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   Table of Contents      
ORIGINAL ARTICLE
Year : 2003  |  Volume : 51  |  Issue : 2  |  Page : 139-145

Spectrum and clinical profile of post cataract surgery endophthalmitis in North India


Department of Ophthalmology, Postgraduate Institute of Medical Education & Research, Chandigarh, India

Correspondence Address:
A Gupta
Department of Ophthalmology, Postgraduate Institute of Medical Education & Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


PMID: 12831144

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  Abstract 

Purpose: To determine the spectrum, clinical profile and risk factors for poor visual outcome in patients of post cataract surgery endophthalmitis.
Methods: Data from 124 eyes were analysed. Various clinical and microbiological parameters were evaluated and risk factors for unfavourable outcome identified.
Results: The mean age of the patients was 59.5013.75 years; 60.5% were males. The median surgery-symptom interval was 7 days (mean 15.8124.01) and the medium symptom-presentation interval 7.5 days (mean 14.1919.13). Corneal infiltrates were seen in 29%, hypopyon in 62 (50%). Smear positivity was 52.5% and culture positivity 38%. Equivocal microbiological positivity was seen in 22 (18%), bacterial 12 (10%), fungal 27 (21.5%), polymicrobial 8 (6.5%) and negative 55 (44%). 20% eyes had total loss of vision at last follow-up. Poor visual acuity at presentation, presence of intraocular lens, shorter surgery-symptom interval, corneal and surgical wound infiltrates, loss of red reflex, microbiological positivity of the vitreous tap and systemic diabetes mellitus were significant risk factors for unfavourable outcome.
Conclusion: Our data highlights a low culture positivity and a predominance of fungal pathogens as a cause of post cataract surgery endophthalmitis. The visual outcome in these patients is still dismal and better treatment strategies should be evolved keeping in mind the microbiological spectrum. The risk factors identified may be helpful in prognosticating the outcome in such patients.

Keywords: Endophthalmitis, cataract surgery, microbiology, risk factors


How to cite this article:
Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P, Chakraborty A. Spectrum and clinical profile of post cataract surgery endophthalmitis in North India. Indian J Ophthalmol 2003;51:139-45

How to cite this URL:
Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P, Chakraborty A. Spectrum and clinical profile of post cataract surgery endophthalmitis in North India. Indian J Ophthalmol [serial online] 2003 [cited 2019 Aug 26];51:139-45. Available from: http://www.ijo.in/text.asp?2003/51/2/139/14714



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Post cataract surgery endophthalmitis is one of the most significant complications of cataract surgery. Major clinical trials from Western countries have demonstrated the predominance of bacteria as a cause of post cataract surgery endophthalmitis.[1],[2],[3],[4],[5],[6],[7] Fungal aetiology is considered rare as a cause of endophthalmitis.[8],[9],[10] Only in recent years have a few reports been published indicating that fungal endophthalmitis may be more prevalent than previously believed,[11],[12],[13] at least in the developing countries. A large series on post cataract surgery endophthalmitis from south India reported a significantly different spectrum of causative organisms, especially in regard to fungal pathogens as a cause of endophthalmitis.[11] We have published another large series on fungal endophthalmitis.[13] This has significant implications on the treatment protocol practiced in such patients. The current management guidelines for postoperative endophthalmitis focus primarily on treating bacterial or presumed bacterial endophthal-mitis.[14],[15],[16] The predominance of fungal endophthalmitis indicates a need to rethink and redefine the treatment strategies in developing countries like India, especially in view of a poorer culture yield from these regions compared to developed countries. Our study aims to present the spectrum, clinical profile and factors governing the adverse outcome of post cataract surgery endophthalmitis in North India.


  Material and Methods Top


One hundred and twenty four eyes (124 patients) clinically diagnosed as post cataract surgery infective endophthalmitis, presenting to the Retina Service of Postgraduate Institute of Medical Education, Chandigarh between October, 1996 and June, 2001 were retrospectively included in this study. Our institute is a major tertiary-care referral hospital in North India. The diagnosis of endophthalmitis was based on presence of pain, inflammation including anterior chamber cellular reaction and flare and vitreous cells, decrease in visual acuity and loss of media clarity with or without the presence of hypopyon following cataract surgery. Patients with incomplete records, a history of trauma preceding or following cataract surgery or follow-up of less than 4 weeks were excluded. Patient records were reviewed for any history of systemic disorders, medication and other predisposing factors leading to a compromised immune status of the patient such as diabetes mellitus, tuberculosis, prolonged corticosteroid use, collagen vascular disorders or use of immunosuppressive agents.

Demographic data, type of cataract surgery, interval between cataract surgery and onset of symptoms, as well as interval between onset of symptoms and presentation to the Institute were recorded in all eyes. At all visits, the ocular examinations included best corrected visual acuity, intraocular pressure (IOP), slitlamp biomicroscopy (anterior segment examination and 90 D examination of posterior segment) and indirect ophthalmoscopy for posterior segment examination. The media clarity was graded from grade I to grade V as described by Das et al.[17] In addition, the routine investigations included estimation of fasting blood sugar, blood pressure and chest X-ray. The primary treatment was always as per the recommendation of the Endophthalmitis Vitrectomy Study (EVS).[15] Briefly, this included injection of intravitreal antibiotics to all patients where the presenting visual acuity was hand movement close to face (HMCF) or better and eyes with vision less than HMCF but with corneal involvement severe enough to preclude vitreous surgery. In all eyes, initial antibiotics injected intravitreally were vancomycin 1 mg in 0.1 ml and ceftazidime 2.25 mg in 0.1 ml. Eyes with presenting visual acuity of less than HMCF received pars plana vitrectomy as the primary procedure. However, the protocol was revised if smear or culture was positive for fungus. The vitreous procedure included obtaining 0.5 to 1 ml of undiluted vitreous sample from the mid-vitreous at the start of the procedure followed by a core vitrectomy. Intravitreal antibiotics were injected at the end of the procedure. The KOH wet mount/calcofluor smear reports were generally available within 12-24 hours. In eyes with a positive KOH wet mount/calcofluor smear from the vitreous sample, intravitreal injection of amphotericin B (5 g in 0.1 ml) with dexamethasone 400 g in 0.1 ml was given as and when the smear report was obtained. A repeat vitrectomy in these eyes was performed only if the eyes showed worsening of intraocular inflammation. The intraocular lens, if present, was explanted in primary surgery only in the event of major decentration due to presence of posterior capsular rent as noted peroperatively. Immediate intervention was not done in eyes where intravitreal injection of antibiotics had been given elsewhere prior to presentation or in eyes with chronic low grade endophthalmitis. Further management was decided depending on clinical observations of the course of disease.

Microbiology

All vitreous samples were examined under Gram stain, KOH 10% and calcoflour stain. They were also inoculated into bacterial and fungal culture media. To obtain cultures, the sample was divided into two parts. One part was transported within 30 minutes to the microbiology facility of the Institute in Robertson's Cooked Meat media, and inoculated into sheep blood Columbia agar base (Hi-Media), chocolate agar, Columbia agar base and McConkey agar media at 37C. The second part was inoculated immediately after procurement on 2 plates of Sabouraud's dextrose agar (SDA) media under sterile conditions and one plate each was incubated at 22C and 37C in the incubator for 6 weeks. For bacterial culture, the samples were incubated aerobically in 10% CO[2] for 10 days and anaerobically for 14 days. Each sample incubated aerobically was checked every day while anaerobic samples were checked every two days for any growth. Samples showing growth were further investigated for sensitivity. The Robertson's cooked meat medium was also incubated and, where any turbidity was seen, further inoculated onto the culture media.

Culture was termed positive if there was semiconfluent growth on at least one solid medium, two or more liquid media or growth on two media from two different study samples. Equivocal growth was defined as growth of less than 11 colony-forming units on solid media or a positive smear.[7] The final diagnosis was made as bacterial, fungal, polymicrobial, equivocal or negative based on the above criteria. Polymicrobial infection was defined as growth on culture of more than one species or strains of bacteria or a positive bacterial culture along with a positive fungal culture from a single or subsequent sample from the same eye.

Patients with a positive KOH or calcofluor smear for fungal elements were subjected to pars plana vitrectomy and intravitreal injection of amphotericin B (5 g in 0.1 ml) with dexamethasone 400 g in 0.1 ml . Eyes with a positive smear and/or culture for fungal elements where poor media clarity precluded vitreous surgery were managed with intravitreal amphotericin B 5 g in 0.1 ml and dexamethasone 400 g alone. All patients diagnosed with fungal endophthalmitis received systemic antifungal drugs (itraconazole 100 mg twice daily or fluconazole 200 mg twice daily) for a minimum period of 6 weeks. However, as itraconazole has a better spectrum against hyphate fungi as compared to fluconazole, it was given orally in all patients with a hyphate fungi on KOH wet mount/calcofluor or a positive culture of hyphate fungi while patients with candida species received fluconazole.[18] All patients, including those who received pars plana vitrectomy were also put on oral prednisolone 1 mg/kg body weight, gradually tapered over 6-8 weeks. The final outcome was divided into two groups: favourable (eyes with final visual acuity of more than HMCF) and unfavourable (eyes with LP or worse vision).

The statistical analysis comprised descriptive analysis and chi square test. The analysis also consisted of mean of age, mean and median of cataract surgery and onset of symptoms, and interval between onset of symptoms and presentation.


  Results Top


The mean age was 59.50 13.75 years (range 14-96 years; median 60 yrs). Seventy five (60.5%) patients were male. Eighty five (68.5%) patients had received intraocular lens (IOL) implantation. Intracapsular cataract extraction (ICCE) was performed in 15 (12%) eyes, extracapsular cataract extraction (ECCE) in 14 (11.5%), ECCE with posterior chamber IOL implantation in 73 (59%), phacoemulsification with posterior chamber IOL in 10 (8%) and anterior chamber IOL implantation in 2 (1.5%) eyes. Aphakia (ICCE or ECCE could not be determined) was present in 10 (8%) eyes. Secondary IOL had not been done in any of the eyes. The median interval between cataract surgery to onset of symptoms was 7 days (range 1-130 days; mean 15.81 24.01 days) and that between onset of symptoms to presentation to us was 7.5 days (range 1-90 days; mean 14.91 19.13 days). One hundred and six (85.5%) patients had onset of symptoms within 4 weeks of cataract surgery including 26 (21%) eyes within 48 hours and 44 (35.5%) eyes within 72 hours. The onset of symptoms was less than one month in 23 (85.5%) fungal, 11 (91.5%) bacterial, 19 (87%) equivocal and 46 (83.5%) culture- negative eyes. The mean follow-up was 15.2 weeks (range 4-150 weeks; median 12 weeks). The visual acuity at presentation was 6/60 in 9 (7%) eyes, less than 6/60 in 53 (43%) eyes, light perception (LP) only 55 (44.5%) eyes and no LP in 7 (5.5%) eyes. Thirteen (10.5%) patients had coexisting diabetes and one patient was using anti-tubercular drugs for pulmonary tuberculosis. One patient had a history of airborne contact dermatitis, 3 had severe dry eye and 1 had ectropion. Surgical predisposing factors for endophthalmitis were documented in 24 (19.5%) eyes. Of these, 5 eyes had undergone suture removal preceding onset of endophthalmitis, 8 had exposed suture knots, 9 had section gape and/or iris prolapse following surgery and 2 had undergone a secondary surgical procedure (lens matter aspiration).

The anterior segment signs included corneal oedema in 91 (73.5%) eyes, corneal infiltrates in 36 (29%) eyes and surgical section infiltrates in 29 (25%) eyes, hypopyon in 62 (50%) eyes, and a fibrinous anterior chamber reaction in 90 (72.5%) eyes. Most of the eyes (88%) presented with grade IV or worse media clarity. The media haze at presentation was grade V in 81 (65.5%) eyes, grade IV in 28 (22.5%) eyes, grade III in 8 (6.5%) eyes, grade II in 6 (5%) eyes and grade I in 1 (0.5%) eye.

Microbiology: Sixty nine (55.5%) eyes had positive smear and/or culture. The smear was positive in 65 (52.5%) eyes and culture in 47 (38%) eyes. The isolates included bacteria in 12 (9.5%) eyes, fungi in 27 (22%) eyes and polymicrobial infection in 8 (6.5%) eyes. An equivocal microbiological result was seen in 22 (18%) samples while 55 (44%) samples were smear as well as culture negative [Figure - 1].

The most common bacterial isolate was Pseudomonas aeroginosa (6 eyes) followed by Staphylococcus aureus and Streptococcus β hemolyticus (2 eyes each), Pneumococcus and Acinetobacter species (1 eye each) [Table - 1]. Aspergillus flavus was the most common fungus isolated (18 eyes), followed by Aspergillus fumigatus (2 eyes), Aspergillus niger (1 eye), Candida albicans (3 eyes), Candida tropicalis , Candida guillermondii and Acremonium kilisense (1 eye each) [Table - 1].

The final visual acuity was 6/60 and better in 41 (33%) eyes, less than 6/60 to better than LP in 35(28%), only LP in 23 (18.5%) and no LP in 25 (20%) eyes. Of the 25 eyes with final visual acuity of no LP, 16 had been eviscerated, 6 eyes had atrophic bulbi and 3 eyes had phthisis bulbi. A majority of patients with a favorable outcome (88.7%) had an initial visual acuity of HMCF or better (P<0.05). Of these, 35 (56.5%) eyes regained a final vision of 6/60 or better. Also, 64.5% of eyes presenting with a visual acuity of LP only or worse had an unfavourable outcome, with only 6 (9.5%) eyes gaining a final visual acuity of 6/60 or better [Figure - 2].

The final visual acuity was also compared to positivity. A negative smear and culture was associated with better visual outcome- 42 (76.5%) smear/culture negative eyes had a final visual acuity of better than HMCF.

(A) Comparison of profiles of culture-positive, equivocal and culture-negative-groups

The comparison of the clinical profile of all groups is given in [Table - 2], and the statistical significance of these differences is discussed below.

1. Comparison of culture-positive and culture-negative groups. The factors significantly associated with culture positivity were corneal infiltrates (36% versus 14.5%,

P =0.02), presence of hypopyon (68% versus 45.5%,

P = 0.04) and a worse visual outcome (49% versus 23.5% unfavorable outcome, P = 0.013).

2. Comparison of culture-positive and equivocal groups. There was no statistically significant difference in the clinical profile and outcome of both these groups Eleven (23.5%) eyes in culture-positive groups had involvement of surgical section versus 12 (54.5%) eyes in the equivocal group (P = 0.02).

3. Comparison of equivocal and culture-negative groups. An equivocal microbiological profile was significantly associated with the presence of corneal infiltrates (P=0.003), surgical section involvement ( P=0.0001) and hypopyon ( P=0.02) when compared to culture-negative eyes. The visual outcome in the equivocal group (54.5% unfavorable outcome versus 23.5% in culture-negative eyes) was also significantly worse than the culture-negative group ( P=0.018).

(B) Clinical profile of eyes with favourable versus unfavorable outcome:


The comparison of the clinical profile of these eyes is given in [Table - 3].

Factors associated with an 'unfavourable' outcome included presenting visual acuity of light perception or worse (29% of the eyes with favourable outcome versus 83.5% of eyes with unfavourable outcome, P=0.000001), presence of corneal infiltrates (10.5% versus 58.5%,

P = <0.0000001), presence of fibrinous anterior chamber reaction (77.5% versus 83.5%, P = 0.05), surgical section involvement (8% versus 48%, P=0.000001), cataract surgery without IOL placement (20% versus 50%, P <0.01), hypopyon 51.5% versus 71%, P<0.05), media clarity at presentation grade IV or worse (81.5% versus 98%, P=0.0003), vitreous tap smear positivity (41% versus 71%, P=0.009) and systemic diabetes mellitus (5% versus 19%, P =0.03) [Table - 3].


  Discussion Top


Post cataract surgery endophthalmitis, while not common, is a very serious complication of cataract surgery. Although several large series on the epidemiology and incidence of endophthalmitis have been reported, data from the Indian subcontinent is inadequate or lacking.[1],[2],[3],[5],[6] A recent study has shown that the spectrum of causative organisms of post-operative endophthalmitis in India is distinctly different from the Western countries.[11] This may be due to the tropical climate, lack of proper surgical protocols for cataract surgery and social, racial or economic factors. World literature on endophthalmitis suggests that Staphylococcus epidermidis is the most common causative agent of post cataract surgery endophthalmitis.[5],[7],[19],[20] Gram-positive cocci have been identified as the commonest cause of postoperative endophthalmitis followed by Gram-negative bacteria. In most studies from Western countries, no fungi have been isolated, including in the Endophthalmitis Vitrectomy Study (EVS) where none of the 420 eyes grew fungi in vitreous isolates.[5],[7],[21] In India, Anand et al[11] have noted that Gram-negative bacteria accounted for 41.7% of postoperative endophthalmitis followed by Gram-positive bacteria (37.6%) and fungi (21.8%). In our series, fungi were the leading cause of endopthalmitis accounting for 57.5% of all cultures followed by Gram-negative bacteria (15.9%). Gram-positive isolates accounted for only 10.5% while polymicrobial infection was seen in 17% eyes. Interestingly, none of the isolates grew Staphylococcus epidermidis . No series from any part of the world has reported such a high prevalence of fungal endophthalmitis [Table - 4].

Our culture positivity differs from that of EVS. In EVS, 69% of the vitreous samples were culture-positive and 12.85% showed equivocal growth while only 38% eyes in our series had a positive culture and 18% had an equivocal microbiological report. Many factors may have contributed significantly to a lower culture positivity in our study. Most of the patients included in this study had been operated elsewhere. As our institute is a tertiary referral center, these patients had been diagnosed elsewhere and initiated on oral antibiotics or given intravitreal antibiotics before being referred to us. The EVS, on the other hand, was a prospective clinical trial with a strict inclusion protocol which included no previous exposure to antibiotics. Also, the investigation procedures were done under stringent settings of a controlled trial with a dedicated laboratory and prompt inoculation which may also have contributed to the high positivity. Our study results are typical of those seen in a clinical setting in a developing country. Our culture positivity is akin to that recorded in another large series from Southern India (44.5%) indicating that there are similar causes of low culture positivity in our patients [Table - 4].[11]

It was suggested in the EVS that diabetics may have a higher culture positivity compared to non-diabetics.[22] We did not find any difference in the culture positivity in diabetics versus non-diabetics. Two of the 13 eyes with diabetes grew Pseudomonas aeroginosa , 3 grew Aspergillus flavus , 3 showed equivocal growth and 5 were both smear and culture negative. None of the diabetics showed growth of Gram-positive organisms, in contrast to some published reports.[5],[22] The EVS did not find any significant difference in the incidence of Gram negative infection in diabetics and non-diabetics whereas Kattan et al did not isolate Gram-negative organisms in any of the 11 diabetic eyes.[5],[22] However, Phillips and Tasman reported increased incidence of Gram-negative infection in diabetics.[23] In our study, however, eyes of patients with systemic diabetes had a worse visual outcome ( P=0.03).

On comparing factors associated with a positive culture isolate in these eyes, presence of corneal infiltrates (P=0.02) and hypopyon (P=0.04) were significantly correlated to positive culture. Systemic diabetes, presence of surgical predisposing factors such as exposed knots, loose sutures, section gape or iris prolapse and secondary surgical procedures following cataract surgery, earlier onset of symptoms, poorer presenting vision, presence of corneal oedema, intraocular lens implantation and media haze at presentation were not significantly associated with culture positivity. In our study eyes with a positive culture were more likely to have an unfavourable visual outcome compared to culture-negative eyes (P=0.013).

We also studied the profile of eyes with an unfavorable visual outcome. The patients in our study were younger compared to the EVS (mean age 59.50 years versus 74.55 years in EVS) with a male preponderance (60.5% males versus 42.6% in EVS). Factors associated with an 'unfavourable' outcome included presenting visual acuity of light perception or worse, presence of corneal infiltrates, presence of fibrinous anterior chamber reaction, surgical section involvement, aphakia, hypopyon, media clarity at presentation grade IV or worse, vitreous tap smear positivity and systemic diabetes [Table - 3]. Similar risk factors for poor visual outcome have been noted in some studies from developed countries.[21],[22],[23]

The use of corticosteroids, both intravitreal and oral, in patients with fungal endophthalmitis remains controversial. The aim of giving corticosteroids in such eyes in our study was to control tissue damage secondary to severe inflammation due to both fungal infection as well as intravitreal antifungal injection, which in itself can have a toxic effect on the eye. The experience of various investigators on combination corticosteroid therapy in conjunction with antifungal therapy has been favourable and has been reported to improve the visual outcome in such eyes.[12],[13],[24],[25]

A large majority of the patients included in our study had been operated in rural areas and referred to our institute for management of endophthalmitis. The possible source of infection may have been introduction of the microorganisms into the eye at the time of surgery despite the fact that none of the eyes grew Staphylococcus epidermidis , the most common commensal of the conjunctival flora. Similarly, Propionobacterium acnes (which may grow often only in anaerobic atmosphere) was not isolated, indicating that conjunctival flora had no role in the post cataract surgery endophthalmitis in this series. Gram-negative bacilli and fungi formed a vast majority of cultured organisms, suggesting that the source of infection may not have been the patient's own conjunctival flora. It would be logical to speculate, therefore, that inadequate sterilization procedures and operating room facility, contaminated irrigation fluids and other factors leading to inadequate sterilization could be responsible.

The visual outcome in these patients was dismal and better treatment strategies should be evolved keeping in mind the microbiological spectrum in this part of the world[Figure - 3].

 
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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]


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