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Pathological findings in poststrabismus surgery endophthalmitis
Pathological findings in poststrabismus surgery endophthalmitis Susan Huang, MD, J. Brooks Crawford, MD, and Tina Rutar, MD
Bacterial entry into the vitreous cavity via inadvertent scleral perforation is one postulated mechanism for poststrabismus surgery endophthalmitis. In a review of 746 cases, we identified 2 pediatric enucleation specimens related to complications of strabismus surgery. In both cases, the patients developed postoperative endophthalmitis and no light perception vision, and the eyes were enucleated when they became phthisical or painful. In both submitted cases, pathology showed a thick band of scar tissue emanating focally from the sclera into the vitreous. Although no needle tracts were visualized, pathological findings were consistent with scleral perforation.
F
rom our review of 746 cases of pediatric enucleation specimens received at the University of California San Francisco Hogan Eye Pathology Laboratory between 1960 and 20081 we identified 2 that were attributable to complications from endophthalmitis after strabismus surgery. We reviewed the original pathological reports, which included gross and microscopic examination findings from specimens processed according to standard pathological techniques.2 The original pathologist performed an external examination of the sclera but did not report on the appearance or location of the extraocular muscle tendons. The glass slides used for microscopic evaluation and paraffin-embedded tissue blocks were available for repeat pathological examination. A different ophthalmic pathologist re-reviewed 20 random sections from the pathological specimens.
Case 1 The pathological specimen was received in 1960 from an ophthalmologist treating a 4-year-old boy who had undergone a 5 mm medial rectus recession and 8 mm lateral rectus resection in the left eye for esotropia 1 year earlier. The operating surgeon did not report scleral perforation. On day 2 after surgery, the patient developed fever with moderate conjunctival injection, but the cornea and anterior chamber appeared clear. On the following day, the eyelid was mildly edematous and could not be opened. Chloramphenicol ointment was started for presumed conjunctivitis. On day 9 after surgery, the eyelid could be opened, and an ocular examination revealed anterior chamber inflammation, engorged iris vessels, and a pupillary membrane. Topical treatment was changed to atropine 2% and cortisone Author affiliations: University of California San Francisco Submitted August 13, 2010. Revision accepted November 24, 2010. Reprint requests: Tina Rutar, MD, University of California San Francisco, Ophthalmology, 10 Koret Way, K301, San Francisco, CA 94143-0730 (email: rutart@ vision.ucsf.edu). J AAPOS 2011;15:98-100. Copyright Ó 2011 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2010.11.018
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2.5%. After the patient developed a systemic reaction to atropine, neosynephrine 10% and then scopolamine 0.5% were used in an attempt to dilate the synechiaed pupil. One month after the initial surgery, a dense white retrolental membrane was observed, and a clinical diagnosis of endophthalmitis was made. The eye was enucleated 1 year later due to no light perception vision and pain. The 17 18 17 mm eye was submitted to pathology. The horizontal pupil-optic nerve segment of the globe was sectioned and microscopically examined.2 A peripheral calotte was used for research purposes and not pathologically examined. The pathological specimen (Figure 1) showed a scar emanating from the sclera posterior to the ora serrata. The scar was continuous with a cyclitic membrane. The scar split the choroid, retinal pigment epithelium, and retina. The ciliary body was infiltrated with chronic inflammatory cells. The retinal pigment epithelium anterior to the scar showed evidence of hyperplasia, whereas the retinal pigment epithelium posterior to the scar was atrophic and necrotic. The retina was detached, disorganized, and atrophic, adherent to the scar. No organisms were seen.
Case 2 The 21 19 21 mm eye was received in 1960 from an ophthalmologist treating a 10-year-old girl who had strabismus surgery performed on the left eye at another institution 2 years earlier. Strabismus surgery was complicated by “orbital infection.” Enucleation was performed due to no light perception vision and phthisis. No additional clinical information was provided. Pathology (Figure 2) showed a well-defined scar interrupting the ciliary body and pigment epithelium at the junction of the pars plana and pars plicata. The scar stretched to the opposite side of the eye and formed a well-developed cyclitic membrane. The ciliary body on one side of the globe was partially separated from the underlying sclera and infiltrated by chronic inflammatory cells. The retina was completely detached, folded, and adherent to the cyclitic membrane with foci of inflammatory cells within the anterior retina. Hemorrhage was also present within the retina. No organisms were seen.
Discussion In these 2 pathological specimens of pediatric poststrabismus surgery endophthalmitis, bacteria likely gained entry into the eye via a perforating scleral wound. Although neither scleral wounds nor epithelial ingrowth was observed, focal scars adherent to the sclera, disrupting the choroid, retinal pigment epithelium, and retina in Case 1 and the junction between pars plicata and pars plana in Case 2,
Journal of AAPOS
Volume 15 Number 1 / February 2011
FIG 1. Histopathological section from enucleation specimen from left eye of 4-year-old boy showing a 0.85 mm wide scar (asterisks) that disrupts the retinal pigment epithelium (arrows) and retina (arrowheads) 7.9 mm posterior to the surgical limbus (L) by chord length (hematoxylin-eosin stain, original magnification 20). K, cornea; O, ora serrata; S, sclera.
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studies reported endophthalmitis occurring without the strabismus surgeon recognizing globe perforation,3-6 although knowledge and documentation of globe perforation may have been incomplete. Other postulated mechanisms for poststrabismus surgery endophthalmitis include the formation of a scleral abscess in a region of thin sclera or intravitreal seeding from bacteremia.3,6 We are unaware of histopathological evidence for the other 2 postulated mechanisms. Three poststrabismus surgery enucleated eyes from cases that did not document perforation showed “disorganization and phthisis” or “retinal detachment and phthisis,” but no additional histopathological information was reported.3,5 The 2 cases documented herein are limited in the amount of clinical information available, and they occurred in 1958-1959, a time period during which surgical preparation, materials and techniques, and endophthalmitis management strategies were different from those of today. As would be expected on the basis of the clinical indications for enucleation, the eyes were studied years after the presumed endophthalmitis, after microbiological confirmation of endophthalmitis was no longer possible and when the eyes showed changes of chronic posterior segment inflammation and scarring. Poststrabismus surgery endophthalmitis is exceedingly rare, with a most recent estimated incidence of 1:185,000 strabismus surgeries7 and would thus be difficult to study prospectively. These pathological cases support scleral perforation as a mechanism for poststrabismus surgery endophthalmitis. Surgical techniques that decrease the likelihood of scleral perforation8 and preparations that decrease the likelihood of bacterial contamination of the ocular surface,9 needle, and suture10 would be logical strategies to decrease the likelihood of endophthalmitis. Cases such as these are also a stark reminder that the eye can occasionally be lost as the result of complications from strabismus surgery.
Literature Search
FIG 2. Histopathological section from enucleation specimen from left eye of 10-year-old girl showing a 0.6 mm scar (asterisks) that splits the pars plicata (arrow) and pars plana (arrowhead) 2.8 mm posterior to the surgical limbus (L) by chord length (hematoxylin-eosin stain, original magnification 20). K, cornea; O, ora serrata; S, sclera.
were unequivocal evidence of perforation. We surmise that needles caused the perforations because the scars were 0.6 to 0.85 mm in diameter, which would be difficult to achieve with other surgical instruments. In Case 1, the scar was 7.9 mm (chord length) posterior to the limbus and posterior to the ora serrata, and thus posterior to the usual anatomical location of the extraocular muscle insertions. In Case 2, the scar was 2.8 mm posterior to the surgical limbus, and thus anterior to the extraocular muscle insertions. Globe perforation may not be the only mechanism by which endophthalmitis can occur. The authors of previous
Journal of AAPOS
PubMed (1948-2010) and Scopus (1960-2010) were searched for the following terms: endophthalmitis AND strabismus surgery; endophthalmitis AND strabismus surgery AND pathology or histopathology. No foreign databases were searched. References 1. Huang S, Crawford JB, Porco T, Rutar T. Clinicopathologic review of pediatric enucleations during the last 50 years. J AAPOS 2010;14: 328-33. 2. Eagle RC. Specimen handling in the ophthalmic pathology laboratory. Ophthalmol Clin N Am 1995;8:1-15. 3. Recchia FM, Baurmal CR, Sivalingam A, Kleiner R, Duker JS, Vrabec TR. Endophthalmitis after pediatric strabismus surgery. Arch Ophthalmol 2000;118:939-44. 4. Thomas JW, Hamill MB, Lambert HM. Streptococcus pneumoniae endophthalmitis following strabismus surgery. Arch Ophthalmol 1993;111:1170-71. 5. Salamon SM, Friberg TR, Luxenberg MN. Endophthalmitis after strabismus surgery. Am J Ophthalmol 1982;931:39-41. 6. Kushner BJ, Meyers FL. Good visual outcome after endophthalmitis in an eye previously treated successfully for amblyopia. J Pediatr Ophthalmol Strabismus 1989;26:69-71.
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7. Simon JW, Lininger LL, Scheraga JL. Recognized scleral perforation during eye muscle surgery: Incidence and sequelae. J Pediatr Ophthalmol Strabismus 1992;29:273-5. 8. de Alba Campomanes AG, Lim AK, Fredrick DR. Cyanoacrylate adhesive use in primary operation and reoperation in rabbit eye muscle surgery. J AAPOS 2009;4:357-63.
Volume 15 Number 1 / February 2011 9. Apt L, Isenberg S, Yoshimori R, Paez JH. Chemical preparation of the eye in ophthalmic surgery. III. Effect of povidone-iodine on the conjunctiva. Arch Ophthalmol 1984;102:728-9. 10. Carothers TS, Coats DK, McCreery KM, Rossman SN, Wilson P, Wu TG, et al. Quantification of incidental needle and suture contamination during strabismus surgery. Binocul Vis Strabismus Q 2003;18:75-9.
Journal of AAPOS
Bacterial entry into the vitreous cavity via inadvertent scleral perforation is one postulated mechanism for poststrabismus surgery endophthalmitis. In a review of 746 cases, we identified 2 pediatric enucleation specimens related to complications of strabismus surgery. In both cases, the patients developed postoperative endophthalmitis and no light perception vision, and the eyes were enucleated when they became phthisical or painful. In both submitted cases, pathology showed a thick band of scar tissue emanating focally from the sclera into the vitreous. Although no needle tracts were visualized, pathological findings were consistent with scleral perforation.
F
rom our review of 746 cases of pediatric enucleation specimens received at the University of California San Francisco Hogan Eye Pathology Laboratory between 1960 and 20081 we identified 2 that were attributable to complications from endophthalmitis after strabismus surgery. We reviewed the original pathological reports, which included gross and microscopic examination findings from specimens processed according to standard pathological techniques.2 The original pathologist performed an external examination of the sclera but did not report on the appearance or location of the extraocular muscle tendons. The glass slides used for microscopic evaluation and paraffin-embedded tissue blocks were available for repeat pathological examination. A different ophthalmic pathologist re-reviewed 20 random sections from the pathological specimens.
Case 1 The pathological specimen was received in 1960 from an ophthalmologist treating a 4-year-old boy who had undergone a 5 mm medial rectus recession and 8 mm lateral rectus resection in the left eye for esotropia 1 year earlier. The operating surgeon did not report scleral perforation. On day 2 after surgery, the patient developed fever with moderate conjunctival injection, but the cornea and anterior chamber appeared clear. On the following day, the eyelid was mildly edematous and could not be opened. Chloramphenicol ointment was started for presumed conjunctivitis. On day 9 after surgery, the eyelid could be opened, and an ocular examination revealed anterior chamber inflammation, engorged iris vessels, and a pupillary membrane. Topical treatment was changed to atropine 2% and cortisone Author affiliations: University of California San Francisco Submitted August 13, 2010. Revision accepted November 24, 2010. Reprint requests: Tina Rutar, MD, University of California San Francisco, Ophthalmology, 10 Koret Way, K301, San Francisco, CA 94143-0730 (email: rutart@ vision.ucsf.edu). J AAPOS 2011;15:98-100. Copyright Ó 2011 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2010.11.018
98
2.5%. After the patient developed a systemic reaction to atropine, neosynephrine 10% and then scopolamine 0.5% were used in an attempt to dilate the synechiaed pupil. One month after the initial surgery, a dense white retrolental membrane was observed, and a clinical diagnosis of endophthalmitis was made. The eye was enucleated 1 year later due to no light perception vision and pain. The 17 18 17 mm eye was submitted to pathology. The horizontal pupil-optic nerve segment of the globe was sectioned and microscopically examined.2 A peripheral calotte was used for research purposes and not pathologically examined. The pathological specimen (Figure 1) showed a scar emanating from the sclera posterior to the ora serrata. The scar was continuous with a cyclitic membrane. The scar split the choroid, retinal pigment epithelium, and retina. The ciliary body was infiltrated with chronic inflammatory cells. The retinal pigment epithelium anterior to the scar showed evidence of hyperplasia, whereas the retinal pigment epithelium posterior to the scar was atrophic and necrotic. The retina was detached, disorganized, and atrophic, adherent to the scar. No organisms were seen.
Case 2 The 21 19 21 mm eye was received in 1960 from an ophthalmologist treating a 10-year-old girl who had strabismus surgery performed on the left eye at another institution 2 years earlier. Strabismus surgery was complicated by “orbital infection.” Enucleation was performed due to no light perception vision and phthisis. No additional clinical information was provided. Pathology (Figure 2) showed a well-defined scar interrupting the ciliary body and pigment epithelium at the junction of the pars plana and pars plicata. The scar stretched to the opposite side of the eye and formed a well-developed cyclitic membrane. The ciliary body on one side of the globe was partially separated from the underlying sclera and infiltrated by chronic inflammatory cells. The retina was completely detached, folded, and adherent to the cyclitic membrane with foci of inflammatory cells within the anterior retina. Hemorrhage was also present within the retina. No organisms were seen.
Discussion In these 2 pathological specimens of pediatric poststrabismus surgery endophthalmitis, bacteria likely gained entry into the eye via a perforating scleral wound. Although neither scleral wounds nor epithelial ingrowth was observed, focal scars adherent to the sclera, disrupting the choroid, retinal pigment epithelium, and retina in Case 1 and the junction between pars plicata and pars plana in Case 2,
Journal of AAPOS
Volume 15 Number 1 / February 2011
FIG 1. Histopathological section from enucleation specimen from left eye of 4-year-old boy showing a 0.85 mm wide scar (asterisks) that disrupts the retinal pigment epithelium (arrows) and retina (arrowheads) 7.9 mm posterior to the surgical limbus (L) by chord length (hematoxylin-eosin stain, original magnification 20). K, cornea; O, ora serrata; S, sclera.
Huang, Crawford, and Rutar
99
studies reported endophthalmitis occurring without the strabismus surgeon recognizing globe perforation,3-6 although knowledge and documentation of globe perforation may have been incomplete. Other postulated mechanisms for poststrabismus surgery endophthalmitis include the formation of a scleral abscess in a region of thin sclera or intravitreal seeding from bacteremia.3,6 We are unaware of histopathological evidence for the other 2 postulated mechanisms. Three poststrabismus surgery enucleated eyes from cases that did not document perforation showed “disorganization and phthisis” or “retinal detachment and phthisis,” but no additional histopathological information was reported.3,5 The 2 cases documented herein are limited in the amount of clinical information available, and they occurred in 1958-1959, a time period during which surgical preparation, materials and techniques, and endophthalmitis management strategies were different from those of today. As would be expected on the basis of the clinical indications for enucleation, the eyes were studied years after the presumed endophthalmitis, after microbiological confirmation of endophthalmitis was no longer possible and when the eyes showed changes of chronic posterior segment inflammation and scarring. Poststrabismus surgery endophthalmitis is exceedingly rare, with a most recent estimated incidence of 1:185,000 strabismus surgeries7 and would thus be difficult to study prospectively. These pathological cases support scleral perforation as a mechanism for poststrabismus surgery endophthalmitis. Surgical techniques that decrease the likelihood of scleral perforation8 and preparations that decrease the likelihood of bacterial contamination of the ocular surface,9 needle, and suture10 would be logical strategies to decrease the likelihood of endophthalmitis. Cases such as these are also a stark reminder that the eye can occasionally be lost as the result of complications from strabismus surgery.
Literature Search
FIG 2. Histopathological section from enucleation specimen from left eye of 10-year-old girl showing a 0.6 mm scar (asterisks) that splits the pars plicata (arrow) and pars plana (arrowhead) 2.8 mm posterior to the surgical limbus (L) by chord length (hematoxylin-eosin stain, original magnification 20). K, cornea; O, ora serrata; S, sclera.
were unequivocal evidence of perforation. We surmise that needles caused the perforations because the scars were 0.6 to 0.85 mm in diameter, which would be difficult to achieve with other surgical instruments. In Case 1, the scar was 7.9 mm (chord length) posterior to the limbus and posterior to the ora serrata, and thus posterior to the usual anatomical location of the extraocular muscle insertions. In Case 2, the scar was 2.8 mm posterior to the surgical limbus, and thus anterior to the extraocular muscle insertions. Globe perforation may not be the only mechanism by which endophthalmitis can occur. The authors of previous
Journal of AAPOS
PubMed (1948-2010) and Scopus (1960-2010) were searched for the following terms: endophthalmitis AND strabismus surgery; endophthalmitis AND strabismus surgery AND pathology or histopathology. No foreign databases were searched. References 1. Huang S, Crawford JB, Porco T, Rutar T. Clinicopathologic review of pediatric enucleations during the last 50 years. J AAPOS 2010;14: 328-33. 2. Eagle RC. Specimen handling in the ophthalmic pathology laboratory. Ophthalmol Clin N Am 1995;8:1-15. 3. Recchia FM, Baurmal CR, Sivalingam A, Kleiner R, Duker JS, Vrabec TR. Endophthalmitis after pediatric strabismus surgery. Arch Ophthalmol 2000;118:939-44. 4. Thomas JW, Hamill MB, Lambert HM. Streptococcus pneumoniae endophthalmitis following strabismus surgery. Arch Ophthalmol 1993;111:1170-71. 5. Salamon SM, Friberg TR, Luxenberg MN. Endophthalmitis after strabismus surgery. Am J Ophthalmol 1982;931:39-41. 6. Kushner BJ, Meyers FL. Good visual outcome after endophthalmitis in an eye previously treated successfully for amblyopia. J Pediatr Ophthalmol Strabismus 1989;26:69-71.
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7. Simon JW, Lininger LL, Scheraga JL. Recognized scleral perforation during eye muscle surgery: Incidence and sequelae. J Pediatr Ophthalmol Strabismus 1992;29:273-5. 8. de Alba Campomanes AG, Lim AK, Fredrick DR. Cyanoacrylate adhesive use in primary operation and reoperation in rabbit eye muscle surgery. J AAPOS 2009;4:357-63.
Volume 15 Number 1 / February 2011 9. Apt L, Isenberg S, Yoshimori R, Paez JH. Chemical preparation of the eye in ophthalmic surgery. III. Effect of povidone-iodine on the conjunctiva. Arch Ophthalmol 1984;102:728-9. 10. Carothers TS, Coats DK, McCreery KM, Rossman SN, Wilson P, Wu TG, et al. Quantification of incidental needle and suture contamination during strabismus surgery. Binocul Vis Strabismus Q 2003;18:75-9.
Journal of AAPOS