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Postoperative Endophthalmitis Resulting From Prosthesis Contamination in a Monocular Patient
Postoperative Endophthalmitis Resulting From Prosthesis Contamination in a Monocular Patient Robert Morris, M.D., Fabrizio I. Camesasca, M.D., James Byrne, M.D., and George John, M.D.
Monocular patients who wear an ocular prosthesis may harbor pathogenic conjunctival flora both in the socket and in the contralateral eye. They may therefore be at increased risk of developing endophthalmitis after intraocular procedures. We studied a monocular, prosthesis-wearing, 86-year-old man who underwent cataract extraction, subtotal transpupillary vitrectomy, and intraocular lens insertion. Fulminant endophthalmitis ensued postoperatively, and despite complete vitrectomy and administration of intraocular antibiotics, the eye lost light perception. Intravitreal as well as conjunctival cultures bilaterally grew Proteus mirabilis. The patient disclosed that he cleaned the prosthesis frequently because of discharge. We considered an association between this bacterial colonization and the risk of developing postoperative endophthalmitis and suggest prophylactic measures for treatment of monocular patients undergoing intraocular procedures.
T HE RISK OF PROSTHESIS-RELATED postoperative endophthalmitis in monocular patients has reAccepted for publication May 12, 1993. From the Helen Keller Eye Research Foundation, Birmingham, Alabama (Dr. Morris); Combined Program in Ophthalmology, Eye Foundation Hospital, University of Alabama, Birmingham, Alabama (Drs. Morris and Byrne); Veterans Administration Medical Center, Birmingham, Alabama (Drs. Morris and Byrne); Department of Ophthalmology, University of Milan Scientific Institute H. 5. Raffaele, Milan, Italy (Dr. Camesasca); and Department of Ophthalmology and Visual Sciences, University of Louisvi1le School of Medicine, Louisville, Kentucky (Dr. John). This study was supported in part by a grant from the Lions Club of Montgomery, Alabama (Dr. Camesasca). Reprint requests to Robert Morris, M.D., Helen Keller Eye Research Foundation, 700 18th St. 5., Suite 605, Birmingham, AL 35233.
346
ceived little attention in ophthalmic published reports.' Explanations for this lack of reporting include the relatively small number of prosthesis wearers subjected to intraocular procedures, the small incidence of this severe complication, a possible reluctance to report this devastating occurrence, a failure to recognize the infection as having been prosthesis related, or the absence of laboratory proof and historical detail sufficient to relate the endophthalmitis to prosthesis wear. We studied the loss of the only remaining eye of a monocular patient resulting from postoperative endophthalmitis related to ocular prosthesis contamination. Patients with an ocular prosthesis may harbor bacterial pathogens in the anophthalmic socket as well as on the contralateral conjunctiva even without clinically evident infection." These pathogens may persist in the surgical field, increasing the risk of developing intraocular infection. In monocular patients, loss of the only remaining eye from postoperative endophthalmitis is a catastrophe for which extraordinary precautionary measures must be taken. We suggest a protocol for the perioperative treatment of monocular patients undergoing ocular procedures.
Case Report At initial ophthalmic examination, an 86year-old man had best-corrected visual acuity of 20/70 in the right eye, the left eye having been lost to injury. Progressive loss of vision caused by cataract had rendered the patient unable to continue his unusually active lifestyle, and cataract extraction was scheduled. When examined with the prosthesis in position, the left socket demonsttated no evidence of infection. Oral tetracycline was administered for one day before the operation, but no topical anti-
©AMERICAN JOURNAL OF OPHTHALMOLOGY 116:346-349, SEPTEMBER, 1993
Vol. 116, No.3
Ocular Prosthesis Contamination
biotics were used preoperatively. Cataract extraction was performed along with subtotal transpupillary vitrectomy. An intraocular lens was then inserted and subconjunctival injection of 20 mg of gentamicin was performed at the conclusion of the operation. A patch was placed over the eye postoperatively. The patient had pain on the first postoperative day and was noted to have a fulminant endophthalmitis. Advanced corneal opacification and extensive hypopyon were noted, which obscured visualization of the intraocular lens and the iris. The retinal reflex was absent, and the patient had a visual acuity of questionable light perception. The eye was immediately reoperated on, with removal of the intraocular lens and anterior chamber hypopyon to allow visualization of the posterior segment. A pars plana vitrectomy was performed, which was limited by visibility, and a red reflex was observed in all quadrants before completing the operation. Gentamicin (100 I1g) and cefazolin (250 I1g) were injected intravitreally, as well as 20 mg of gentamicin and 100 mg of cefazolin subconjunctivally. Vitreous aspirate collected intraoperatively disclosed abundant gram-negative rods, subsequently identified as Proteus mirabilis. Despite continued systemic and local gentamicin and cefazolin, to which the organism was sensitive, the right eye lost light perception and phthisis ensued. The prosthesis was worn continuously throughout hospitalization, including the perioperative period. The patient managed the prosthesis at all times except once when a nurse rinsed it, at his request, immediately before the cataract operation. Postoperative cultures of the contralateral socket and of the conjunctiva on the operative side both grew P. mirabilis. The patient disclosed that he routinely removed the prosthesis several times daily to clean socket discharge. By habit he performed this cleaning coincident with using the lavatory.
Discussion
Although severe postoperative complications can be associated with any intraocular procedure/ the most frequent setting for postoperative endophthalmitis is cataract extraction. In the United States, this operation is now performed at a rate of over 1/350/000 procedures
347
annually." A recently reported incidence of 0.07% for postoperative endophthalmitis after cataract extraction translates into an estimated 950 individuals in the United States who have this complication annually.' The actual incidence would be higher if other types of intraocular procedures are also considered. As recently as the early 1950s, various institutions reported rates of postcataract endophthalmitis as being 0.3%." Some investigators advocated preoperative cultures of the conjunctiva on all patients, with postponement of operations in patients who had pathogenic flora, and administration of prophylactic antibiotics." The threat posed by gram-negative organisms and the effectiveness of preoperative cultures were also described." The incidence of postoperative endophthalmitis has decreased over the past 30 years because of the introduction of disposable supplies/ improved sterilization techniques, improved surgical procedures, and advances in available antibiotics. Consequently, most surgeons have abandoned the routine use of preoperative cultures even though the bacterial flora of the operative field continues to be recognized as the primary cause of postoperative endophthalmitis.":" Instead, short treatment courses of preoperative and postoperative broad-spectrum topical antibiotics, or both, are commonly used to reduce the quantity of bacteria and the likelihood that these organisms will infect the operated-on eye. The type of prophylactic antibiotics used in ocular operations and the frequency of application vary according to the individual surgeon's preference." Reporting the incidence of postoperative endophthalmitis in a large series of cataract extractions, Allen and Mangiaracine" concluded that the preoperative administration of topical antibiotics markedly reduced the occurrence of postoperative endophthalmitis. Speaker and Menikoff!' recently noted the additional protection offered by preoperative conjunctival preparation using povidone-iodine. Ironically, while the routine use of preoperative cultures was being abandoned, several investigators demonstrated the increased incidence of colonization by pathogenic bacteria in prosthetic sockets as compared to normal conjunctival flora. Cultures of prosthetic sockets isolated pathogenic bacteria in 35% to 85% of cases. 2•12•14 Gram-negative rods occurred in 10% to 16% of socket cultures.v"" and in only 1% to 5% of cultures from normal conjunctiva.":" Anaerobes are also found with increased fre-
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AMERICAN JOURNAL OF OPHTHALMOLOGY
quency in prosthetic sockets." The frequent occurrence of similar bacterial flora colonizing the conjunctiva of both eyes has been demonstrated by Allansmith, Ostler, and Butterworth." Culture of the conjunctiva of the fellow eye in monocular patients wearing a prosthesis yielded gram-negative rods in up to 16.8% of cases.":" In our patient, the history volunteered postoperatively suggests that the prosthesis was handled with fecally contaminated fingers, resulting in colonization by gram-negative organisms. Gram-negative bacteria, mainly rods, have been isolated in 12.6% to 28.5% of all culure-positive patients with postoperative endophthalmitis.P'f Postoperative growth of the organism (P. Mirabilis), which accounted for endophthalmitis in our patient, from both the operative and anophthalmic conjunctivae, supports the hypothesis that this organism was present in the operative field at the time of the operation. Risk factors for endophthalmitis in this patient included the presence of virulent conjunctival organisms together with the absence of preoperative topical antibiotic prophylaxis, the loss of an intact posterior capsule, and anterior vitrectomy. Although different antibiotic endophthalmitis treatment regimens may be used, the failure of endophthalmitis therapy in this instance was probably most related to the advanced state of infection at the time of diagnosis and to the virulence of the infecting organism. The increased presence of pathogenic organisms capable of causing severe endophthalmitis, and the risk of total blindness in monocular prosthesis-wearing patients with this complication, justify special attention. We recommend the following for perioperative prophylaxis of monocular patients. 1. Both the prosthetic socket and the contralateral eye should be examined for clinical signs of infection or inflammation (for example, purulent discharge, conjunctival hyperemia, and lash crusting). 2. Bilateral aerobic and anaerobic bacterial cultures of the conjunctival fornices should be performed preoperatively. 3. If the cultures are negative, broad-spectrum topical antibiotics should be applied bilaterally for 48 to 72 hours preoperatively, coincident with cessation of prosthesis wear. 4. If either culture is positive, prosthesis wear should be discontinued, and topical antibiotics, chosen on the basis of in vitro antibiotic sensi-
tivities, should be applied bilaterally until conjunctival cultures are reliably negative. Surgery may then be performed. 5. The perioperative skin of the operative field and the socket should be prepared with 10% povidone-iodine and 5% povidone-iodine should be applied to the conjunctiva to be operated on and to the socket. 6. A nonocclusive shield without a patch should be used postoperatively. 7. Prosthesis wear should be resumed postoperatively according to the surgeon's clinical judgment (for example, patient reliability and hygiene, status of wound healing, and absence of excessive postoperative inflammation). Removal of the ocular prosthesis preoperatively eliminates a possible source of contamination that may not be sterilized by antibiotics alone. Although the optimal timing of prosthesis removal and replacement has not been defined experimentally, we recommend removal coincident with instituting antibiotic therapy. Follow-up examination of monocular patients should be scheduled to identify any complication as quickly as possible. An examination on the first postoperative day is essential. The patient and the family should be especially carefully instructed regarding the need to report increasing pain or decreasing vision, or both, in the operated-on eye. With these reasonable precautions, the risk of blinding postoperative endophthalmitis in monocular patients undergoing intraocular procedures will likely be markedly reduced.
References 1. Forster, R. K.: Endophthalmitis. In Tasman, W., and Jaeger, E. A. (eds.): Duane's Clinical Ophthalmology, vol. 4, chap. 24. Philadelphia, J. B. Lippincott, 1991, p. 18. 2. Miller, S. D., Smith, R. E., Dippe, D. W., Lacey, D. R., and Abel, M.: Bacteriology of the socket in patients with prostheses. Can. J. Ophthalmol. 11:126,1976. 3. Clinical Practice Guidelines. Cataracts in Adults. Washington, D.C., Center for Healthcare Policy and Research. Healthcare Finance Administration, 1991, U. S. Department of Health and Human Services. 4. Kattan, H. M., Flynn, H. W., Pflugfelder, S. c.. Robertson, C., and Forster, R. K.: Nosocomial Endophthalmitis Survey. Current incidence of infection after intraocular surgery. Ophthalmology 98:227, 1991.
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Ocular Prosthesis Contamination
5. Callahan, A.: Effect of sulfonamides and antibiotics on panophthalmitis complicating cataract extraction. Arch. Ophthalmol. 49:212, 1953. 6. Goodner, E. K.: Routine preoperative post-surgical management. Int. Ophthalmol. Clin. 3: 119, 1963. 7. Starr, M. B.: Prophylactic antibiotics for ophthalmic surgery. Surv. Ophthalmol. 27:353, 1983. 8. Speaker, M. G., Milch, F. A., Shah, M. K., Eisner, W., and Kreiswirth, B. N.: Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology 98:639, 1991. 9. Wong, I. G., and Vaughan, D. G.: Prevention of surgical infections. In Friedlaender, M. H. (ed.): Prevention of Eye Disease. New York, Mary Ann Liebert, Inc., 1988, p. 20. 10. Allen, H. F., and Mangiaracine, A. B.: Bacterial endophthalmitis after cataract extraction. A study of 22 infections in 20,000 operations. Arch. Ophthalmol. 72:454, 1964. 11. Speaker, M. G., and Menikoff, J. A.: Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 98:1769,1991. 12. Patillon, J. C,; Rousse, C.; Gauthier, C.; Guyot, F., Barbier, A., Royer, J., and Michel-Briand, Y.: La flore bacterienne de la conjonctive des sujets enuclees. Bull. Soc. Ophtalmol. Fr. 11:781, 1978. 13. Christensen, J. N., and Fahmy, J. A.: The bacterial flora of the conjunctival anophthalmic socket in glass prosthesis-carriers. Acta Ophthalmol. 52:801, 1974. 14. Dayal, Y., Subba Rao, 5., and Mahajan, V. M.:
349
Comparative study of bacterial and fungal floras of contracted sockets and fellow eyes. Ann. Ophthalmol. 16:154, 1984. 15. Walker, C. B., and Claoue, C. M. P.: Incidence of conjunctival colonization by bacteria capable of causing postoperative endophthalmitis. J. R. Soc. Med. 79:520, 1986. 16. Newton, N. L., and Jones, R.: Prophylactic antibiotic therapy for endophthalmitis with intraocular lens implantation. J. Arkansas Med. Soc. 80:249, 1983. 17. Allansmith, M. R., Ostler, H. B., and Butterworth, M.: Concomitance of bacteria in various areas of the eye. Arch. Ophthalmol. 82:37, 1969. 18. Fahmy, J. A., Moller,S., and Weis Bentzen, M.: Bacterial flora of the normal conjunctiva. I. Topographical distribution. Acta Ophthalmol. 52:786, 1974. 19. Allansmith, M. R., Anderson, R. P., and Butterworth, M.: The meaning of preoperative cultures in ophthalmology. Trans. Am. Acad. Ophthalmol. Otolaryngol. 73:683, 1969. 20. Driebe, W. T., Jr., Mandelbaum,S., Forster, R. K., Schwartz, L. K., and Culbertson, W. W.: Pseudophakic endophthalmitis. Diagnosis and management. Ophthalmology 93:442, 1986. 21. Puliafito, C. A., Baker, A. 5., Haaf, J., and Foster, C. 5.: Infectious endophthalmitis. Review of 36 cases. Ophthalmology 89:921, 1982. 22. Forster, R. K., Abbott, R. L., and Gelender, H.: Management of infectious endophthalmitis. Ophthalmology 87:313,1980.
Monocular patients who wear an ocular prosthesis may harbor pathogenic conjunctival flora both in the socket and in the contralateral eye. They may therefore be at increased risk of developing endophthalmitis after intraocular procedures. We studied a monocular, prosthesis-wearing, 86-year-old man who underwent cataract extraction, subtotal transpupillary vitrectomy, and intraocular lens insertion. Fulminant endophthalmitis ensued postoperatively, and despite complete vitrectomy and administration of intraocular antibiotics, the eye lost light perception. Intravitreal as well as conjunctival cultures bilaterally grew Proteus mirabilis. The patient disclosed that he cleaned the prosthesis frequently because of discharge. We considered an association between this bacterial colonization and the risk of developing postoperative endophthalmitis and suggest prophylactic measures for treatment of monocular patients undergoing intraocular procedures.
T HE RISK OF PROSTHESIS-RELATED postoperative endophthalmitis in monocular patients has reAccepted for publication May 12, 1993. From the Helen Keller Eye Research Foundation, Birmingham, Alabama (Dr. Morris); Combined Program in Ophthalmology, Eye Foundation Hospital, University of Alabama, Birmingham, Alabama (Drs. Morris and Byrne); Veterans Administration Medical Center, Birmingham, Alabama (Drs. Morris and Byrne); Department of Ophthalmology, University of Milan Scientific Institute H. 5. Raffaele, Milan, Italy (Dr. Camesasca); and Department of Ophthalmology and Visual Sciences, University of Louisvi1le School of Medicine, Louisville, Kentucky (Dr. John). This study was supported in part by a grant from the Lions Club of Montgomery, Alabama (Dr. Camesasca). Reprint requests to Robert Morris, M.D., Helen Keller Eye Research Foundation, 700 18th St. 5., Suite 605, Birmingham, AL 35233.
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ceived little attention in ophthalmic published reports.' Explanations for this lack of reporting include the relatively small number of prosthesis wearers subjected to intraocular procedures, the small incidence of this severe complication, a possible reluctance to report this devastating occurrence, a failure to recognize the infection as having been prosthesis related, or the absence of laboratory proof and historical detail sufficient to relate the endophthalmitis to prosthesis wear. We studied the loss of the only remaining eye of a monocular patient resulting from postoperative endophthalmitis related to ocular prosthesis contamination. Patients with an ocular prosthesis may harbor bacterial pathogens in the anophthalmic socket as well as on the contralateral conjunctiva even without clinically evident infection." These pathogens may persist in the surgical field, increasing the risk of developing intraocular infection. In monocular patients, loss of the only remaining eye from postoperative endophthalmitis is a catastrophe for which extraordinary precautionary measures must be taken. We suggest a protocol for the perioperative treatment of monocular patients undergoing ocular procedures.
Case Report At initial ophthalmic examination, an 86year-old man had best-corrected visual acuity of 20/70 in the right eye, the left eye having been lost to injury. Progressive loss of vision caused by cataract had rendered the patient unable to continue his unusually active lifestyle, and cataract extraction was scheduled. When examined with the prosthesis in position, the left socket demonsttated no evidence of infection. Oral tetracycline was administered for one day before the operation, but no topical anti-
©AMERICAN JOURNAL OF OPHTHALMOLOGY 116:346-349, SEPTEMBER, 1993
Vol. 116, No.3
Ocular Prosthesis Contamination
biotics were used preoperatively. Cataract extraction was performed along with subtotal transpupillary vitrectomy. An intraocular lens was then inserted and subconjunctival injection of 20 mg of gentamicin was performed at the conclusion of the operation. A patch was placed over the eye postoperatively. The patient had pain on the first postoperative day and was noted to have a fulminant endophthalmitis. Advanced corneal opacification and extensive hypopyon were noted, which obscured visualization of the intraocular lens and the iris. The retinal reflex was absent, and the patient had a visual acuity of questionable light perception. The eye was immediately reoperated on, with removal of the intraocular lens and anterior chamber hypopyon to allow visualization of the posterior segment. A pars plana vitrectomy was performed, which was limited by visibility, and a red reflex was observed in all quadrants before completing the operation. Gentamicin (100 I1g) and cefazolin (250 I1g) were injected intravitreally, as well as 20 mg of gentamicin and 100 mg of cefazolin subconjunctivally. Vitreous aspirate collected intraoperatively disclosed abundant gram-negative rods, subsequently identified as Proteus mirabilis. Despite continued systemic and local gentamicin and cefazolin, to which the organism was sensitive, the right eye lost light perception and phthisis ensued. The prosthesis was worn continuously throughout hospitalization, including the perioperative period. The patient managed the prosthesis at all times except once when a nurse rinsed it, at his request, immediately before the cataract operation. Postoperative cultures of the contralateral socket and of the conjunctiva on the operative side both grew P. mirabilis. The patient disclosed that he routinely removed the prosthesis several times daily to clean socket discharge. By habit he performed this cleaning coincident with using the lavatory.
Discussion
Although severe postoperative complications can be associated with any intraocular procedure/ the most frequent setting for postoperative endophthalmitis is cataract extraction. In the United States, this operation is now performed at a rate of over 1/350/000 procedures
347
annually." A recently reported incidence of 0.07% for postoperative endophthalmitis after cataract extraction translates into an estimated 950 individuals in the United States who have this complication annually.' The actual incidence would be higher if other types of intraocular procedures are also considered. As recently as the early 1950s, various institutions reported rates of postcataract endophthalmitis as being 0.3%." Some investigators advocated preoperative cultures of the conjunctiva on all patients, with postponement of operations in patients who had pathogenic flora, and administration of prophylactic antibiotics." The threat posed by gram-negative organisms and the effectiveness of preoperative cultures were also described." The incidence of postoperative endophthalmitis has decreased over the past 30 years because of the introduction of disposable supplies/ improved sterilization techniques, improved surgical procedures, and advances in available antibiotics. Consequently, most surgeons have abandoned the routine use of preoperative cultures even though the bacterial flora of the operative field continues to be recognized as the primary cause of postoperative endophthalmitis.":" Instead, short treatment courses of preoperative and postoperative broad-spectrum topical antibiotics, or both, are commonly used to reduce the quantity of bacteria and the likelihood that these organisms will infect the operated-on eye. The type of prophylactic antibiotics used in ocular operations and the frequency of application vary according to the individual surgeon's preference." Reporting the incidence of postoperative endophthalmitis in a large series of cataract extractions, Allen and Mangiaracine" concluded that the preoperative administration of topical antibiotics markedly reduced the occurrence of postoperative endophthalmitis. Speaker and Menikoff!' recently noted the additional protection offered by preoperative conjunctival preparation using povidone-iodine. Ironically, while the routine use of preoperative cultures was being abandoned, several investigators demonstrated the increased incidence of colonization by pathogenic bacteria in prosthetic sockets as compared to normal conjunctival flora. Cultures of prosthetic sockets isolated pathogenic bacteria in 35% to 85% of cases. 2•12•14 Gram-negative rods occurred in 10% to 16% of socket cultures.v"" and in only 1% to 5% of cultures from normal conjunctiva.":" Anaerobes are also found with increased fre-
348
September, 1993
AMERICAN JOURNAL OF OPHTHALMOLOGY
quency in prosthetic sockets." The frequent occurrence of similar bacterial flora colonizing the conjunctiva of both eyes has been demonstrated by Allansmith, Ostler, and Butterworth." Culture of the conjunctiva of the fellow eye in monocular patients wearing a prosthesis yielded gram-negative rods in up to 16.8% of cases.":" In our patient, the history volunteered postoperatively suggests that the prosthesis was handled with fecally contaminated fingers, resulting in colonization by gram-negative organisms. Gram-negative bacteria, mainly rods, have been isolated in 12.6% to 28.5% of all culure-positive patients with postoperative endophthalmitis.P'f Postoperative growth of the organism (P. Mirabilis), which accounted for endophthalmitis in our patient, from both the operative and anophthalmic conjunctivae, supports the hypothesis that this organism was present in the operative field at the time of the operation. Risk factors for endophthalmitis in this patient included the presence of virulent conjunctival organisms together with the absence of preoperative topical antibiotic prophylaxis, the loss of an intact posterior capsule, and anterior vitrectomy. Although different antibiotic endophthalmitis treatment regimens may be used, the failure of endophthalmitis therapy in this instance was probably most related to the advanced state of infection at the time of diagnosis and to the virulence of the infecting organism. The increased presence of pathogenic organisms capable of causing severe endophthalmitis, and the risk of total blindness in monocular prosthesis-wearing patients with this complication, justify special attention. We recommend the following for perioperative prophylaxis of monocular patients. 1. Both the prosthetic socket and the contralateral eye should be examined for clinical signs of infection or inflammation (for example, purulent discharge, conjunctival hyperemia, and lash crusting). 2. Bilateral aerobic and anaerobic bacterial cultures of the conjunctival fornices should be performed preoperatively. 3. If the cultures are negative, broad-spectrum topical antibiotics should be applied bilaterally for 48 to 72 hours preoperatively, coincident with cessation of prosthesis wear. 4. If either culture is positive, prosthesis wear should be discontinued, and topical antibiotics, chosen on the basis of in vitro antibiotic sensi-
tivities, should be applied bilaterally until conjunctival cultures are reliably negative. Surgery may then be performed. 5. The perioperative skin of the operative field and the socket should be prepared with 10% povidone-iodine and 5% povidone-iodine should be applied to the conjunctiva to be operated on and to the socket. 6. A nonocclusive shield without a patch should be used postoperatively. 7. Prosthesis wear should be resumed postoperatively according to the surgeon's clinical judgment (for example, patient reliability and hygiene, status of wound healing, and absence of excessive postoperative inflammation). Removal of the ocular prosthesis preoperatively eliminates a possible source of contamination that may not be sterilized by antibiotics alone. Although the optimal timing of prosthesis removal and replacement has not been defined experimentally, we recommend removal coincident with instituting antibiotic therapy. Follow-up examination of monocular patients should be scheduled to identify any complication as quickly as possible. An examination on the first postoperative day is essential. The patient and the family should be especially carefully instructed regarding the need to report increasing pain or decreasing vision, or both, in the operated-on eye. With these reasonable precautions, the risk of blinding postoperative endophthalmitis in monocular patients undergoing intraocular procedures will likely be markedly reduced.
References 1. Forster, R. K.: Endophthalmitis. In Tasman, W., and Jaeger, E. A. (eds.): Duane's Clinical Ophthalmology, vol. 4, chap. 24. Philadelphia, J. B. Lippincott, 1991, p. 18. 2. Miller, S. D., Smith, R. E., Dippe, D. W., Lacey, D. R., and Abel, M.: Bacteriology of the socket in patients with prostheses. Can. J. Ophthalmol. 11:126,1976. 3. Clinical Practice Guidelines. Cataracts in Adults. Washington, D.C., Center for Healthcare Policy and Research. Healthcare Finance Administration, 1991, U. S. Department of Health and Human Services. 4. Kattan, H. M., Flynn, H. W., Pflugfelder, S. c.. Robertson, C., and Forster, R. K.: Nosocomial Endophthalmitis Survey. Current incidence of infection after intraocular surgery. Ophthalmology 98:227, 1991.
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Ocular Prosthesis Contamination
5. Callahan, A.: Effect of sulfonamides and antibiotics on panophthalmitis complicating cataract extraction. Arch. Ophthalmol. 49:212, 1953. 6. Goodner, E. K.: Routine preoperative post-surgical management. Int. Ophthalmol. Clin. 3: 119, 1963. 7. Starr, M. B.: Prophylactic antibiotics for ophthalmic surgery. Surv. Ophthalmol. 27:353, 1983. 8. Speaker, M. G., Milch, F. A., Shah, M. K., Eisner, W., and Kreiswirth, B. N.: Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology 98:639, 1991. 9. Wong, I. G., and Vaughan, D. G.: Prevention of surgical infections. In Friedlaender, M. H. (ed.): Prevention of Eye Disease. New York, Mary Ann Liebert, Inc., 1988, p. 20. 10. Allen, H. F., and Mangiaracine, A. B.: Bacterial endophthalmitis after cataract extraction. A study of 22 infections in 20,000 operations. Arch. Ophthalmol. 72:454, 1964. 11. Speaker, M. G., and Menikoff, J. A.: Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology 98:1769,1991. 12. Patillon, J. C,; Rousse, C.; Gauthier, C.; Guyot, F., Barbier, A., Royer, J., and Michel-Briand, Y.: La flore bacterienne de la conjonctive des sujets enuclees. Bull. Soc. Ophtalmol. Fr. 11:781, 1978. 13. Christensen, J. N., and Fahmy, J. A.: The bacterial flora of the conjunctival anophthalmic socket in glass prosthesis-carriers. Acta Ophthalmol. 52:801, 1974. 14. Dayal, Y., Subba Rao, 5., and Mahajan, V. M.:
349
Comparative study of bacterial and fungal floras of contracted sockets and fellow eyes. Ann. Ophthalmol. 16:154, 1984. 15. Walker, C. B., and Claoue, C. M. P.: Incidence of conjunctival colonization by bacteria capable of causing postoperative endophthalmitis. J. R. Soc. Med. 79:520, 1986. 16. Newton, N. L., and Jones, R.: Prophylactic antibiotic therapy for endophthalmitis with intraocular lens implantation. J. Arkansas Med. Soc. 80:249, 1983. 17. Allansmith, M. R., Ostler, H. B., and Butterworth, M.: Concomitance of bacteria in various areas of the eye. Arch. Ophthalmol. 82:37, 1969. 18. Fahmy, J. A., Moller,S., and Weis Bentzen, M.: Bacterial flora of the normal conjunctiva. I. Topographical distribution. Acta Ophthalmol. 52:786, 1974. 19. Allansmith, M. R., Anderson, R. P., and Butterworth, M.: The meaning of preoperative cultures in ophthalmology. Trans. Am. Acad. Ophthalmol. Otolaryngol. 73:683, 1969. 20. Driebe, W. T., Jr., Mandelbaum,S., Forster, R. K., Schwartz, L. K., and Culbertson, W. W.: Pseudophakic endophthalmitis. Diagnosis and management. Ophthalmology 93:442, 1986. 21. Puliafito, C. A., Baker, A. 5., Haaf, J., and Foster, C. 5.: Infectious endophthalmitis. Review of 36 cases. Ophthalmology 89:921, 1982. 22. Forster, R. K., Abbott, R. L., and Gelender, H.: Management of infectious endophthalmitis. Ophthalmology 87:313,1980.