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Endophthalmitis following cataract surgery
froll1 the editor
Endophthalmitis following cataract surgery
C
ase reports are useful contributions to the ophthalmic literature for they draw attention to the unique or unusual circumstance and stimulate observation for parallel occurrences. Endophthalmitis after cataract surgery is a serious if unusual problem. An example of a particular form and its treatment is reported by Busin in this issue of the journal. The occurrence of endophthalmitis following intraocular surgery, particularly cataract surgery, is a poignant witness to the possibility of disaster. Although rare-the approximate prevalence is 1 per 1000 surgical cases (0.1 %)- exact data about the incidence for all cataract surgery are not available so each institution must examine its own records. Knowing the major source of infection-the commensal bacteria on the patient's eyelid, eyelashes, and conjunctival surface and fornices-one can make every attempt to isolate the eye in the surgical field. However, even careful draping may not prevent the natural bacterial flora on these areas from entering and thereby remaining in the eye. The adsorption of bacteria onto the surface of an intraocular lens (lOL) if it brushes against a contaminated surface 1 emphasizes the importance of isolating the 10L from the ocular surface and surrounding drape. Despite careful sterilization of the operating area and a sound aseptic technique, it is difficult to avoid some surface contact when using forceps to implant poly(methyl methacrylate) 10Ls and, even more, when undertaking forceps insertion of foldable 10Ls. The most common pathogens that may be carried into the eye under these circumstances are Staphylococcus aureus, coagulase negative Staphylococcus epidermidis, Propionibacterium acnes, and nonspore forming gram positive Corynebacterium species. 1,2 Staphylococcus aureus in particular causes a serious infection within days of surgery that usually resul ts in loss of vision, possibly even loss of the eye. Other bacteria that can cause even more
serious effects include the beta-hemolytic streptococci and Streptococcus pyogenes. Fungal infection, although rare, may also be catastrophic. Although low virulence coagulase negative staphylococci and Propionibacterium acnes cause low-grade infections, they cause considerable unexpected morbidity for the patient. Most cataract surgeons adopt preventive regimens that might include some of the following: (a) povidone-iodine application to the conjunctival fornices, cornea, eyelids, and surrounding skin immediately before surgery, which will reduce or at best eliminate bacterial populations; (b) careful draping of the eyelid to isolate the eye from the eyelids and eyelashes; (c) preoperative broad spectrum topical antibiotic applications prior to surgery; (d) addition of antibiotics to the irrigation fluids to nullifY contaminating bacteria; (e) immediate postoperative injection of a subconjunctival solution of high-dose antibiotic; (f) isolation of the 10L during transfer from package to capsular bag to prevent bacterial adsorption onto its surface. The last measure has not received the attention it deserves for potentially the only reliable method of isolating IOLs is to "inject" them through the nozzle of a cartridge, the loading of which is remote from the eye, which further reduces the possibility of contamination from the operating field. This prospect is worth further investigation for it is possible that 10Ls handled by forceps for insertion are readily, if inadvertently, exposed to adulteration and the possibility of intraocular inoculation with pathogenic flora. If it can be demonstrated that isolating the IOL from package to capsular bag does eliminate the potential of bacterial transfer, then one element in the multifactorial etiology of endophthalmitis may be reduced or eliminated while preserving the concept of minimally invasive surgery.3 Hard data on the prevalence of endophthalmitis can only be acquired by the use of stable operative
J CATARACT REFRACT SURG-VOL22, APRIL 1996
279
FROM THE EDITOR
techniques performed over several years in a number of
References
centers so sufficient facts can be gathered about a
1. Doyle A, Beigi B, Early A, et al. Adherence of bacteria to intraocular lenses: a prospective study. Br J Ophthalmol 1995; 79:347-349 2. Ariyasu RG, Kumar S, LaBrie LD, et al. Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair. Am J Ophthalmol 1995; 119: 181-188 3. Corbett MC, Hingorani N, BoultonJE, SchillingJS. Difficulty of surgery most significantly related to post-operative inflammation. Eur J Ophthalmol 1995; 1:40-47
rare event but one of such consequence that it has to be prevented. Long-term multicenter studies are now being organized in the United States and Europe. Meanwhile, case reports of unusual circumstance and outcome are useful contributions to our experience.
Emanuel S. Rosen, FReS
280
J CATARACT REFRACT SURG-VOL 22, APRIL 1996
Endophthalmitis following cataract surgery
C
ase reports are useful contributions to the ophthalmic literature for they draw attention to the unique or unusual circumstance and stimulate observation for parallel occurrences. Endophthalmitis after cataract surgery is a serious if unusual problem. An example of a particular form and its treatment is reported by Busin in this issue of the journal. The occurrence of endophthalmitis following intraocular surgery, particularly cataract surgery, is a poignant witness to the possibility of disaster. Although rare-the approximate prevalence is 1 per 1000 surgical cases (0.1 %)- exact data about the incidence for all cataract surgery are not available so each institution must examine its own records. Knowing the major source of infection-the commensal bacteria on the patient's eyelid, eyelashes, and conjunctival surface and fornices-one can make every attempt to isolate the eye in the surgical field. However, even careful draping may not prevent the natural bacterial flora on these areas from entering and thereby remaining in the eye. The adsorption of bacteria onto the surface of an intraocular lens (lOL) if it brushes against a contaminated surface 1 emphasizes the importance of isolating the 10L from the ocular surface and surrounding drape. Despite careful sterilization of the operating area and a sound aseptic technique, it is difficult to avoid some surface contact when using forceps to implant poly(methyl methacrylate) 10Ls and, even more, when undertaking forceps insertion of foldable 10Ls. The most common pathogens that may be carried into the eye under these circumstances are Staphylococcus aureus, coagulase negative Staphylococcus epidermidis, Propionibacterium acnes, and nonspore forming gram positive Corynebacterium species. 1,2 Staphylococcus aureus in particular causes a serious infection within days of surgery that usually resul ts in loss of vision, possibly even loss of the eye. Other bacteria that can cause even more
serious effects include the beta-hemolytic streptococci and Streptococcus pyogenes. Fungal infection, although rare, may also be catastrophic. Although low virulence coagulase negative staphylococci and Propionibacterium acnes cause low-grade infections, they cause considerable unexpected morbidity for the patient. Most cataract surgeons adopt preventive regimens that might include some of the following: (a) povidone-iodine application to the conjunctival fornices, cornea, eyelids, and surrounding skin immediately before surgery, which will reduce or at best eliminate bacterial populations; (b) careful draping of the eyelid to isolate the eye from the eyelids and eyelashes; (c) preoperative broad spectrum topical antibiotic applications prior to surgery; (d) addition of antibiotics to the irrigation fluids to nullifY contaminating bacteria; (e) immediate postoperative injection of a subconjunctival solution of high-dose antibiotic; (f) isolation of the 10L during transfer from package to capsular bag to prevent bacterial adsorption onto its surface. The last measure has not received the attention it deserves for potentially the only reliable method of isolating IOLs is to "inject" them through the nozzle of a cartridge, the loading of which is remote from the eye, which further reduces the possibility of contamination from the operating field. This prospect is worth further investigation for it is possible that 10Ls handled by forceps for insertion are readily, if inadvertently, exposed to adulteration and the possibility of intraocular inoculation with pathogenic flora. If it can be demonstrated that isolating the IOL from package to capsular bag does eliminate the potential of bacterial transfer, then one element in the multifactorial etiology of endophthalmitis may be reduced or eliminated while preserving the concept of minimally invasive surgery.3 Hard data on the prevalence of endophthalmitis can only be acquired by the use of stable operative
J CATARACT REFRACT SURG-VOL22, APRIL 1996
279
FROM THE EDITOR
techniques performed over several years in a number of
References
centers so sufficient facts can be gathered about a
1. Doyle A, Beigi B, Early A, et al. Adherence of bacteria to intraocular lenses: a prospective study. Br J Ophthalmol 1995; 79:347-349 2. Ariyasu RG, Kumar S, LaBrie LD, et al. Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair. Am J Ophthalmol 1995; 119: 181-188 3. Corbett MC, Hingorani N, BoultonJE, SchillingJS. Difficulty of surgery most significantly related to post-operative inflammation. Eur J Ophthalmol 1995; 1:40-47
rare event but one of such consequence that it has to be prevented. Long-term multicenter studies are now being organized in the United States and Europe. Meanwhile, case reports of unusual circumstance and outcome are useful contributions to our experience.
Emanuel S. Rosen, FReS
280
J CATARACT REFRACT SURG-VOL 22, APRIL 1996