Year : 2005 | Volume
: 53 | Issue : 1 | Page : 5--16
Relationship between clinical presentation and visual outcome in postoperative and posttraumatic endophthalmitis in South Central India
Taraprasad Das1, Derek Y Kunimoto2, Savitri Sharma1, Subhadra Jalali1, Ajit B Majji1, T Nagaraja Rao1, Usha Gopinathan1, Sreedharan Athmanathan3,
1 L V Prasad Eye Institute, Hyderabad, India
2 Wills Eye Hospital, Philadelphia, PA, USA
3 King Khaled Eye Specilaist Hospital, Saudi Arabia
L V Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad - 500 034
PURPOSE: To determine risk factors for poor visual outcome in postoperative and posttraumatic endophthalmitis in a large referral center in south central India. METHODS: In this prospective observational series the authors examined 388 patients of postoperative (n= 206) and posttraumatic (n= 182) endophthalmitis at the L V Prasad Eye Institute in Hyderabad, India between 1991 and 1997.The analysis was confined to 236 patients-128 (62.1%) postoperative and 108 (59.3%) posttraumatic patients who were followed for a minimum period of 3 months. A detailed protocol was followed. Chi-square and logistic regression analysis were used to determine risk factors for visual outcome worse than 6/18 and worse than 6/120. RESULTS: Postoperative endophthalmitis: In univariate analysis the features associated with poor visual acuity (grouped as < 6/18 and < 6/120) included intracapsular cataract surgery, poor presenting visual acuity, presence of vitreous cells, inability to visualise the optic disc on indirect ophthalmoscopy, presence of vitreous membranes on ultrasonography, and a culture-positive vitreous biopsy. In the multivariate analysis, visual acuity of < light perception (LP) at presentation was associated with a 3-month postoperative visual acuity of < 6/18, with an odds ratio of 5.85 [ 1.25 - 27.42, 95% CI], and vitreous membranes seen on ultrasonography was associated with a final visual acuity of < 6/120, with an odds ratio of 2.47 [1.05 - 5.83, 95% CI]. Posttraumatic endophthalmitis: In univariate analysis the features associated with poor visual acuity (grouped as < 6/18 and < 6/120) included a retained intraocular foreign body (IOFB), trauma by needle (hypodermic or sewing), poor presenting visual acuity, inability to visualise the optic disc on indirect ophthalmoscopy, presence of vitreous membranes on ultrasonography, and a culture-positive vitreous biopsy. In multivariate analysis, IOFB was associated with a 3-month follow-up visual acuity of < 6/18, with an odds ratio of 5.90 [1.85 - 18.78, 95% CI], and trauma by a needle (hypodermic or sewing) and retained IOFB was associated with a final visual acuity of < 6/120, with an odds ratio of 4.47 [1.22 - 16.38, 95%CI] and 3.76 [1.36 - 10.37, 95% CI] respectively. CONCLUSION: This is the largest, single-centre, prospective study on risk factors for poor visual outcome in postoperative and posttraumatic endophthalmitis. The independent risk factor for 3-month follow-up visual acuity of < 6/18 was the presenting visual acuity of ≤LP in postoperative endophthalmitis and a retained IOFB in posttraumatic endophthalmitis. The independent risk factor for 3-month visual acuity of <6/120 was the presence of vitreous membranes on ultrasonography in postoperative endophthalmitis, and trauma by a needle (hypodermic/ sewing) and retained IOFB in posttrauamtic endophthalmitis.
|How to cite this article:|
Das T, Kunimoto DY, Sharma S, Jalali S, Majji AB, Nagaraja Rao T, Gopinathan U, Athmanathan S. Relationship between clinical presentation and visual outcome in postoperative and posttraumatic endophthalmitis in South Central India.Indian J Ophthalmol 2005;53:5-16
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Das T, Kunimoto DY, Sharma S, Jalali S, Majji AB, Nagaraja Rao T, Gopinathan U, Athmanathan S. Relationship between clinical presentation and visual outcome in postoperative and posttraumatic endophthalmitis in South Central India. Indian J Ophthalmol [serial online] 2005 [cited 2023 May 30 ];53:5-16
Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?2005/53/1/5/15298
Endophthalmitis remains a rare but devastating complication of ocular surgery and trauma. In recent past several large series are published on postoperative,,,,,,,,,,,, and posttrauamtic endophthalmitis,,,, (Pubmed search using the key words: endophthalmitis, postoperative, trauma.) One large multicentre, prospective study, the Endophthalmitis Vitrectomy Study (EVS), has described the relationship between clinical presentation and clinical outcome in postcataract/secondary intraocular lens (IOL) acute bacterial endophthalmitis. The EVS protocol denied recruitment of severe cases of endophthalmitis, fungal endophthalmitis and posttraumatic endophthalmitis patients.
We herein report a large single-centre, prospective study describing the relationship between clinical presentation and visual outcome. This may be of interest for two important reasons: 1) to validate the findings of the other studies on this topic; and 2) to provide single-centre information, which ensures greater uniformity in data. In this study, we prospectively analysed 206 and 182 patients with postoperative and posttraumatic endophthalmitis respectively and performed a multivariate analysis of presenting clinical features to determine independent risk factors for poor visual outcome in each instance.
Materials and Methods
These 388 patients were seen between 1991-1997 at the L V Prasad Eye Institute, a large tertiary care eye center in Hyderabad, south central India. Of these, 128 and 108 patients of postoperative and posttraumatic endophthalmitis respectively were followed for a minimum of 3 months. Following the Institutional Review Board approval a database was expressly designed to collect clinical information on endophthalmitis patients. All patients were examined by one of the three vitreoretinal surgeons (TD, SJ, and ABM). The detailed protocol included demographic information (gender and age), history (predisposing ocular surgery/ trauma, complications of the surgery, duration of symptoms, interval between the event and presentation to this institution, and use of medications (topical or systemic), examination findings (presenting visual acuity, presence of hypopyon, presence of vitreous cells, and optic disc visibility), ultrasonography (with attention to the presence of vitreous membranes), and microbiology (including culture and susceptibilities).
All patients in this study received vitrectomy. Eyes were prepared with 5% povidone-iodine solution. After sclerotomy, but before initiating the infusion fluid, 0.5-0.75 ml of undiluted vitreous was manually aspirated from mid-vitreous into a 3-ml syringe for microbiology (microscopy and culture). Once the sample was obtained, the infusion was initiated and automated cutting- suction continued with collection into a vitrectomy cassette. It was the goal of surgery to remove the core vitreous with an attempt to clear as much vitreous debris as possible. Surgery was considered adequate if visualisation of the disc and second retinal vessels was possible.
Using standard techniques, the undiluted vitreous biopsy samples were immediately inoculated directly onto sheep blood agar, chocolate agar, non-nutrient agar, Sabouraud′s dextrose agar, potato dextrose agar, thioglycolate, and brain heart infusion broth. Sabouraud′s and potato dextrose agar plates were incubated at 250C to enhance the growth of fungi, and the remainder was incubated at 370C. Blood agar plates were incubated under aerobic and anaerobic conditions, and chocolate agar was incubated with 5% carbon dioxide. Gram stain, Giemsa stain, and KOH with calcofluor white under fluorescence were included as part of the standard protocol for microscopic evaluation of biopsy samples. A culture was considered positive when there was growth of the same organism on two or more media, confluent growth at site of inoculation on one solid medium, or growth in one medium with consistent direct microscopy findings.
All patients received intravitreal and topical antibiotics, and those not suspected to have fungal endophthalmitis also received oral corticosteroids. Intravitreal antibiotics included amikacin (0.4 mg in 0.1 ml) or ceftazidinme (2.25 mg in 0.1 ml) for empiric gram-negative organism coverage and vancomycin (1 mg in 0.1 ml) or cefazoline (2.25 mgin 0.1 ml) for empiric gram-positive organism coverage. The topical antibiotics included the fortified gentamicin (40 mg/ml), cefazoline (50 mg/ml), and/or amphotericin B. Approximately half the patients received intravenous antibiotics, according to surgeon preference, which included gentamicin (4 mg/kg in divided doses) and cefazoline (40 mg/kg in divided doses). Patients receiving aminoglycosides underwent renal function screening (serum BUN and creatinine) prior to surgery and postoperative day 5. Patients receiving ketoconazole (200 mg twice daily) underwent liver function tests before surgery, and then once a fortnight until therapy was discontinued.
Statistical analysis was done as follows. Frequencies and percentages were reported for all variables. As the objective of the study was to determine presenting factors associated with final vision, visual acuity at 3 months follow-up visit was classified for the purpose of analysis into 2 variables, namely worse than (Bacillus species than postoperative endophthalmitis (11.0% versus 1.0%, p=0.0005).
Limitations of this study include those fundamental to statistical studies. First, statistical studies of this size can result in significant associations that make little clinical sense. These associations were excluded from logistic regression analysis. Second, the analysis in this study did not allow us to combine variables. For instance, a poor presenting visual acuity with a culture-positive vitreous biopsy may be a strong predictor of poor visual outcome though, only single variables were analysed in this study. It may also appear that combining different postoperative endophthalmitis aetiologies (such as acute postoperative endophthalmitis from cataract surgery and delayed-onset endophthalmitis from YAG capsulotomy) might skew results. But the multivariate logistic regression accounted for different dependent variables (such as operative aetiology) and allows us to parse variables and analyze multiple patient characteristics without skewing results. The other limitation of the study could be the analysis of the last decade data, 1991-1997. We have published the microbiology data of this period earlier. We believe that this analysis of clinical features and the risk factor analysis will complement the other reports. Further, this data will help us compare the more recent data (1998 onwards) and look for any alterations in the trends and outcome. Two Indian single centre studies on postoperative endophthalmitis have been published recently. , The similarity was the greater gram negative organism in all studies, but none have done the risk factors analysis. Our study is likely to bridge this gap.
In summary, this is the largest, single-centre, prospective study on risk factors for poor visual outcome in postoperative and posttraumatic endophthalmitis. It is hoped that recognition of the risk factors identified in this study will aid clinicians in discussing the visual prognosis in their endophthalmitis patients.
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