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Endophthalmitis, Postoperative: Follow-up

Author: Mehran Taban, MD, Vitreoretinal Fellow, Cole Eye Institute, Cleveland Clinic Foundation
Coauthor(s): William B Trattler, MD, Ophthalmologist, The Center for Excellence in Eye Care; Volunteer Assistant Professor of Ophthalmology, Bascom Palmer Eye Institute; William Lloyd Clark, MD, Consulting Staff, Palmetto Retina; Peter K Kaiser, MD, Consulting Staff, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation
Contributor Information and Disclosures

Updated: Nov 6, 2008

Follow-up

Further Outpatient Care

  • Initially, administer topical therapy hourly and taper only after clinical improvement is seen.
  • Examine patients on a daily basis during the initial treatment period to ensure adequate sterilization of the vitreous cavity, to control intraocular inflammation, and to identify the need for additional intervention.
  • In the EVS, a total of 44 patients (10.5%) underwent an additional procedure during the first week after initial treatment, with 6 undergoing a procedure due to a complication of the disease or treatment and 38 due to worsening inflammation.20
    • Of the patients in the TAP group that underwent repeat intraocular cultures, 71% had persistent positive cultures, compared to 13% in the VIT group, suggesting that vitrectomy may be more effective in sterilization of the ocular contents.
    • The EVS also evaluated the need for additional procedures between 1 week and 1 year, the endpoint for follow-up care. A total of 26.9% of patients underwent a late additional procedure. The most common reasons for intervention included opacified posterior capsule (9.0%), retinal detachment (4.3%), recurrent endophthalmitis (3.3%), and glaucoma (2.6%).

Complications

  • The main complication associated with postoperative endophthalmitis is severe visual loss. This occurs most commonly in patients who develop infections from virulent organisms (non–coagulase-negative staphylococci, streptococci, and gram-negative organisms), receive delayed treatment, or have vision worse than hand motion at presentation.1,11,18
  • An important late complication of treatment of postoperative endophthalmitis remains retinal detachment. In a report from the EVS, retinal detachment can occur in 10% of patients after treatment. Possible factors involved include iatrogenic retinal tears at the time of vitreous tap, injection of antibiotics, vitrectomy, late tears associated with subtotal posterior vitrectomy, or just a consequence of the infection/inflammation and the secondary retinal necrosis. Prompt treatment of retinal detachment may result in good visual outcomes in select cases.11

Patient Education

  • One of the most important factors related to good visual outcomes after postoperative endophthalmitis is prompt recognition and diagnosis. It is critically important to counsel patients to look for the early signs and symptoms of endophthalmitis (eg, pain, redness, decreased vision) and to contact the operating physician immediately if present. If diagnosed and treated promptly, most cases may result in acceptable visual outcomes.

Miscellaneous

Medicolegal Pitfalls

  • Although endophthalmitis is a rare complication of cataract surgery it ranks as the third most common malpractice claim paid by the Ophthalmic Mutual Insurance Company.22 It ranks first in the average total payment of $177,000 per case. Therefore, great care should be taken in communication between the clinicians and between the treating physician and the patient. Prompt diagnosis by the operating surgeon and either treatment or referral to a vitreoretinal specialist is important along with open communication with the patient both before and after the procedure. Because endophthalmitis is a well-recognized complication of intraocular surgery, complete preoperative informed consent, including benefits, risks, and alternatives, is crucial in patient preparation.
 


More on Endophthalmitis, Postoperative

Overview: Endophthalmitis, Postoperative
Differential Diagnoses & Workup: Endophthalmitis, Postoperative
Treatment & Medication: Endophthalmitis, Postoperative
Follow-up: Endophthalmitis, Postoperative
References
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References

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  2. Gibb AP, Fleck BW, Kempton-Smith L. A cluster of deep bacterial infections following eye surgery associated with construction dust. J Hosp Infect. Jun 2006;63(2):197-200. [Medline].

  3. Cruciani M, Malena M, Amalfitano G, et al. Molecular epidemiology in a cluster of cases of postoperative Pseudomonas aeruginosa endophthalmitis. Clin Infect Dis. Feb 1998;26(2):330-3. [Medline].

  4. Eifrig CW, Flynn HW Jr, Scott IU, et al. Acute-onset postoperative endophthalmitis: review of incidence and visual outcomes (1995-2001). Ophthalmic Surg Lasers. Sep-Oct 2002;33(5):373-8. [Medline].

  5. Taban M, Behrens A, Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. May 2005;123(5):613-20. [Medline].

  6. West ES, Behrens A, McDonnell PJ, et al. The incidence of endophthalmitis after cataract surgery among the U.S. Medicare population increased between 1994 and 2001. Ophthalmology. Aug 2005;112(8):1388-94. [Medline].

  7. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. Jun 2007;33(6):978-88. [Medline].

  8. Lundström M, Wejde G, Stenevi U, et al. Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology. May 2007;114(5):866-70. [Medline].

  9. Ng JQ, Morlet N, Pearman JW, et al. Management and outcomes of postoperative endophthalmitis since the endophthalmitis vitrectomy study: the Endophthalmitis Population Study of Western Australia (EPSWA)'s fifth report. Ophthalmology. Jul 2005;112(7):1199-206. [Medline].

  10. 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. Dec 1995;113(12):1479-96. [Medline].

  11. Lemley CA, Han DP. Endophthalmitis: a review of current evaluation and management. Retina. Jul-Aug 2007;27(6):662-80. [Medline].

  12. Lalwani GA, Flynn HW Jr, Scott IU, et al. Acute-onset endophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology. Mar 2008;115(3):473-6. [Medline].

  13. Mandelbaum S, Meisler DM. Postoperative chronic microbial endophthalmitis. Int Ophthalmol Clin. Winter 1993;33(1):71-9. [Medline].

  14. Clark WL, Kaiser PK, Flynn HW Jr, et al. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. Sep 1999;106(9):1665-70. [Medline]. [Full Text].

  15. Fang YT, Chien LN, Ng YY, et al. Association of hospital and surgeon operation volume with the incidence of postoperative endophthalmitis: Taiwan experience. Eye. Aug 2006;20(8):900-7. [Medline].

  16. Maxwell DP Jr, Diamond JG, May DR. Surgical wound defects associated with endophthalmitis. Ophthalmic Surg. Mar 1994;25(3):157-61. [Medline].

  17. Kunimoto DY, Kaiser RS. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy. Ophthalmology. Dec 2007;114(12):2133-7. [Medline].

  18. Johnson MW, Doft BH, Kelsey SF, et al. The Endophthalmitis Vitrectomy Study. Relationship between clinical presentation and microbiologic spectrum. Ophthalmology. Feb 1997;104(2):261-72. [Medline].

  19. Busbee BG, Recchia FM, Kaiser R, et al. Bleb-associated endophthalmitis: clinical characteristics and visual outcomes. Ophthalmology. Aug 2004;111(8):1495-503; discussion 1503. [Medline].

  20. Doft BH, Kelsey SF, Wisniewski SR. Additional procedures after the initial vitrectomy or tap-biopsy in the Endophthalmitis Vitrectomy Study. Ophthalmology. Apr 1998;105(4):707-16. [Medline].

  21. Park SS, Vallar RV, Hong CH, et al. Intravitreal dexamethasone effect on intravitreal vancomycin elimination in endophthalmitis. Arch Ophthalmol. Aug 1999;117(8):1058-62. [Medline].

  22. Brick DC. Risk management lessons from a review of 168 cataract surgery claims. Surv Ophthalmol. Jan-Feb 1999;43(4):356-60. [Medline].

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Further Reading

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Keywords

postoperative endophthalmitis, eye infection, vitritis, hypopyon, bacterial infection

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Contributor Information and Disclosures

Author

Mehran Taban, MD, Vitreoretinal Fellow, Cole Eye Institute, Cleveland Clinic Foundation
Mehran Taban, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, Association for Research in Vision and Ophthalmology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

William B Trattler, MD, Ophthalmologist, The Center for Excellence in Eye Care; Volunteer Assistant Professor of Ophthalmology, Bascom Palmer Eye Institute
William B Trattler, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

William Lloyd Clark, MD, Consulting Staff, Palmetto Retina
William Lloyd Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Peter K Kaiser, MD, Consulting Staff, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation
Peter K Kaiser, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, and Society for Neuroscience
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

R Christopher Walton, MD, Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital
R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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