Documenta Ophthalmologica 82: 109-114, 1992. 9 1992 Kluwer Academic Publishers. Printed in the Netherlands.
Pseudophakic endophthalmitis G.V. J A G E R , a C.J.J. B R I N K M A N , 1 C.J.G. VAN T I L B U R G , 2 W.H. B E E K H U I S 2 & M.V. J O O S S E 2 tDepartment of Ophthalmology, Academic Medical Center, Amsterdam; Rotterdam, The Netherlands
2Eye Hospital,
Accepted 1 September 1992 Key words: Antimicrobial resistance, Intravitreal antibiotics, Pseudophakic endophthalmitis,
Staphylococcus epidermidis, Vitrectomy Abstract. We performed a retrospective study on 45 patients admitted to the Rotterdam Eye
Hospital and the Ophthalmic Department of the Academic Medical Center in Amsterdam with pseudophakic endophthalmitis. Vitreous loss during cataract extraction was associated with a significantly increased risk of postoperative endophthalmitis when compared with uncomplicated cataract extraction (p 0.05)**
(p < 0.0001)**
* Controls consisted of pseudophakic patients who did not develop endophthalmitis. (N = 564 in the first comparison, N = 1764 in the second comparison). **Chi-square test.
111 statistically significant. The cataract extraction had been complicated by vitreous loss in 12 (26.7%) of the endophthalmitis patients as compared to 73 (4.1%) of the control group (Table 1). This difference is highly significant (p 20/40
%
7
15
17 13 8
38 29 18
20/200, while of the 17 non-vitrectomized patients 11 (65%) developed a final visual acuity equal to or better than 20/200.
Discussion
The initial therapy for bacterial endophthalmitis includes the use of antibiotics before culture and sensitivity results are available. Cephazolin and gentamicin have been recommended earlier as the first-line intravitreal therapy for endophthalmitis because of efficacy against common intraocular pathogens and a combined broad spectrum of coverage [4]. Staphylococcus epidermidis is the most common cultured intraocular pathogen [3, 5]. In the present study it accounts for 63% of the culture-positive endophthalmitis cases. Davis [6] reports increased resistance of coagulase-negative staphylococci to methicillin (19 versus 27%) and to gentamicin (0 versus 35%) on comparing cases before and after 1982. No isolates were resistant to vancomycin. More than half of the S. epidermidis isolates in the present study showed resistance to methicillin. Although none showed resistance to the combination of gentamicin and methicillin or cephazolin, gentamicin and vancomycin might be expected to provide better coverage for endophthalmitis due to staphylococci. There is still no consensus on the use of vitrectomy in the management of endophthalmitis. Vitrectomy offers several theoretical advantages, including removal of the infecting organisms and their toxins, removal of vitreous membranes, clearing of the vitreous, better distribution of antibiotics and provision of adequate material for culture. In animal studies vitrectomy, followed by intraocular antibiotics, has been shown to offer advantages over intraocular antibiotics alone [7, 8]. Data from human studies, however, have been less conclusive. Like previous studies [4, 5, 9], the present sttrdy showed that, on the grounds of the percentage of eyes achieving 20/200 or 20/400 visual acuity or better, non-vitrectomized eyes do better than vitrectomized eyes. In these human studies however the eyes selected for vitrectomy were those with the worst clinical presentation. This selection bias makes it impossible to determine whether vitrectomy results in better
113
visual acuity or not. The exact role of vitrectomy in the initial management of endophthalmitis remains controversial and is still a subject for further
study [101. In 1955 Maylath & Leopold [11] suggested that the vitreous cavity plays a special role in the pathogenesis of postoperative endophthalmitis. They demonstrated in rabbits that injection of bacteria into the vitreous produced endophthalmitis even though similar injections into the anterior chamber were rapidly cleared. They concluded that the vitreous was an excellent culture medium. Other clinical studies, like the present study, have shown an association of postoperative endophthalmitis with procedures involving vitreous loss [3, 5, 13, 14]. In addition, vitreous cultures in eyes suspected of having endophthalmitis are more frequently positive than aqueous humor cultures. This difference in culture results between aqueous homor and vitreous has been described before [3, 12]. It is well documented that patients with diabetes mellitus are more prone to multiple systemic infections [5]. A recent review of postoperative endophthalmitis at the Bascom Palmer Eye Institute demonstrated a statistically significant relationship between endophthalmitis and diabetes mellitus [2]. Our study and previous ones [13, 16] could not confirm this relationship.
References 1. Javitt JC, Vitale S, Canner JK, et al. National outcomes of cataract extraction: Endophthalmitis following inpatient surgery. Arch Ophthalmol 1991; 109: 1085-89. 2. Kattan HM, Flynn HW, Pflugfelder SC, et al. Nosocomial endophthalmitis survey: Current incidence of infection after intraocular surgery. Ophthalmology 1991; 98: 227-38. 3. Puliafito CA, Baker AS, Haaf J, et al. Infectious endophthalmitis: Review of 36 cases. Ophthalmology 1982; 89: 921-29. 4. Forster RK, Abbott RL, Gelender H. Management of infectious endophthalmitis: Ophthalmology 1980; 87: 313-19. 5. Driebe WT, Mandelbaum S, Forster RK. Pseudophakic endophthalmitis: Diagnosis and management. Ophthalmology 1986; 93: 442-48. 6. Davis JL, Koidou-Tsiligianni A, Pflugfelder SC, et al. Coagulase-negative staphylococal endophthalmitis: Increase in antimicrobial resistance. Ophthalmology 1988; 95: 1404-10. 7. Peyman GA, Vastine DW, Raichand M. Symposium: Postoperative endophthalmitis Experimental aspects and their clinical applications. Ophthalmology (AAO) 1978; 85: 374-85. 8. Talley AR, D'Amico DJ, Talamo JH, et al. The role of vitrectomy in the treatment of postoperative endophthalmitis: An experimental study. Arch Ophthalmol 1987; 105: 1699-702. 9. Diamond JG. Intraocular management of endophthalmitis: The systemic approach. Arch Ophthalmol 1981; 99: 96-99. 10. Dolt BH. The endophthalmitis vitrectomy study. Arch Ophthalmol 1991; 109: 487-89. 11. Maylath FR, Leopold IH. Study of experimental intraocular infection, I: The recoverability of organisms inoculated into ocular tissues and fluids. Am J Ophthalmol 1955; 40: 86-101. 12. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology 1991; 98: 639-50.
114 13. Menikoff JA, Speaker MG, Marmor M, et al. A case control study of risk factors for postoperative endophthalmitis. Ophthalmology 1991; 98: 1761-68. 14. Christy NE, Lall P. Postoperative endophthalmitis following cataract surgery: Effects of subconjunctival antibiotict and other factors. Arch Ophthalmol 1973; 90: 361-66. 15. Schoenbaum SC. Infection in diabetes. In: Kozak GP, ed. Clinical diabetes mellitus. Philadelphia: WB Saunders, 1982: 327-32. 16. Allan HF, Mangiaracine AB. Bacterial endophthalmitis after cataract extraction: A study of 22 infections in 20.000 operations. Arch OphthalmoI 1964; 72: 454-62.
Address for correspondence: G.V. Jager, Department of Ophthalmology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam ZO, The Netherlands.
Pseudophakic endophthalmitis G.V. J A G E R , a C.J.J. B R I N K M A N , 1 C.J.G. VAN T I L B U R G , 2 W.H. B E E K H U I S 2 & M.V. J O O S S E 2 tDepartment of Ophthalmology, Academic Medical Center, Amsterdam; Rotterdam, The Netherlands
2Eye Hospital,
Accepted 1 September 1992 Key words: Antimicrobial resistance, Intravitreal antibiotics, Pseudophakic endophthalmitis,
Staphylococcus epidermidis, Vitrectomy Abstract. We performed a retrospective study on 45 patients admitted to the Rotterdam Eye
Hospital and the Ophthalmic Department of the Academic Medical Center in Amsterdam with pseudophakic endophthalmitis. Vitreous loss during cataract extraction was associated with a significantly increased risk of postoperative endophthalmitis when compared with uncomplicated cataract extraction (p 0.05)**
(p < 0.0001)**
* Controls consisted of pseudophakic patients who did not develop endophthalmitis. (N = 564 in the first comparison, N = 1764 in the second comparison). **Chi-square test.
111 statistically significant. The cataract extraction had been complicated by vitreous loss in 12 (26.7%) of the endophthalmitis patients as compared to 73 (4.1%) of the control group (Table 1). This difference is highly significant (p 20/40
%
7
15
17 13 8
38 29 18
20/200, while of the 17 non-vitrectomized patients 11 (65%) developed a final visual acuity equal to or better than 20/200.
Discussion
The initial therapy for bacterial endophthalmitis includes the use of antibiotics before culture and sensitivity results are available. Cephazolin and gentamicin have been recommended earlier as the first-line intravitreal therapy for endophthalmitis because of efficacy against common intraocular pathogens and a combined broad spectrum of coverage [4]. Staphylococcus epidermidis is the most common cultured intraocular pathogen [3, 5]. In the present study it accounts for 63% of the culture-positive endophthalmitis cases. Davis [6] reports increased resistance of coagulase-negative staphylococci to methicillin (19 versus 27%) and to gentamicin (0 versus 35%) on comparing cases before and after 1982. No isolates were resistant to vancomycin. More than half of the S. epidermidis isolates in the present study showed resistance to methicillin. Although none showed resistance to the combination of gentamicin and methicillin or cephazolin, gentamicin and vancomycin might be expected to provide better coverage for endophthalmitis due to staphylococci. There is still no consensus on the use of vitrectomy in the management of endophthalmitis. Vitrectomy offers several theoretical advantages, including removal of the infecting organisms and their toxins, removal of vitreous membranes, clearing of the vitreous, better distribution of antibiotics and provision of adequate material for culture. In animal studies vitrectomy, followed by intraocular antibiotics, has been shown to offer advantages over intraocular antibiotics alone [7, 8]. Data from human studies, however, have been less conclusive. Like previous studies [4, 5, 9], the present sttrdy showed that, on the grounds of the percentage of eyes achieving 20/200 or 20/400 visual acuity or better, non-vitrectomized eyes do better than vitrectomized eyes. In these human studies however the eyes selected for vitrectomy were those with the worst clinical presentation. This selection bias makes it impossible to determine whether vitrectomy results in better
113
visual acuity or not. The exact role of vitrectomy in the initial management of endophthalmitis remains controversial and is still a subject for further
study [101. In 1955 Maylath & Leopold [11] suggested that the vitreous cavity plays a special role in the pathogenesis of postoperative endophthalmitis. They demonstrated in rabbits that injection of bacteria into the vitreous produced endophthalmitis even though similar injections into the anterior chamber were rapidly cleared. They concluded that the vitreous was an excellent culture medium. Other clinical studies, like the present study, have shown an association of postoperative endophthalmitis with procedures involving vitreous loss [3, 5, 13, 14]. In addition, vitreous cultures in eyes suspected of having endophthalmitis are more frequently positive than aqueous humor cultures. This difference in culture results between aqueous homor and vitreous has been described before [3, 12]. It is well documented that patients with diabetes mellitus are more prone to multiple systemic infections [5]. A recent review of postoperative endophthalmitis at the Bascom Palmer Eye Institute demonstrated a statistically significant relationship between endophthalmitis and diabetes mellitus [2]. Our study and previous ones [13, 16] could not confirm this relationship.
References 1. Javitt JC, Vitale S, Canner JK, et al. National outcomes of cataract extraction: Endophthalmitis following inpatient surgery. Arch Ophthalmol 1991; 109: 1085-89. 2. Kattan HM, Flynn HW, Pflugfelder SC, et al. Nosocomial endophthalmitis survey: Current incidence of infection after intraocular surgery. Ophthalmology 1991; 98: 227-38. 3. Puliafito CA, Baker AS, Haaf J, et al. Infectious endophthalmitis: Review of 36 cases. Ophthalmology 1982; 89: 921-29. 4. Forster RK, Abbott RL, Gelender H. Management of infectious endophthalmitis: Ophthalmology 1980; 87: 313-19. 5. Driebe WT, Mandelbaum S, Forster RK. Pseudophakic endophthalmitis: Diagnosis and management. Ophthalmology 1986; 93: 442-48. 6. Davis JL, Koidou-Tsiligianni A, Pflugfelder SC, et al. Coagulase-negative staphylococal endophthalmitis: Increase in antimicrobial resistance. Ophthalmology 1988; 95: 1404-10. 7. Peyman GA, Vastine DW, Raichand M. Symposium: Postoperative endophthalmitis Experimental aspects and their clinical applications. Ophthalmology (AAO) 1978; 85: 374-85. 8. Talley AR, D'Amico DJ, Talamo JH, et al. The role of vitrectomy in the treatment of postoperative endophthalmitis: An experimental study. Arch Ophthalmol 1987; 105: 1699-702. 9. Diamond JG. Intraocular management of endophthalmitis: The systemic approach. Arch Ophthalmol 1981; 99: 96-99. 10. Dolt BH. The endophthalmitis vitrectomy study. Arch Ophthalmol 1991; 109: 487-89. 11. Maylath FR, Leopold IH. Study of experimental intraocular infection, I: The recoverability of organisms inoculated into ocular tissues and fluids. Am J Ophthalmol 1955; 40: 86-101. 12. Speaker MG, Milch FA, Shah MK, et al. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology 1991; 98: 639-50.
114 13. Menikoff JA, Speaker MG, Marmor M, et al. A case control study of risk factors for postoperative endophthalmitis. Ophthalmology 1991; 98: 1761-68. 14. Christy NE, Lall P. Postoperative endophthalmitis following cataract surgery: Effects of subconjunctival antibiotict and other factors. Arch Ophthalmol 1973; 90: 361-66. 15. Schoenbaum SC. Infection in diabetes. In: Kozak GP, ed. Clinical diabetes mellitus. Philadelphia: WB Saunders, 1982: 327-32. 16. Allan HF, Mangiaracine AB. Bacterial endophthalmitis after cataract extraction: A study of 22 infections in 20.000 operations. Arch OphthalmoI 1964; 72: 454-62.
Address for correspondence: G.V. Jager, Department of Ophthalmology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam ZO, The Netherlands.
