An outbreak of acute postoperative endophthalmitis after cataract surgery

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Endophthalmitis is one of the most serious complications of ophthalmic surgery, which includes postoperative cataract extraction. Outbreak of acute postoperative endophthalmitis after cataract surgery has been reported in Thailand and other
   J Med Assoc Thai Vol. 91 No. 8 20081239 Correspondence to: Ausayakhun S, Department of Ophthal-mology, Faculty of Medicine, Chiang Mai University,Chiang Mai 50200, Thailand. Phone: 053-945-512, Mobile: 08-6911-7181, Fax: 053-946-121, E-mail: sausayak An Outbreak of Acute Postoperative Endophthalmitisafter Cataract Surgery Sakarin Ausayakhun MD*,Nimitr Itthipunkul MD*, Direk Patikulsila MD*,Janejit Choovuthayakorn MD*, Paradee Kunavisarut MD*,Sopa Wattananikorn MD*, Somsanguan Ausayakhun MD, MHSc* * Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai  Background:    Endophthalmitis is one of the most serious complications of ophthalmic surgery, which includes postoperative cataract extraction. Outbreak of acute postoperative endophthalmitis after cataract surgeryhas been reported in Thailand and other countries. Objective:   To describe an outbreak of acute postoperative endophthalmitis after cataract surgery that wasreferred to Chiang Mai University Hospital during March 2006.  Material and Method:   Observational case series were made from the records of inpatients and outpatients,who had been referred for treatment of acute postoperative endophthalmitis after cataract surgery at adistrict hospital in northern Thailand. The surgery was conducted on two consecutive days by volunteer ophthalmologists of a non-profit foundation from Bangkok.  Results:  In this outbreak, the authors recorded 31 endophthalmitis cases, with 33 eyes (bilateral 2 cases). Of the 33 endophthalmitis eyes, 32 occurred following extracapsular cataract extraction with intraocular lensand one after the secondary intraocular lens implant. Microbiological investigations in the hospital weredone with aqueous tapping, vitreous tapping, and vitreous from pars plana vitrectomy.   Gram-positive cocciwere detected from vitreous tapping in four eyes.   Thirty-two cases were managed with intravitreous antibiotics,one with subconjunctival antibiotic only, and all eyes were treated with fortified topical antibiotics.   Fifteeneyes underwent pars plana vitrectomy. Assessment of visual acuity (VA) before and after treatment showed improvement in 75.8% (25/33), decrease of VA in 9.1% (3/33), while visual acuity remained stable in 15.2%(5/33). Conclusion:    In high-volume cataract surgery, an outbreak of endophthalmitis is always possible. Prompt and appropriate treatment can improve the visual outcome.  Keywords:  Endophthalmitis, Outbreak, Acute postoperative, Cataract surgery Endophthalmitis is a serious and devastatingcomplication of intraocular surgery including cataractextraction (1-5) . The authors report an outbreak of acutepostoperative endophthalmitis after cataract surgery,with attention to visual outcomes following treatment. Material and Method During March 2006, 31 cases of acute post-operative endophthalmitis were referred to Chiang MaiUniversity Hospital, Chiang Mai, Thailand. All of thereferred patients had been treated at a district hospitalin northern Thailand on two consecutive days byvolunteer ophthalmologists of a non-profit foundation.This foundation had previously carried out ocularsurgery campaigns in this hospital for more than 10settings, without any prior severe complications. In thissetting, 184 eyes of 179 patients underwent surgery,  J Med Assoc Thai 2008; 91 (8): 1239-43 Full text. e-Journal:  1240J Med Assoc Thai Vol. 91 No. 8 2008 including 153 extra-capsular cataract extraction (ECCE),16 phacoemusification (PE), five trabeculectomy, threepterygium excision, one secondary intraocular lens(IOL) implantation, and one entropion correction.Endophthalmitis occurred in 33 eyes of 31 patients, of which 32 eyes (30 cases) had undergone ECCE, andone eye had undergone secondary IOL implantation.Endophthalmitis was defined as the inflammory diseaseof the intraocular tissue predominantly in the vitreouscavity and/or anterior chamber, either infectious ornoninfectious (6) .The patients’ data, including age, sex, sys-temic diseases, date and type of operations, durationof symptoms, previous treatment, visual acuity (VA),and details of ocular findings, were recorded.Investigations from the anterior chamber and/ or the vitreous specimens consisted of Gram stainingand KOH wet preparation, and cultivation on theconventional culture media, which consisted of bloodagar, chocolate agar, and Sabouraud’s dextrose agar.All inoculations were directly done on each media. Eacheye was analyzed separately for visual outcome bycomparing the visual acuity on the date of admissionwith that on the date of discharge. Improved ordecreased visual outcome was defined for eyeswith VA 3/60 or better by a change of two or morelines on the Snellen chart. Eyes with VA less than 3/60were defined by a change from one of the followingcategories to another: finger count (FC), hand motion(HM), light projection (PJ), light perception (PL), andno light perception (NPL). Stabilization was defined asno change in VA or a change less than those describedabove (7) .Statistical analysis and computations wereperformed with the statistical program, SPSS forWindows Version 10.0 (SPSS Inc., Chicago, USA). Thefrequency table, with number and percentage, wasdescribed with descriptive statistics (range, mean andSD).The present study protocol was approvedby the research ethics committee of the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand(No. 096/2006). Results The baseline characteristics of the patientson admission date are shown in Table 1. Duration of symptoms ranged from one to four days after surgery.Most of the patients (21 cases) had no systemicdiseases, but the others had some diseases asfollows: three had hypertension (HT), two diabetesmellitus (DM), one anemia, one pulmonary disease,one heart disease, and one DM with HT and goutyarthritis.Microbiologic analysis showed Gram-positivecocci in four vitreous tap specimens, but the culturesfrom these specimens had no growth. The specimensboth from the aqueous tapping and the vitreous frompars plana vitrectomy were negative on Gram stain andculture.All eyes were treated with the fortified topicalantibiotics of cefazoline and gentamicin. Intravitrealantibiotics of ceftazidime and vancomycin wereadministered in all cases except one eye, which hada VA on admission of 6/12 and received only sub-conjunctival antibiotic of vancomycin. Pars planavitrectomy (PPV) was performed in 15 eyes. Intravitrealsteroid of dexamethasone was administered in 12 eyesof PPV. Subconjunctival steroid was injected in 11 eyes,of which three eyes had PPV. Fortified topical steroidwas given in 21 eyes.The VA on discharge date was recordedand compared to that on admission date, as shown inTable 2. The final visual outcome, which was comparedto the VA on admission date, is shown in Table 3. CharacteristicsNumber (%)No. of patients 31Age (years)Mean + SD 70.4 + 1.4Range 45-97SexMale 17 (54.8)Female 14 (45.2)LateralityUnilateral 29Bilateral 2Visual acuity (eyes)6/12-6/18 2< 6/18-3/60 6< 3/60-Fc 5HM 7PJ 6PL 5NPL 2*Fc = finger count, HM = hand motion, PJ = projection of light, PL = perception of light, NPL = no light perception* VA prior to operation Table 1. The baseline characteristics of the patients onadmission date   J Med Assoc Thai Vol. 91 No. 8 20081241 solution (25,26) .When an outbreak is identified, the sourceof infection should be pursued using microbiologicalculture specimens from the operative suite, the operatingteam, IOL, irrigating fluids, and surgical equipment. Oneshould also seek or undertake an epidemiologic inves-tigation to determine risk factors (17,24-27) . In this setting,no source of infection was found. The retrospectivereview of the surgical team was reported that mostreferred cases had used the same series of IOL fromone manufactory, so the common risk factor was sus-pected to be the hypersensitivity reaction to the IOL.The overall reported incidence of endophthal-mitis after extracataract extraction (ECCE) and phaco-emusification (PE) in the United States ranged from0.07% to 0.13% (5) . The reported incidence in a medicalhospital in Thailand was 0.37% after ECCE and 0.28%after PE (28) . Clearly, in the high-volume circumstances,an outbreak of endophthalmitis is always possible.This present report underscores the need for bettersurveillance of this condition to provide early detec-tion and prompt intervention of the outbreak.Toxic anterior segment syndrome (TASS)should be considered when there is no positive culture,because four cases in the present investigation werefound to have Gram-positive cocci. TASS (29)  is a sterilepostoperative inflammation caused by noninfectioussubstances that enter the anterior segment, resultingin toxic damage to intraocular tissues. The processusually starts 12 to 48 hours after anterior segmentsurgery, is typically limited to the anterior segment of the eye, is always Gram stain and culture negative,and usually improves with steroid treatment alone.Because of a negative culture, TASS may be a suspectedetiology of these postoperative inflammation.From the report of the surgical team, thefollow up VA at two weeks after discharge from thehospital was as follows: 12 eyes had 6/6-6/18, 15 eyeshad < 6/18-3/60, two eyes had < 3/60-Fc, 1eye had PJ,and two had NPL. No eye was enucleation since theeyes with NPL had that vision before surgery.The present study wishes to address theawareness of postoperative endophthalmitis fromsurgery in a mass campaign, either infectious or non-infectious. Early recognition with prompt and appro-priate treatment can improve the visual outcome. Acknowledgement The authors wish to thank Winai Chaidaroon,MD, who coordinated with the district hospital to gatherprevious data of the patients. VANo. on admissionNo. on discharge6/12-6/18 2 7< 6/18-3/60 618< 3/60-Fc 5 5HM 7 1PJ 6 0PL 5 0NPL 2* 2 Table 2. The visual acuity (VA) on discharge date comparedto that on admission dateFc = finger count, HM = hand motion, PJ = projection of light, PL = perception of light, NPL = no light perception* VA prior to operationVA on admission Visual outcomeTotalImprovedStableDecreased6/12-6/18 - 1 1 2< 6/18-3/60 3 2 1 6< 3/60-Fc 4 - 1 5HM 7 - - 7PJ 6 - - 6PL 5 - - 5NPL - 2 - 2*Total 25 5 3 33Fc = finger count, HM = hand motion, PJ = projection of light, PL = perception of light, NPL = no light perception* VA prior to operation Table 3. The final visual outcome compared to the visualacuity (VA) on admission date Discussion Postoperative endophthalmitis is the mostdevastating complication following cataract surgery.It may result in visual loss, and many investigators areinterested in ways to prevent it (5,8-12) . An outbreak of acute postoperative endophthalmitis after cataractsurgery is uncommon, but it has been reported severaltimes (13-23) .In Thailand, there also have been somereports of this unfortunate event (24-27) , which revealedseveral factors including defects in sterilization of surgical instruments, poor operating room hygiene,contaminated tap water, the use of multiple-dosefluids and medication (24,27) , and the intraoperative useof intrinsically contaminated intraocular irrigating  1242J Med Assoc Thai Vol. 91 No. 8 2008 References 1.Miller JJ, Scott IU, Flynn HW Jr, Smiddy WE,Newton J, Miller D. Acute-onset endophthalmitisafter cataract surgery (2000-2004): incidence,clinical settings, and visual acuity outcomes aftertreatment. Am J Ophthalmol 2005; 139: 983-7.2.West ES, Behrens A, McDonnell PJ, Tielsch JM,Schein OD. The incidence of endophthalmitisafter cataract surgery among the U.S. Medicarepopulation increased between 1994 and 2001.Ophthalmology 2005; 112: 1388-94.3.Taban M, Behrens A, Newcomb RL, Nobe MY,Saedi G, Sweet PM, et al. Acute endophthalmitisfollowing cataract surgery: a systematic review of the literature. Arch Ophthalmol 2005; 123: 613-20.4.Wong TY, Chee SP. The epidemiology of acuteendophthalmitis after cataract surgery in an Asianpopulation. Ophthalmology 2004; 111: 699-705.5.Buzard K, Liapis S. Prevention of endophthalmitis.J Cataract Refract Surg 2004; 30: 1953-9.6.Marx J. Endophthalmitis. In: Yanoff M, Duker JS,editors. Ophthalmology. London: Mosby; 1999: 1-6.7.Holland GN, Buhles WC Jr, Mastre B, Kaplan HJ.A controlled retrospective study of ganciclovirtreatment for cytomegalovirus retinopathy. Useof a standardized system for the assessment of disease outcome. UCLA CMV Retinopathy. StudyGroup. Arch Ophthalmol 1989; 107: 1759-66.8.Baird DR, Henry M, Liddell KG, Mitchell CM,Sneddon JG. Post-operative endophthalmitis: theapplication of hazard analysis critical control points(HACCP) to an infection control problem. J HospInfect 2001; 49: 14-22.9.Sandvig KU, Dannevig L. Postoperative endoph-thalmitis: establishment and results of a nationalregistry. J Cataract Refract Surg 2003; 29: 1273-80.10.Olson RJ. Reducing the risk of postoperativeendophthalmitis. Surv Ophthalmol 2004; 49(Suppl2): S55-61.11.Field D, Merrick E. Postoperative endophthalmitis:caution is the watchword. J Perioper Pract 2006;16: 16-20.12.Prophylaxis of postoperative endophthalmitisfollowing cataract surgery: results of the ESCRSmulticenter study and identification of risk factorsJ Cataract Refract Surg 2007; 33: 978-88.13.Pettit TH, Olson RJ, Foos RY, Martin WJ. Fungalendophthalmitis following intraocular lens implan-tation. A surgical epidemic. Arch Ophthalmol 1980;98: 1025-39.14.McCray E, Rampell N, Solomon SL, Bond WW,Martone WJ, O’Day D. Outbreak of Candidaparapsilosis endophthalmitis after cataract extrac-tion and intraocular lens implantation. J ClinMicrobiol 1986; 24: 625-8.15.O’Day DM, Head WS, Robinson RD. An outbreak of Candida parapsilosis endophthalmitis: analysisof strains by enzyme profile and antifungal sus-ceptibility. Br J Ophthalmol 1987; 71: 126-9.16.Mirza GE, Karakucuk S, Doganay M, CaglayangilA. Postoperative endophthalmitis caused by anEnterobacter species. J Hosp Infect 1994; 26: 167-72.17.Fridkin SK, Kremer FB, Bland LA, Padhye A,McNeil MM, Jarvis WR. Acremonium kilienseendophthalmitis that occurred after cataractextraction in an ambulatory surgical center andwas traced to an environmental reservoir. ClinInfect Dis 1996; 22: 222-7.18.Arsan AK, Adisen A, Duman S, Aslan B, Kocak I.Acute endophthalmitis outbreak after cataractsurgery. J Cataract Refract Surg 1996; 22: 1116-20.19.Tabbara KF, al Jabarti AL. Hospital construction-associated outbreak of ocular aspergillosis aftercataract surgery. Ophthalmology 1998; 105: 522-6.20.Orsi GB, Aureli P, Cassone A, Venditti M, Fara GM.Post-surgical Bacillus cereus endophthalmitisoutbreak. J Hosp Infect 1999; 42: 250-2.21.Janknecht P, Schneider CM, Ness T. Outbreak of Empedobacter brevis endophthalmitis after cata-ract extraction. Graefes Arch Clin Exp Ophthalmol2002; 240: 291-5.22.Boks T, van Dissel JT, Teterissa N, Ros F, MahmutMH, Utama ED, et al. An outbreak of endophthal-mitis after extracapsular cataract surgery probablycaused by endotoxin contaminated distilled waterused to dissolve acetylcholine. Br J Ophthalmol2006; 90: 1094-7.23.Pitaksiripan S, Butpongsapan S, PravithayakarnL, Tippayadarapanich D. An outbreak of post-operative endophthalmitis in Lampang Hospital.J Med Assoc Thai 1995; 78(Suppl 2): S95-8.24.Hugonnet S, Dosso A, Dharan S, Martin Y, HerreroML, Regnier C, et al. Outbreak of endophthalmitisafter cataract surgery: the importance of thequality of the surgical wound. Infect ControlHosp Epidemiol 2006; 27: 1246-8.25.Swaddiwudhipong W, Tangkitchot T, Silarug N.An outbreak of Pseudomonas aeruginosa post-operative endophthalmitis caused by contaminatedintraocular irrigating solution. Trans R Soc TropMed Hyg 1995; 89: 288.26.Centers for Disease Control and Prevention (CDC).   J Med Assoc Thai Vol. 91 No. 8 20081243 Outbreaks of postoperative bacterial endophthal-mitis caused by intrinsically contaminated oph-thalmic solutions - Thailand, 1992, and Canada,1993. MMWR Morb Mortal Wkly Rep 1996; 45:491-4.27.Swaddiwudhipong W, Linlawan P, Prasantong R,Kitphati R, Wongwatcharapaiboon P. A report of an outbreak of postoperative endophthalmitis. J รายงานการระบาดของการอักเสบในลกตาแบบเฉยบพลันหลังผาตัดตอกระจก ศักรนทร   อัษญคณ , นมตร    อทธพันธ กล , ดเรก   ผาตกลศลา , เจนจต   ชวฒยากร  , ภารด   คณาวศรต , โสภา   วัฒนานกร  , สมสงวน   อัษญคณภมหลัง : การอักเสบในลกตาเปนภาวะแทรกซอนทรนแรงทสดอยางหนงของการผาตัดตาซงรวมถงการผาตัดตอกระจก การระบาดของการอักเสบในลกตาแบบเฉยบพลันหลังผาตัดตอกระจกเคยมรายงานในประเทศไทยและประเทศอน   ๆ วัตถประสงค :   เพอรายงานการระบาดของการอักเสบในลกตาแบบเฉยบพลันหลังผาตัดตอกระจกทไดสงตอผปวยมารักษาทคณะแพทยศาสตร   มหาวทยาลัยเชยงใหม   ระหวางมนาคม   พ . ศ . 2549 วัสดและวธการ  :   ทการศกษาแบบสังเกตในกลมผ ปวยจากเวชระเบยนผ ปวย   ซงถกสงตัวมารับการรักษาการอักเสบ ในลกตาแบบเฉยบพลันหลังผาตัดตอกระจกทโรงพยาบาลชมชนแหงหนงในภาคเหนอของประเทศไทย   ซงไดทการผาตัดในเวลา  2 วันโดยอาสาสมัครจากมลนธหนง ผลการศกษา :   ผ ศกษาไดรายงานผปวยอักเสบในลกตาแบบเฉยบพลันหลังผาตัดตอกระจก  31 ราย  (33 ตา  ) โดยเกดหลังผาตัดใสเลนสเทยม   แบบ  extracapsular cataract extraction 32 ตา   และ    ผาตัดใสเลนสเทยมแบบทตยภม 1 ตา   ผลการสบสวนทางจลชววทยาพบ  Gram positive cocci จากน ว นตา  4 ราย   ผปวยทกรายไดรับการรักษา ดวยยาหยอดตาปฏชวนะแบบเขมขน   รวมกับฉดยาปฏชวนะเขาวนตา  32 ตา   ฉดยาปฏชวนะเขาใตเยอบตา  1 ตาและทผาตัดแบบ  pars plana vitrectomy 15 ตา   จากการประเมนสภาพการมองเหนกอนและหลังรักษา   พบวาสายตาดข น  75.8% (25 ตา  ) สายตาลดลง  9.1% (3 ตา  ) และสายตาคงเดม  15.2% (5 ตา  ) สรป  :   การผาตัดตาตอกระจกในปรมาณมาก   อาจเกดการระบาดของ   การอักเสบในลกตาแบบเฉยบพลันได   การรักษาทเหมาะสมและทันทจะชวยใหสายตาดขน Med Assoc Thai 2000; 83: 902-7.28.Trinavarat A, Atchaneeyasakul LO. Surgicaltechniques of cataract surgery and subsequentpostoperative endophthalmitis. J Med Assoc Thai2005; 88(Suppl 9): S1-5.29.Mamalis N, Edelhauser HF, Dawson DG, Chew J,LeBoyer RM, Werner L. Toxic anterior segmentsyndrome. J Cataract Refract Surg 2006; 32: 324-33.
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