Endophthalmitis Following Cataract Surgery: Prophylaxis and Treatment

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Article initiated by:

Harry W. Flynn Jr., M.D., Avinash Pathengay MD

All contributors:

Harry W. Flynn Jr., M.D., Vinay A. Shah M.D., Leo A. Kim, MD, PhD, Koushik Tripathy, MD (AIIMS), Derek W DelMonte, MD, Christina Y. Weng, MD, MBA, Dylan Griffiths

Assigned editor:

Cullen Ryburn, MD, Mark P. Breazzano, MD, FACS

Review:

Assigned status Up to Date

 by Christina Y. Weng, MD, MBA on June 16, 2024.

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Contributing Editors:	add

Incidence

The incidence of endophthalmitis after cataract surgery is variable

	Author	Years	No. of Cases	Incidence %
1	Leopold	(1920-1940)	Meta-analysis	2.00
2	Allen	(1958-1962)	22/20,000	0.09
3	Aaberg	(1984-1994)	34/41,654	0.07
4	West	(1994-2001)	1026/4,77,627	0.21
5	Jensen	(1997-2007)	40/29,276	0.14
6	Moshirfar	(2003-2005)	14/20,013	0.07
7	Freeman	(1996-2005)	754/4,90,690	0.15
8	Ravindran	(2007-2008)	38/42,426	0.09
9	Wykoff	(1995-2009)	8/28,568	0.03

Endophthalmitis Following Cataract Surgery at Bascom Palmer Eye Institute

Year	#/Total	Incidence (%)
1995	1/3,213	0.03
1996	3/3,398	0.09
1997	0/3,139	0.00
1998	1/3,036	0.03
1999	0/3,135	0.00
2000	1/2,949	0.03
2001	1/3,162	0.03
2002	0/3,434	0.00
2003	3/3,531	0.09
2004	1/3,082	0.03
2005	1/3,475	0.03
2006	1/3,699	0.03
2007	1/4,066	0.03
2008	1/4,219	0.02
2009	1/4,884	0.02
2010	0/4,865	0.00
15 Year Total	16/57,284	0.03

References

1.Leopold I. Incidence of endophthalmitis after cataract surgery. Trans Ophthalmol Soc. UK 1971; 191: 575-609.
2.Allen HF, Mangiaracine AB. Bacterial endophthalmitis after cataract extraction: a study of 22 infections in 20,000 operations. Arch Ophthalmol 1964; 72: 454-462.
3.Aaberg TM, Jr, Flynn HW Jr, Schiffman J, Newton J. Nosocomial acute-onset postoperative endophthalmitis surgery: a ten-year review of incidence and outcomes. Ophthalmology 1998; 105: 1004-1010.
4.West ES, Behrens A, McDonnell PJ, et al. The incidence of endophthalmitis after cataract surgery among U.S. Medicare population increased between 1994 and 2001. Ophthalmology 2005; 112: 1388-1394
5.Jensen MK, Fiscella RG, et al. Third-and fourth-generation fluoroquinolones: Retrospective comparison of endophthalmitis after cataract surgery performed over 10 years. J Cataract Refract Surg 2008; 34: 1460-1467
6.Moshirfar M, Feiz V, Vitale AT, Vegelin JA et al. Endophthalmitis after Uncomplicated Cataract Surgery with the Use of Fourth-Generation Fluoroquinolones. Ophthalmology 2007; 114: 686-691.
7.Freeman EE, Roy-Gagnon MH, Fortin E et al. Rate of Endophthalmitis after Cataract Surgery in Quebec, Canaca 1996-2005. Arch Ophthalmol. 2010; 128: 230-234
8.Ravindran RD, Venkatesh R, Chang DF, Sengupta S, Gyatsho J, Talwar B. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital, Outcomes of more than 42000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg 2009: 35:4; 629-636.
9.Wykoff CC, Parrott MB, Flynn HW Jr, Shi W, Miller D, Alfonso EC. Nosocomial acute-onset postoperative endophthalmitis at a
university teaching hospital (2002-2009). Am J Ophthalmol. 2010 Sep;150(3):392-398.

Risk Factors

Preoperative

1. Diabetes Mellitus
2. Immune compromise/HIV
3. Chronic Blepharitis
4. Infection of the lacrimal drainage system
5. Contaminated eye drops
6. Contact lens wear
7. Contralateral ocular prosthesis

Reports Indicating a Possible Increasing Incidence of Endophthalmitis Following Clear Corneal Cataract
Systemic review of 215 studies:  (1992-2003)-Taban, et al
a.  Limbal incision                                   -0.062%
b.  Scleral incision                                   -0.074%
c.  Clear corneal incision                        -0.189%
Endophthalmitis Following Clear Corneal Cataract Surgery at Bascom Palmer Eye Institute (Lalwani, et al 2008)
a.  Retrospective consecutive series of 73 patients
b.  Mean time to diagnosis:  13.8 days
c.  Most common organism:  Coagulase negative staphylococci (CNS)
d.  CNS Frequent resistance to 4th generation fluoroquinolones (~30%)
e.  All patients treated with intravitreal vancomycin, ceftazidime and dexamethasone
f.   Visual outcomes:  46% 20/40 or better

Intraoperative

1. Application of 2% Xylocaine gel before Povidone-iodine may block access of antiseptic to the bulbar conjunctiva
2. Prolonged surgery
3. Secondary IOL
4. Posterior capsular rupture
5. Vitreous loss
6. Contaminated irrigating solution
7. Clear corneal incision
8. Concurrent nasolacrimal duct surgery

Post operative

1. Wound leak
2. Vitreous incarceration

References

1: Hatch WV, Cernat G, Wong D, Devenyi R, Bell CM. Risk factors for acute endophthalmitis after cataract surgery: a population-based study. Ophthalmology. 2009 ;116(3):425-30. 
2: Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk
factors. J Cataract Refract Surg. 2007 ;33(6):978-88.
3: Lundström M, Wejde G, Stenevi U, Thorburn W, Montan P. Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology. 2007 ;114(5):866-70
4: Faulkner HW. Association between clear corneal cataract incisions and postoperative endophthalmitis. J Cataract Refract Surg. 2007 ;33(4):562.
5: Nichamin LD, Chang DF, Johnson SH, Mamalis N, Masket S, Packard RB, Rosenthal KJ; American Society of Cataract and Refractive Surgery Cataract Clinical Committee. ASCRS White Paper: What is the association between clear corneal cataract incisions and postoperative endophthalmitis? J Cataract Refract Surg.2006 ;32(9):1556-9.
6: Kamalarajah S, Ling R, Silvestri G, Sharma NK, Cole MD, Cran G, Best RM. Presumed infectious endophthalmitis following cataract surgery in the UK: a case-control study of risk factors. Eye (Lond). 2007 ;21(5):580-6.
7: Wejde G, Samolov B, Seregard S, Koranyi G, Montan PG. Risk factors for endophthalmitis following cataract surgery: a retrospective case-control study. J Hosp Infect. 2005 ;61(3):251-6.

Classification, Isolates and Clinical features

Acute-onset postoperative endophthalmitis (≤ 6 weeks)

Isolates

• Coagulase (-) staphylococci
• Staphylococcus aureus
• Streptococcus species
• Gram negative bacteria

Clinical features

• Marked intraocular inflammation
• Hypopyon
• Reduced vision (marked)
• Pain (75%)

Delayed-onset (chronic) postoperative endophthalmitis (> 6 weeks)

Isolates

Bacteria	Fungi
P.acnes	Candida parapsilosis
S.epidermidis	Other Candida spp
Corynebacterium spp	Paecilomyces spp
Xanthomonas maltophilia	Aspergillus spp
Alcaligenes xylosoxidans	Acremonium spp

Typical time frame of postoperative endophthalmitis

Staphylococcus epidermidis within 6 week after surgery

Candida 6 week to 3 months

Propionibacterium acnes 2 months to 2 years

(The Massachusetts Eye and Ear Infirmary review manual for ophthalmology / Rama D. Jager, Jeffrey C. Lamkin.-- 3rd ed.)

Clinical features

• P. acnes - white intracapsular plaque, granulomatous uveitis, fibrin strands in anterior chamber, vitritis
• Coagulase negative staphylococcus - vitritis, hypopyon
• Fungi - vitreous infiltrates, "string of pearls" lesions

References

1.Lalwani GA, Flynn HW Jr, Scott IU, Quinn CM, Berrocal AM, Davis JL, Murray TG, Smiddy WE, Miller D. Acute-onset endophthalmitis after clear corneal cataractsurgery (1996-2005). Clinical features, causative organisms, and visual acuity outcomes. Ophthalmology. 2008 ;115(3):473-6.
2: Benz MS, Scott IU, Flynn HW Jr, Unonius N, Miller D. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol. 2004 ;137(1):38-42.
3: Clark WL, Kaiser PK, Flynn HW Jr, Belfort A, Miller D, Meisler DM. Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis. Ophthalmology. 1999 ;106(9):1665-70
4: Aaberg TM Jr, Rubsamen PE, Joondeph BC, Flynn HW Jr. Chronic postoperative gram-negative endophthalmitis. Retina. 1997;17(3):260-2.
5: Winward KE, Pflugfelder SC, Flynn HW Jr, Roussel TJ, Davis JL. Postoperative Propionibacterium endophthalmitis. Treatment strategies and long-term results.Ophthalmology. 1993;100(4):447-51
6.Han DP, Wisniewski SR, Wilson LA, Barza M, Vine AK, Doft BH, Kelsey SF.Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol. 1996 ;122(1):1-17
7.Mezaine HS, Al-Assiri A, Al-Rajhi AA. Incidence, clinical features, causative organisms, and visual outcomes of delayed-onset pseudophakic endophthalmitis. Eur J Ophthalmol 19, 804-811 (2009).
8.Fox GM, Joondeph BC, Flynn HW Jr, Pflugfelder SC, Roussel TJ. Delayed-onsetpseudophakic endophthalmitis. Am J Ophthalmol. 1991 Feb 15;111(2):163-73
9. Johnson MW, Doft BH, Kelsey SF, et al. The Endophthalmitis Vitrectomy Study: relationship between clinical presentationand microbiologic spectrum. Ophthalmology 1997;104(2):261–272.

Differential Diagnosis of Endophthalmitis after Cataract Surgery

Toxic anterior segment syndrome (TASS)

1. Toxin-mediated
2. Symptoms within 1 or 2 days
3. Little or no pain
4. Diffuse “limbus to limbus” corneal edema
5. No or minimal posterior segment inflammation

References

1.Doshi RR, Arevalo JF, Flynn HW Jr, Cunningham ET Jr. Evaluating exaggerated,prolonged, or delayed postoperative intraocular inflammation. Am J Ophthalmol.2010 ;150(3):295-304.
2. Cutler Peck CM, Brubaker J, Clouser S, Danford C, Edelhauser HE, Mamalis N.Toxic anterior segment syndrome: common causes. J Cataract Refract Surg. 2010;36(7):1073-80.
3.Kim JE, Flynn HW Jr, Rubsamen PE, Murray TG, Davis JL, Smiddy WE.Endophthalmitis in patients with retained lens fragments after phacoemulsification. Ophthalmology. 1996;103(4):575-8.
4.Irvine WD, Flynn HW Jr, Murray TG, Rubsamen PE. Retained lens fragments after phacoemulsification manifesting as marked intraocular inflammation with hypopyon.Am J Ophthalmol. 199215;114(5):610-4.
5.Berrocal AM, Davis JL. Uveitis following intraocular surgery.Ophthalmol Clin North Am 2002;15(3):357–364.
6. Estafanous MF, Lowder CY, Meisler DM, Chauhan R.Phacoemulsification cataract extraction and posterior chamber
lens implantation in patients with uveitis. Am J Ophthalmol2001;131(5):620–625.
7. Hooper PL, Rao NA, Smith RE. Cataract extraction in uveitis patients. Surv Ophthalmol 1990;35(2):120 –144.
8. Nguyen JK, Fung AE, Flynn HW Jr, Scott IU. Hypopyon and pseudoendophthalmitis associated with chronic vitreous hemorrhage. Ophthalmic Surg Lasers Imaging. 2006;37(4):317-9.

Endophthalmitis Treatment

Obtain intraocular specimen

1. 30-gauge needle for AC-tap (optional)
2. 25- or 23-gauge needle for vitreous tap
3. Small gauge pars plana vitrectomy (PPV)

Dosages for intravitreal injection

1. Vancomycin 1 mg/0.1 cc (for coverage of gram-positive organisms)
2. Ceftazidime 2.25 mg/0.1 cc or Amikacin 0.4 mg/0.1 cc (for gram-negative organisms)
3. Dexamethasone 0.4 mg/0.1 (optional)

References

1. Schwartz SG, Flynn HW Jr, Das T. Retinal Pharmcotherapy.Ocular infections-Endopthalmitis.Elseiver.2010 ; 170-175
2.Roth DB, Flynn HW Jr. Antibiotic selection in the treatment of endophthalmitis: the significance of drug combinations and synergy. SurvOphthalmol. 1997 ;41(5):395-401.
3.Das T, Sharma S; Hyderabad Endophthalmitis Research Group. Current management strategies of acute postoperative endophthalmitis. Semin Ophthalmol. 2003;18(3):109-15.
4. Kohnen T. Post-cataract endophthalmitis: can we do better? J Cataract Refract Surg. 2009 Apr;35(4):609.
5.Results of the Endophthalmitis Vitrectomy Study. A randomized trial ofimmediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group.
Arch Ophthalmol. 1995 ;113(12):1479-96.
6. Das T, Jalali S, Gothwal VK, et. al. Intravitreal dexamethasone in exogenous bacterial endophthalmitis: results of a prospective randomized study. Br J Ophthalmol 1999; 83: 1050-1055.

Endophthalmitis Vitrectomy Study (EVS) (1991-1994)

Background - largest series of endophthalmitis after cataract surgery (N=420)

1. EVS endophthalmitis patients after ECCE, scleral tunnel phacoemulsification, or secondary IOL.
2. Initial results were reported in 1995 and subsequent reports were published in the following years.

EVS primary results

1. Patients with LP vision fare better with initial pars plana vitrectomy.
2. When patients presented with HM or better vision, equal visual acuity outcomes were achieved in the vitrectomy and vitreous tap groups.
3. There was no apparent benefit from the use of EVS systemic antibiotics (amikacin and ceftazidime) compared to controls (no IV antibiotics).

EVS secondary results

1. Patients with diabetes mellitus and vision better than LP achieved better visual outcomes with initial vitrectomy surgery (not statistically significant).
2. Additional procedures (as a result of worsening intraocular inflammation or infection or for complications) after the initial treatment: 8% of vitrectomy eyes and 13% of tap eyes.
3. There was no statistical difference between vitrectomy and tap groups in terms of microbiological yield, operative complications, retinal detachment (8.3%) or visual acuity outcomes (overall, 53% equal to or better than 20/40 in EVS).

References

1. Results of the Endophthalmitis Vitrectomy Study. A randomized trial ofimmediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group.
Arch Ophthalmol. 1995 ;113(12):1479-96.
2.Doft BH, Barza M. Optimal management of postoperative endophthalmitis and results of the Endophthalmitis Vitrectomy Study. Curr Opin Ophthalmol. 1996;7(3):84-94.
3.Han DP, Wisniewski SR, Wilson LA, Barza M, Vine AK, Doft BH, Kelsey SF.Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol. 1996 ;122(1):1-17.
4.Microbiologic factors and visual outcome in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol. 1996 ;122(6):830-46.
5.Bannerman TL, Rhoden DL, McAllister SK, Miller JM, Wilson LA. The source of coagulase-negative staphylococci in the Endophthalmitis Vitrectomy Study. Acomparison of eyelid and intraocular isolates using pulsed-field gel
electrophoresis. Arch Ophthalmol. 1997 ;115(3):357-61.
6.Han DP, Wisniewski SR, Kelsey SF, Doft BH, Barza M, Pavan PR. Microbiologic yields and complication rates of vitreous needle aspiration versus mechanized vitreous biopsy in the Endophthalmitis Vitrectomy Study. Retina.
1999;19(2):98-102.
7.Wisniewski SR, Hammer ME, Grizzard WS, Kelsey SF, Everett D, Packo KH, Yarian DL, Doft BH. An investigation of the hospital charges related to the treatment of endophthalmitis in the Endophthalmitis Vitrectomy Study. Ophthalmology. 1997;104(5):739-45.
8. Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study; a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995; 113:1479–1496.
9.Flynn HW Jr, Scott IU. Legacy of the Endophthalmitis Vitrectomy Study. Arch Ophthalmol. 2008;126(4):559-61.

Prophylaxis For Post-Cataract Surgery Endophthalmitis

Proposed Methods

1. Preoperative povidone-iodine antisepsis
2. Preoperative topical antibiotics
3. Preoperative treatment of lid disease
4. Properly-sized and constructed incision
5. Antibiotics in irrigating solution
6. Intracameral antibiotics
7. Avoiding concurrent procedures
8. Postoperative subconjunctival antibiotics
9. Postoperative topical antibiotics

Current Choices for Intracameral Antibiotics

1. Vancomycin
2. Cefuroxime
3. Moxifloxacin (Routine intracameral moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold (3-fold for manual small incision vataract surgery and nearly 6-fold for phacoemulsification in a large study. https://www.ncbi.nlm.nih.gov/pubmed/28214101/)

Potential Complications of Intracameral Antibiotics

1. Fungal contamination during mixing
2. Incorrect preparation and dosage
3. Allergy
4. Cystoid macular edema
5. Corneal edema
6. Hemorrhagic occlusive retinal vasculitis (HORV)

References

1.Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery; an evidence-based update Ophthalmology 2002; 109:13–24
2.Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M. Prophylaxis of postoperative endophthalmitis after cataract surgery; results of the 2007 ASCRS member survey; the ASCRS Cataract Clinical Committee. J Cataract Refract Surg 2007; 33:1801–1805
3.Gordon YJ. Vancomycin prophylaxis and emerging resistance: are ophthalmologists the villains? The heroes? Am J Ophthalmol 2001; 131:371–376.
4.Ou JI, Ta CN. Endophthalmitis prophylaxis. Ophthalmol Clin N Am 2006; 19(4):449−456
Carrim ZI, Mackie G, Gallacher G, Wykes WN. The efficacy of 5% povidone−iodine for 3 minutes prior to cataract surgery. Eur J Ophthalmol 2009; 19:560−564
5.Ang GS, Barras CW. Prophylaxis against infection in cataract surgery: a survey of routine practice. Eur J Ophthalmol 2006; 16:394−400
6.Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone–iodine. Ophthalmology 1991; 98:1769–1775
7.Halachimi-Eyal O, Lang Y, Keness Y, Miron D. Preoperative topical moxifloxacin 0.5% and povidone−iodine 5.0% versus povidone−iodine 5.0% alone to reduce bacterial colonization in the conjunctival sac. J Cataract Refract Surg 2009; 35: 2109−2114
8.Buzard K, Liapis S. Prevention of endophthalmitis. J Cataract Refract Surg 2004; 30:1953−1959.
9. Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral cefuroxime; efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2002; 28:977–981.
10.Montan PG, Wejde G, Setterquist H, Rylander M, Zetterström C. Prophylactic intracameral cefuroxime; evaluation of safety and kinetics in cataract surgery. J Cataract Refract Surg 2002; 28:982–987.
11.Liesegang TJ. Intracameral antibiotics: questions for the United States based on prospective studies. J Cataract Refract Surg 2008; 34:505–509
12.Espiritu CRG, Caparas VL, Bolinao JG. Safety of prophylactic intracameral moxifloxacin 0.5% ophthalmic solution in cataract surgery patients. J Cataract Refract Surg 2007; 33:63–68.
13.Hui M, Lam PTH, Cheung SW, Pang CP, Chan CY, Lam DSC. In vitro compatibility study of cephalosporin with intraocular irrigating solutions and intracameral medications. Clin Exp Ophthalmol 2010 Aug 26. [Epub ahead of print]
14.Lockington D, Flowers H, Young D, Yorston D. Assessing the accuracy of intracameral antibiotic preparation for use in cataract surgery. J Cataract Refract Surg 2010; 36:286–289
15. Garat M, Moser CL, Martin-Baranera M, Alonso-Tarres C, Alvarez-Rubio L. Prophylactic intracameral cefazolin after cataract surgery, Endophthalmitis risk reduction and safety results in a 6-year study. J Cataract Refract Surg 2009: 35: 4; 637-642.
16. Anijeet DR, Palimar P, Peckar CO. Intracameral vancomycin following cataract surgery: An eleven-year study. Clin Ophthalmol. 2010 Apr 26;4:321-6.
17. Wykoff CC, Flynn HW Jr, Han DP. Allergy to povidone-iodine and cephalosporins:the clinical dilemma in ophthalmic use. Am J Ophthalmol. 2011 Jan;151(1):4-6.

18. Witkin AJ, Chang DF, Jumper JM, Charles S, Eliott D, Hoffman RS, Mamalis N, Miller KM, Wykoff CC. Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis. Ophthalmology. 2017;124(5):583-95.

ESCRS Endophthalmitis Study (2007)

• Four study groups (Rates of endophthalmitis)
  • No cefuroxime (CEF), No levofloxacin 13/3438
  • Intracameral CEF, only 3/3408
  • Perioperative levofloxacin only 10/3424
  • Intracameral CEF and periop levo 2/3428
• Combined totals
  • Intracameral cefuroxime: 5/6836 (0.07%)
  • No intracameral cefurox: 23/6862 (0.33%)
• ESCRS Study Points
  • 24 Ophthalmology units in Europe
  • Total of 16,603 patients
  • Clear corneal (5.88 X higher) vs. Scleral tunnel
  • Silicone IOL (3.13 X higher) vs acrylic IOL
  • Surgical complications (4.95 X higher) vs none
• Microbiologic Outcomes of ESCRS Study
  • 29 cases clinically diagnosed
  • 14/29 culture or PCR proven
• Shortcomings of Study and Use of Cefuroxime
  • Study stopped prematurely (groups combined)
  • Cefuroxime reconstituted from powder (not commercially available)
  • Short-term stability of mixed powder Cefuroxime
  • Risk of beta-lactam hypersensitivity
  • Cefuroxime not ideal for Staphylococcus
  • Potential microbial contamination of mixed powder to solution (Fungus or Pseudomonas)
• Summary
  • Use of intracameral antibiotics in this study was associated with a nearly 5-fold decrease in incidence of postoperative endophthalmitis
  • Use of intracameral antibiotics is increasing, but has not yet been universally adopted (41% use amongst respondents of the 2017 American Society of Cataract and Refractive Surgery Clincial Survey) for several reasons including: need for more prospective data, safety concerns, lack of a commercially-prepared formulation for use
• Other Pertinent Studies
  • A large study of 16,264 patients who had undergone cataract surgery within the Kaiser Permanente health system over 3 time periods with progressively increasing use of intracameral antibiotics showed progressively decreasing rates of postoperative endophthalmitis (Rates per 1,000 cases from early to later time frames were: 3.13, 1.43, 0.14)
  • Observational, longitudinal cohort study compared the effectiveness of topical versus intracameral antibiotics on the risk of endophthalmitis in 315,246 cataract procedures between 2005-2012 and found that intracameral anbiotics were more effective than topical agent alone (OR, 0.58; CI, 0.38-0.91). Combining topical antibiotics (gatifloxacin or ofloxacin) with intracameral antibiotics did not seem to be more effective than using intracameral agent alone.

References

1.ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007; 33:978–988.
2.Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW; ESCRSEndophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32(3):407-10.
3. Seal DV, Barry P, Gettinby G, Lees F, Peterson M, Revie CW, Wilhelmus KR;ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Case for a European multicenter study. J Cataract Refract Surg. 2006;32(3):396-406.
4.Seal D, Reischl U, Behr A, Ferrer C, Alió J, Koerner RJ, Barry P; ESCRS Endophthalmitis Study Group. Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract &Refractive Surgeons multicenter study and susceptibility testing. J Cataract Refract Surg. 2008 ;34(9):1439-50.

5. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg. 2013;39(1):8-14.

6. Herrinton LJ, Shorstein NH, Paschal JF, Liu L, Contreras R, Winthrop KL, Chang WJ, Melles RB, Fong DS. Comparative Effectiveness of Antibiotic Prophylaxis in Cataract Surgery. Ophthalmology. 2016;123(2):287-94.

Antibiotics and Sensitivity Patterns

Microbiological spectrum and antibiotic sensitivity: a 25-year review, 2014

1. Evaluated spectrum and susceptibility pattern of pathogens responsible for 988 cases of culture-positive endophthalmitis referred to a single institution over a 25-year period.
2. Most prevalent pathogens were:
   • Coagulase-negative staphylococcus (39.4%)
   • Streptococcus viridans species (12.1%)
   • Staphylococcus aureus (11.1%)
   • Gram-negative organisms and fungi accounted for 10.3% and 4.6% of all isolates, respectively
3. 99.7% of gram-positive bacteria were susceptible to vancomycin (only Enterococcus faecium and Nocardia exalbida were not)
4. For 8 antibiotics, increasing microbial resistance over time was observed: cefazolin (P = 0.02), cefotetan (P = 0.006), cephalothin (P<0.0001), clindamycin (P = 0.04), erythromycin (P<0.0001), methicillin/oxacillin (P<0.0001), ampicillin (P = 0.01), and ceftriaxone (P = 0.006).
5. Decreasing microbial resistance against aminoglycosides and imipenem was observed.

Ocular TRUST (Ocular Tracking Resistance in US today), 2008

1. Fluoroquinolones- susceptibility rates
   • MSSA - 80.5%
   • MRSA - 15.2%
   • Strep pneumoniae - 100% (gati and moxifloxacin)
   • Hemophilus influenzae 100%
2. Conclusions: If MRSA is a suspected pathogen, alternatives to FQs’ should be considered.

Coagulase Negative Staphylococcus (Miller, et al- Arch Ophthal), 2006

Susceptibility rates:
	Years	Percentage
Levofloxacin
	1990-1994	96.6%
	1995-1999	83.0%
	2000-2004	61.5%
	2005-2009	47.0%
Gatifloxacin
	1990-1994	96.6%
	1995-1999	78.2%
	2000-2004	65.4%
	2005-2009	48.0%
Moxifloxacin
	1990-1994	96.6%
	1995-1999	78.2%
	2000-2004	65.4%
	2005-2009	49.0%

References

1.Miller D, Flynn PM, Scott IU, Alfonso EC, Flynn HW Jr. In vitro fluoroquinolone resistance in Staphylococcal endophthalmitis. Arch Ophthalmol 2005 124: 479-483, 2006.
2.Miyanaga M, Nejima R, Miyai T, Miyata K, Ohashi Y, Inoue Y, Toyokawa M, Asari S. Changes in drug susceptibility and the quinolone-resistance determining region of Staphylococcus epidermidis after administration of fluoroquinolones. J Cataract Refract Surg 2009; 35: 1970-1978.
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Conclusions: Endophthalmitis following cataract surgery

• The incidence of endophthalmitis after cataract surgery ranges from 0.03%-0.15% in the literature.
• Povidone-iodine prophylaxis is generally recommended for cataract surgery.
• Intracameral antibiotic use for the prevention of cataract surgery-related endophthalmitis is increasing, but has not been universally adopted.
• Blepharitis, vitreous loss and wound leak are potential preoperative, intra-operative and post operative risk factors for endophthalmitis.
• The significance of clear corneal incision as a potential risk factor for endophthalmitis remains controversial.
• The differential diagnosis of endophthalmitis include TASS, RLF, uveitis and chronic vitreous hemorrhage.
• Most common organism causing post operative endophthalmitis is coagulase-negative staphylococci.
• In the treatment of presumed bacterial endophthalmitis, intravitreal vancomycin and ceftazidime are commonly used for empiric coverage of both Gram positive and Gram negative bacteria.