organisms, management, and outcomes of endophthalmitis after GDI surgery or trabeculectomy over 2 time periods from 1983 to 1999 and 2000 to 2011 at a tertiary care eye hospital in the Kingdom of Saudi Arabia.
METHODS The Ethics Committee and Internal Review Board at King Khalid Eye Specialist Hospital (KKESH) approved this study. This study adhered to the tenets of the Declaration of Helsinki. The medical records were reviewed for all cases of endophthalmitis after GDI group or trabeculectomy (trabeculectomy group) between 1983 and 2011 including cases referred for treatment to KKESH, Riyadh, Kingdom of Saudi Arabia. After glaucoma surgery, endophthalmitis was diagnosed clinically as severe intraocular inflammation with decreasing vision and vitreous involvement that was treated with intravitreal antibiotics or pars plana vitrectomy (PPV). The total number of GDI and trabeculectomy procedures performed at KKESH was determined through the KKESH medical record coding system. The demographic data, incidence, microbiological profile, management, and final outcome of the cases were grouped by 2 periods: group 1 (1983 to 1999) and group 2 (2000 to 2011). The grouping was arbitrary to compare outcomes at least 10 years apart. For the trabeculectomy group the surgeons began using lower concentrations of mitomycin C (MMC) during trabeculectomy around 2000. Improvement of visual acuity was defined as a gain of Z2 lines of Snellen acuity at the last visit compared with baseline. Deterioration of vision was defined as a loss of
e70 | www.glaucomajournal.com J Glaucoma Volume 25, Number 2, February 2016 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 25, Number 2, February 2016
Endophthalmitis Trends and Outcomes
TABLE 1. The Demographics and Type of Glaucoma in Patients Who Underwent Trabeculectomy or Surgery for Glaucoma Drainage Implants Diagnosed With Postoperative Endophthalmitis Over 2 Time Periods
Group 1 (1983-1999) GDI (Ahmed valve) Age (y) Mean (SD) Range Sex [n (%)] Female Male Type of glaucoma [n (%)] Congenital Primary Secondary Follow-up (mo) Mean (SD) Range Trabeculectomy Age (y) Mean (SD) Range Sex [n (%)] Female Male Type of glaucoma [n (%)] Congenital Primary Secondary Follow-up (mo) Mean (SD) Range
39.2 (31.04) 12-93
Group 2 (2000-2001)
P
One patient 14 y old
4 (40.00) 6 (60.00)
0 (0.00) 1 (100.00)
— —
5 (50.00) 3 (30.00) 2 (20.00)
1 (100.00) 0 (0.00) 0 (0.00)
— — —
93 (48)
One patient 69.93
No P value because only 1 patient in GDI for group 2
43-187 0.317 48.48 (21.37) 9-84
52.76 (23.05)
18 (32.14) 38 (67.86)
10 (58.82) 7 (41.18)
— —
17 (30.36) 32 (57.14) 7 (12.50)
3 (17.65) 13 (76.47) 1 (5.88)
— — — 0.001
68.93 (63.31) 0-235
58.63 (29.79) 5-107
GDI indicates glaucoma drainage implants. P < 0.05 is statistically significant.
Snellen acuity of >2 lines at the last visit compared with baseline. In the trabeculectomy group we also reviewed the surgical approach including the type of conjunctival dissection [limbal based or fornix based (FB)], use of MMC, concentration of MMC, and duration of application. Data on the treatment of endophthalmitis were also collected. Statistical analysis was performed with SPSS for Windows, version V.17 (IBM Corp., Armonk, NY). As the data were not normally distributed, nonparametric statistical comparisons were performed. The 95% confidence intervals were calculated. A P value 0.05). Culture-negative cases had a worse visual outcome than culture-positive cases (21.6% vs. 16%, respectively) in group 1 (P = 0.64). In group 2, culture-positive cases had the worse visual outcome (22.2% vs. 0%, respectively) (P = 0.1) (Table 5). The final visual outcome based on treatment by intravitreal antibiotic compared with PPV is presented in Table 6. In group 1, the vision improved in 64.3% of eyes that underwent PPV and in 31.8%% eyes that underwent vitreous tap and intravitreal antibiotics (P = 0.09). In group 2, vision improved in 66.7%% of eyes after PPV and in 38.5% % of eyes that underwent vitreous tap (P = 0.188).
Total
22 22 10 54
Negative
Group 1 (1983-1999) [n (%)] Improved 12 (32.4) Same 17 (45.9) Worse 8 (21.6) Total 37 (100.0) Group 2 (2000-2011) [n (%)] Improved 4 (57.1) Same 3 (42.9) Worse 0(0.0) Total 7 (100.0)
2015 Wolters Kluwer Health, Inc. All rights reserved.
PPV
Total
9 3 2 14
(64.3) (21.4) (14.3) (100.0)
23 24 11 58
(39.7) (41.4) (19.1) (100.0)
2 0 1 3
(66.7) (0.0) (33.3) (100.0)
7 7 2 16
(43.8) (43.8) (12.5) (100.0)
PPV indicates pars plana vitrectomy.
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e73
Al Rashaed et al
We found that the number of endophthalmitis cases after trabeculectomy accounted for 84.8% and 94.4% in groups 1 and 2, respectively. However, endophthalmitis after GDI accounted for 15.2% and 5.6% of cases in groups 1 and 2, respectively. This observation concurs with a previous report that showed the incidence of endophthalmitis after trabeculectomy was higher than the incidence after GDI surgery.12,13 This finding might be attributed to the fact that number of trabeculectomy procedures are more frequent than GDIs. The outcomes of the current study indicate that the rates for both procedures were much lower than previously reported. For example, previous studies have published rates of endophthalmitis after trabeculectomy ranging from 0.2% to 9.6%1–8 and after GDI ranging from 0.8% to 6.3%.10,11 However, our study showed that the incidence of endophthalmitis after trabeculectomy was 0.0065 an 0.0017 in groups 1 and 2, respectively, and 0.0105 and 0.0074 after GDI in groups 1 and 2, respectively. In addition, other indicators of ocular morbidity such as rate of phthisis and rate of evisceration decreased from 2000 to 2011 compared with 1983 to 1999. The surgical approach changed over the 2 time periods for cases of endophthalmitis after trabeculectomy at KKESH. Over time, we found that there was a 23.5% decrease in the number of cases receiving higher concentrations of MMC. In addition, the duration of MMC application decreased with only 14.3% of the cases being exposed to MMC for >3 minutes between 2000and 2011 compared with 45.2% between 1983 and 1999. Although the FB approach was more common (57.1%) in 2000 to 2011, it was not statistically different from the period spanning 1983 to 1999. We suggest that this change in MMC exposure and change in surgical technique may have resulted in the decreased rate of endophthalmitis in the recent years. Our finding concurs with a recent study9 that showed that the rate of endophthalmitis after trabeculectomy decreased significantly from 5.7% in 1993 to 1997 to 1.2% in 1999 to 2005. The authors9 suggested that this decrease in endophthalmitis was related to the change in the surgical technique from limbus-based to a FB conjunctival flap. However, in the current study, the concentration of MMC and the surgical technique were changed around the same time. Hence, we believe it was likely a combination of both changes that contributed to the decrease incidence of endophthalmitis. In the GDI group a larger number of cases in group 1 received MMC application compared with group 2. As the sample size was small, we cannot draw a definitive conclusion regarding the contribution of MMC application to the greater incidence of endophthalmitis in group 1. Similar to previous reports from western countries, we found that the most commonly isolated microbes between 1983 and 2001 were the Streptococcus species.10 Interestingly, from 2000 to 2011, Staphylococcus isolates were the most common causative organism in cultures in trabeculectomy-related endophthalmitis cases (40% of isolates). This observation might have been influenced by the fewer cases of endophthalmitis during 2000 to 2011 when we found more culture-negative cases. We found that the poor visual outcome following treatment did not change over time (37.1% % vs. 43.8% in groups 1 and 2, respectively). This outcome is consistent with a similar study of 86 eyes from 1996 to 2009 at a tertiary care hospital–based eye care center in the United
J Glaucoma
Volume 25, Number 2, February 2016
States.10 We also investigated the correlation between visual outcomes, type of glaucoma, type of microbe, and initial management. We observed that those undergoing PPV as initial management had better visual outcome than those that underwent vitreous tap and intravitreal antibiotic injection in both the study periods. This observation confirms a study by Gedde et al14 who reported that patients with BAE treated with prompt vitrectomy had significantly better visual outcomes, less likelihood of severe visual decline, and lower incidence of no light perception vision than treatment with vitreous tap and intravitreal injection alone. In contrast, Busbeer et al15 reported that patients initially treated with PPV and intravitreal antibiotics had worse visual outcome than eyes that initially received initial vitreous tap with intravitreal injection of antibiotics. Wentzloff et al11 showed no effect on the final visual outcome when the initial management was PPV with intravitreal antibiotics or intravitreal antibiotic injection alone in endophthalmitis following Ahmed valve implants. Although our study also showed a trend towards better visual outcomes after PPV, there was no statistical difference between this treatment variable. We believe that the severity and nature of the disease at presentation may be a contributing factor that influences outcomes despite prompt management. In conclusion, endophthalmitis rates were higher after trabeculectomy compared with GDI with a significant reduction in endophthalmitis rates over the 2 time periods. This decrease might be related to the changes in the surgical trends over the period. However, significant visual morbidity does occur despite prompt treatment.
REFERENCES 1. Ciulla TA, Baker AS. Endophthalmitis following glaucoma filtering surgery. Int Ophthalmol Clin. 1996;36: 87–96. 2. DeBry PW, Perkins TW, Heatley G, et al. Incidence of lateonset bleb-related complications following trabeculectomy with mitomycin. Arch Ophthalmol. 2002;120:297–300. 3. Hattenhauer JM, Lipsich MP. Late endophthalmitis after filtering surgery. Am J Ophthalmol. 1971;72:1097–1101. 4. Katz LJ, Cantor LB, Spaeth GL. Complications of surgery in glaucoma. Early and late bacterial endophthalmitis following glaucoma filtering surgery. Ophthalmology. 1985;92: 959–963. 5. Muckley ED, Lehrer RA. Late-onset blebitis/endophthalmitis: incidence and outcomes with mitomycin C. Optom Vis Sci. 2004;81:499–504. 6. Sharan S, Trope GE, Chipman M, et al. Late-onset bleb infections: prevalence and risk factors. Can J Ophthalmol. 2009;44:279–283. 7. Shigeeda T, Tomidokoro A, Chen YN, et al. Long-term follow-up of initial trabeculectomy with mitomycin C for primary open-angle glaucoma in Japanese patients. J Glaucoma. 2006;15:195–199. 8. Zahid S, Musch DC, Niziol LM, et al. Collaborative Initial Glaucoma Treatment Study Group. Risk of endophthalmitis and other long-term complications of trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS). Am J Ophthalmol. 2013;155:674–680. 9. Murdoch IE, Bunce C, Barton K. Changing trends in the incidence of bleb-related infection in trabeculectomy. Br J Ophthalmol. 2012;96:971–975. 10. Jacobs DJ, Leng T, Flynn HW Jr, et al. Delayed-onset blebassociated endophthalmitis: presentation and outcome by culture result. Clin Ophthalmol. 2011;5:739–744.
e74 | www.glaucomajournal.com Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 25, Number 2, February 2016
11. Wentzloff JN, Grosskreutz CL, Pasquale LR, et al. Endophthalmitis after glaucoma drainage implant surgery. Int Ophthalmol Clin. 2007;7:109–115. 12. Al-Torbaq A, Edward DP. Delayed endophthalmitis in a child following an Ahmed glaucoma valve implant. JAAPOS. 2002;6:123–125. 13. Gedde SJ, Herndon LW, Brandt JD, et al. Surgical complications in the Tube Versus Trabeculectomy Study
Copyright
r
Endophthalmitis Trends and Outcomes
during the first year of follow-up. Am J Ophthalmol. 2007;143: 23–31. 14. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the tube versus trabeculectomy study after one year of follow-up. Am J Ophthalmol. 2007;143:9–22. 15. Busbeer BG, Recchia FM, Kaiser R, et al. Bleb-associated endophthalmitis: clinical characteristics and visual outcomes. Ophthalmology. 2004;111:1495–1503.
2015 Wolters Kluwer Health, Inc. All rights reserved.
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e75
Endophthalmitis Trends and Outcomes Following Glaucoma Surgery at a Tertiary Eye Care Hospital in Saudi Arabia Saba Al Rashaed, MD,* Fernando Arevalo, MD, FACS,*w Sulaiman Al Sulaiman, MD,* Jelewy Masoud, MD,* Abdulaziz Rushood, MD,* Nasira Asghar, MS,* and Deepak P. Edward, MD*
Purpose: To compare the incidence, microbial profile, management and outcomes of endophthalmitis after glaucoma drainage implant (GDI), or trabeculectomy over 2 separate time periods before and after the year 2000. Methods: A chart review was performed for patients with endophthalmitis after trabeculectomy (trabeculectomy group) or GDI group between 1983 to 1999 (group 1) and 2000 to 2011 (group 2) at a tertiary care hospital. Data were compared between groups and time periods. Results: There were 56 cases of endophthalmitis after trabeculectomy in group 1 and 17 cases in group 2. After GDI, there were 10 cases of endophthalmitis in group 1 and 1 case in group 2. The incidence of endophthalmitis after GDI decreased significantly from 0.0105% to 0.00074% in groups 1 and 2, respectively (P < 0.05). The incidence of endophthalmitis decreased significantly after trabeculectomy from 0.007% in group 1 to 0.00197% in group 2 (P = 0.0004). There were 26 culture-positive cases in group 1 and 10 in group 2. The most common isolates were Streptococcus species in group 1 and Staphylococcus species in group 2. Indicators of morbidity were lower in group 2. The final visual outcome in either group was not correlated to the type of surgery, microbes, or initial management. Conclusions: There was a greater incidence of endophthalmitis after trabeculectomy compared with GDI. The incidence of endophthalmitis decreased from 2001 to 2011 compared with 1983 to 1999, which is likely due to advances in surgical technique. However, significant visual morbidity does occur despite prompt treatment. Key Words: endophthalmitis, trabeculectomy, glaucoma drainage implant
(J Glaucoma 2016;25:e70–e75)
G
laucoma-filtering procedures and implantation of drainage devices are common intraocular procedures performed in cases that are poor responders or unresponsive to conservative treatment of glaucoma. However,
Received for publication April 24, 2014; accepted March 25, 2015. From the *Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia; and wRetina Division, Wilmer Eye Institute, Johns Hopkins University, School of Medicine, Baltimore, MD. Disclosure: The authors declare no conflict of interest. Reprints: Saba Al Rashaed, MD, Vitreoretinal Division, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Kingdom of Saudi Arabia (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000261
postoperative endophthalmitis can occur as a rare complication resulting in permanent visual loss. The incidence of bleb-related endophthalmitis ranges between 0.2% and 9.6%.1–7 A recent study8 suggested that changes in surgical technique may have contributed to a 4.5% decrease in the incidence of endophthalmitis over 2 time periods (1993 to 1997 and 1999 to 2005). Visual acuity after treatment of bleb-associated endophthalmitis (BAE) is typically poor.9 Only 22% to 67% of eyes with BAE achieve visual acuity of 20/400 or better.9 The most frequent causative organisms include Streptococcus species and gram-negative microbes.9 Endophthalmitis after glaucoma drainage implant (GDI) is rare with several retrospective studies reporting only a single case or a few cases. The incidence of endophthalmitis after GDI ranges between 0.8% and 6.3%.10,11 This study compares the incidence, causative organisms, management, and outcomes of endophthalmitis after GDI surgery or trabeculectomy over 2 time periods from 1983 to 1999 and 2000 to 2011 at a tertiary care eye hospital in the Kingdom of Saudi Arabia.
METHODS The Ethics Committee and Internal Review Board at King Khalid Eye Specialist Hospital (KKESH) approved this study. This study adhered to the tenets of the Declaration of Helsinki. The medical records were reviewed for all cases of endophthalmitis after GDI group or trabeculectomy (trabeculectomy group) between 1983 and 2011 including cases referred for treatment to KKESH, Riyadh, Kingdom of Saudi Arabia. After glaucoma surgery, endophthalmitis was diagnosed clinically as severe intraocular inflammation with decreasing vision and vitreous involvement that was treated with intravitreal antibiotics or pars plana vitrectomy (PPV). The total number of GDI and trabeculectomy procedures performed at KKESH was determined through the KKESH medical record coding system. The demographic data, incidence, microbiological profile, management, and final outcome of the cases were grouped by 2 periods: group 1 (1983 to 1999) and group 2 (2000 to 2011). The grouping was arbitrary to compare outcomes at least 10 years apart. For the trabeculectomy group the surgeons began using lower concentrations of mitomycin C (MMC) during trabeculectomy around 2000. Improvement of visual acuity was defined as a gain of Z2 lines of Snellen acuity at the last visit compared with baseline. Deterioration of vision was defined as a loss of
e70 | www.glaucomajournal.com J Glaucoma Volume 25, Number 2, February 2016 Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 25, Number 2, February 2016
Endophthalmitis Trends and Outcomes
TABLE 1. The Demographics and Type of Glaucoma in Patients Who Underwent Trabeculectomy or Surgery for Glaucoma Drainage Implants Diagnosed With Postoperative Endophthalmitis Over 2 Time Periods
Group 1 (1983-1999) GDI (Ahmed valve) Age (y) Mean (SD) Range Sex [n (%)] Female Male Type of glaucoma [n (%)] Congenital Primary Secondary Follow-up (mo) Mean (SD) Range Trabeculectomy Age (y) Mean (SD) Range Sex [n (%)] Female Male Type of glaucoma [n (%)] Congenital Primary Secondary Follow-up (mo) Mean (SD) Range
39.2 (31.04) 12-93
Group 2 (2000-2001)
P
One patient 14 y old
4 (40.00) 6 (60.00)
0 (0.00) 1 (100.00)
— —
5 (50.00) 3 (30.00) 2 (20.00)
1 (100.00) 0 (0.00) 0 (0.00)
— — —
93 (48)
One patient 69.93
No P value because only 1 patient in GDI for group 2
43-187 0.317 48.48 (21.37) 9-84
52.76 (23.05)
18 (32.14) 38 (67.86)
10 (58.82) 7 (41.18)
— —
17 (30.36) 32 (57.14) 7 (12.50)
3 (17.65) 13 (76.47) 1 (5.88)
— — — 0.001
68.93 (63.31) 0-235
58.63 (29.79) 5-107
GDI indicates glaucoma drainage implants. P < 0.05 is statistically significant.
Snellen acuity of >2 lines at the last visit compared with baseline. In the trabeculectomy group we also reviewed the surgical approach including the type of conjunctival dissection [limbal based or fornix based (FB)], use of MMC, concentration of MMC, and duration of application. Data on the treatment of endophthalmitis were also collected. Statistical analysis was performed with SPSS for Windows, version V.17 (IBM Corp., Armonk, NY). As the data were not normally distributed, nonparametric statistical comparisons were performed. The 95% confidence intervals were calculated. A P value 0.05). Culture-negative cases had a worse visual outcome than culture-positive cases (21.6% vs. 16%, respectively) in group 1 (P = 0.64). In group 2, culture-positive cases had the worse visual outcome (22.2% vs. 0%, respectively) (P = 0.1) (Table 5). The final visual outcome based on treatment by intravitreal antibiotic compared with PPV is presented in Table 6. In group 1, the vision improved in 64.3% of eyes that underwent PPV and in 31.8%% eyes that underwent vitreous tap and intravitreal antibiotics (P = 0.09). In group 2, vision improved in 66.7%% of eyes after PPV and in 38.5% % of eyes that underwent vitreous tap (P = 0.188).
Total
22 22 10 54
Negative
Group 1 (1983-1999) [n (%)] Improved 12 (32.4) Same 17 (45.9) Worse 8 (21.6) Total 37 (100.0) Group 2 (2000-2011) [n (%)] Improved 4 (57.1) Same 3 (42.9) Worse 0(0.0) Total 7 (100.0)
2015 Wolters Kluwer Health, Inc. All rights reserved.
PPV
Total
9 3 2 14
(64.3) (21.4) (14.3) (100.0)
23 24 11 58
(39.7) (41.4) (19.1) (100.0)
2 0 1 3
(66.7) (0.0) (33.3) (100.0)
7 7 2 16
(43.8) (43.8) (12.5) (100.0)
PPV indicates pars plana vitrectomy.
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e73
Al Rashaed et al
We found that the number of endophthalmitis cases after trabeculectomy accounted for 84.8% and 94.4% in groups 1 and 2, respectively. However, endophthalmitis after GDI accounted for 15.2% and 5.6% of cases in groups 1 and 2, respectively. This observation concurs with a previous report that showed the incidence of endophthalmitis after trabeculectomy was higher than the incidence after GDI surgery.12,13 This finding might be attributed to the fact that number of trabeculectomy procedures are more frequent than GDIs. The outcomes of the current study indicate that the rates for both procedures were much lower than previously reported. For example, previous studies have published rates of endophthalmitis after trabeculectomy ranging from 0.2% to 9.6%1–8 and after GDI ranging from 0.8% to 6.3%.10,11 However, our study showed that the incidence of endophthalmitis after trabeculectomy was 0.0065 an 0.0017 in groups 1 and 2, respectively, and 0.0105 and 0.0074 after GDI in groups 1 and 2, respectively. In addition, other indicators of ocular morbidity such as rate of phthisis and rate of evisceration decreased from 2000 to 2011 compared with 1983 to 1999. The surgical approach changed over the 2 time periods for cases of endophthalmitis after trabeculectomy at KKESH. Over time, we found that there was a 23.5% decrease in the number of cases receiving higher concentrations of MMC. In addition, the duration of MMC application decreased with only 14.3% of the cases being exposed to MMC for >3 minutes between 2000and 2011 compared with 45.2% between 1983 and 1999. Although the FB approach was more common (57.1%) in 2000 to 2011, it was not statistically different from the period spanning 1983 to 1999. We suggest that this change in MMC exposure and change in surgical technique may have resulted in the decreased rate of endophthalmitis in the recent years. Our finding concurs with a recent study9 that showed that the rate of endophthalmitis after trabeculectomy decreased significantly from 5.7% in 1993 to 1997 to 1.2% in 1999 to 2005. The authors9 suggested that this decrease in endophthalmitis was related to the change in the surgical technique from limbus-based to a FB conjunctival flap. However, in the current study, the concentration of MMC and the surgical technique were changed around the same time. Hence, we believe it was likely a combination of both changes that contributed to the decrease incidence of endophthalmitis. In the GDI group a larger number of cases in group 1 received MMC application compared with group 2. As the sample size was small, we cannot draw a definitive conclusion regarding the contribution of MMC application to the greater incidence of endophthalmitis in group 1. Similar to previous reports from western countries, we found that the most commonly isolated microbes between 1983 and 2001 were the Streptococcus species.10 Interestingly, from 2000 to 2011, Staphylococcus isolates were the most common causative organism in cultures in trabeculectomy-related endophthalmitis cases (40% of isolates). This observation might have been influenced by the fewer cases of endophthalmitis during 2000 to 2011 when we found more culture-negative cases. We found that the poor visual outcome following treatment did not change over time (37.1% % vs. 43.8% in groups 1 and 2, respectively). This outcome is consistent with a similar study of 86 eyes from 1996 to 2009 at a tertiary care hospital–based eye care center in the United
J Glaucoma
Volume 25, Number 2, February 2016
States.10 We also investigated the correlation between visual outcomes, type of glaucoma, type of microbe, and initial management. We observed that those undergoing PPV as initial management had better visual outcome than those that underwent vitreous tap and intravitreal antibiotic injection in both the study periods. This observation confirms a study by Gedde et al14 who reported that patients with BAE treated with prompt vitrectomy had significantly better visual outcomes, less likelihood of severe visual decline, and lower incidence of no light perception vision than treatment with vitreous tap and intravitreal injection alone. In contrast, Busbeer et al15 reported that patients initially treated with PPV and intravitreal antibiotics had worse visual outcome than eyes that initially received initial vitreous tap with intravitreal injection of antibiotics. Wentzloff et al11 showed no effect on the final visual outcome when the initial management was PPV with intravitreal antibiotics or intravitreal antibiotic injection alone in endophthalmitis following Ahmed valve implants. Although our study also showed a trend towards better visual outcomes after PPV, there was no statistical difference between this treatment variable. We believe that the severity and nature of the disease at presentation may be a contributing factor that influences outcomes despite prompt management. In conclusion, endophthalmitis rates were higher after trabeculectomy compared with GDI with a significant reduction in endophthalmitis rates over the 2 time periods. This decrease might be related to the changes in the surgical trends over the period. However, significant visual morbidity does occur despite prompt treatment.
REFERENCES 1. Ciulla TA, Baker AS. Endophthalmitis following glaucoma filtering surgery. Int Ophthalmol Clin. 1996;36: 87–96. 2. DeBry PW, Perkins TW, Heatley G, et al. Incidence of lateonset bleb-related complications following trabeculectomy with mitomycin. Arch Ophthalmol. 2002;120:297–300. 3. Hattenhauer JM, Lipsich MP. Late endophthalmitis after filtering surgery. Am J Ophthalmol. 1971;72:1097–1101. 4. Katz LJ, Cantor LB, Spaeth GL. Complications of surgery in glaucoma. Early and late bacterial endophthalmitis following glaucoma filtering surgery. Ophthalmology. 1985;92: 959–963. 5. Muckley ED, Lehrer RA. Late-onset blebitis/endophthalmitis: incidence and outcomes with mitomycin C. Optom Vis Sci. 2004;81:499–504. 6. Sharan S, Trope GE, Chipman M, et al. Late-onset bleb infections: prevalence and risk factors. Can J Ophthalmol. 2009;44:279–283. 7. Shigeeda T, Tomidokoro A, Chen YN, et al. Long-term follow-up of initial trabeculectomy with mitomycin C for primary open-angle glaucoma in Japanese patients. J Glaucoma. 2006;15:195–199. 8. Zahid S, Musch DC, Niziol LM, et al. Collaborative Initial Glaucoma Treatment Study Group. Risk of endophthalmitis and other long-term complications of trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS). Am J Ophthalmol. 2013;155:674–680. 9. Murdoch IE, Bunce C, Barton K. Changing trends in the incidence of bleb-related infection in trabeculectomy. Br J Ophthalmol. 2012;96:971–975. 10. Jacobs DJ, Leng T, Flynn HW Jr, et al. Delayed-onset blebassociated endophthalmitis: presentation and outcome by culture result. Clin Ophthalmol. 2011;5:739–744.
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11. Wentzloff JN, Grosskreutz CL, Pasquale LR, et al. Endophthalmitis after glaucoma drainage implant surgery. Int Ophthalmol Clin. 2007;7:109–115. 12. Al-Torbaq A, Edward DP. Delayed endophthalmitis in a child following an Ahmed glaucoma valve implant. JAAPOS. 2002;6:123–125. 13. Gedde SJ, Herndon LW, Brandt JD, et al. Surgical complications in the Tube Versus Trabeculectomy Study
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during the first year of follow-up. Am J Ophthalmol. 2007;143: 23–31. 14. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the tube versus trabeculectomy study after one year of follow-up. Am J Ophthalmol. 2007;143:9–22. 15. Busbeer BG, Recchia FM, Kaiser R, et al. Bleb-associated endophthalmitis: clinical characteristics and visual outcomes. Ophthalmology. 2004;111:1495–1503.
2015 Wolters Kluwer Health, Inc. All rights reserved.
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