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Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 147-150

To study the incidence of endophthalmitis after manual small incision cataract surgery in a tertiary eye care center

Department of Vitreo-Retina, Sankara Eye Centre, Sathy Road, Sivanandapuram, Coimbatore, Tamilnadu, India

Date of Submission01-Mar-2013
Date of Acceptance01-Jun-2013
Date of Web Publication23-Aug-2013

Correspondence Address:
Prabhushanker Mahalingam
Sankara Eye Centre, Sathy Road, Sivanandapuram, Coimbatore, Tamilnadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2320-3897.116844

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Purpose: We studied the incidence and outcome of endophthalmitis after manual small incision cataract surgery in a high volume tertiary eye care center. Materials and Method: It was a retrospective study and the data were retrieved from the hospital records of the patients who underwent manual small incision cataract surgery in a tertiary eye care center from April 2010 to October 2012. The preoperative visual acuity, cataract grading, preoperative risk factors, surgical complications, postoperative visual acuity, time interval between surgery and endopthalmitis, microbiological profile, treatment given, and final visual acuity were recorded. Results: A total of 64,926 patients were operated between April 2010 and October 2012. All the patients were followed up at Day 1, Day 7, and 6 weeks postoperatively. Of these, 31 cases were diagnosed as endophthalmitis and were treated accordingly. Conclusion: The incidence of endophthamitis in this study is 0.048%, which is comparable to all modern studies.

Keywords: Cataract surgery, endophthalmitis, manual small incision cataract surgery

How to cite this article:
Mahalingam P, Sambhav K. To study the incidence of endophthalmitis after manual small incision cataract surgery in a tertiary eye care center. J Clin Ophthalmol Res 2013;1:147-50

How to cite this URL:
Mahalingam P, Sambhav K. To study the incidence of endophthalmitis after manual small incision cataract surgery in a tertiary eye care center. J Clin Ophthalmol Res [serial online] 2013 [cited 2022 Jul 1];1:147-50. Available from: https://www.jcor.in/text.asp?2013/1/3/147/116844

Cataract is the most common cause of treatable blindness in developed as well as underdeveloped countries. [1],[2] Over the past few years, there has been a significant advancement in the field of cataract surgery. Phacoemulsification and manual small incision cataract surgery are the most commonly performed procedures. With improvement in technique and sterilization protocols, there has been a reduction in the complication and infection rate after surgery. But still, there are chance of infection, most dreaded of which is endophthalmitis.

Endophthalmitis is the infection of the intraocular tissues. It may be exogenous or endogenous. The exogenous endophthalmitis forms the bulk, with postoperative endophthalmitis being the most common. The improvement in preoperative prophylactic measures, improved sterilization measures, and good postoperative care and follow up has helped in reducing the incidence of this devastating condition.

This study was done to investigate the incidence, microbiological profile, and final outcome of patients of endophthalmitis following manual small incision cataract surgery in a tertiary eye care center.

  Materials and Methods Top

We did a retrospective study from computerized data of patients, who underwent manual small incision cataract surgery, in a high volume tertiary eye care center from April 2010 to October 2012. All the patients belong to the rural background and were selected for charity surgeries from outreach camps. All the patients were operated by surgeons in training. These include fellows and the postgraduate students. Temporal or superior site manual small incision cataract surgery was done in all cases. The size of incision was 6.5-7.5 mm. The nucleus was delivered by viscoexpression or sandwich method using wire vectis. All the operated patients were examined at their respective camps between 4 and 6 weeks and those diagnosed with endophthalmitis or any other complications were brought to the base hospital for further evaluation and treatment. There is a follow up of 85% of all operated cases based on hospital records.

Institutional ethics committee approval was taken. Data were collected, which included patient demography, preoperative visual acuity (VA), cataract grading, preoperative risk factors, systemic conditions and medications, type of cataract surgery, surgical complications, postoperative VA, time interval between surgery and endopthalmitis, microbiological profile, treatment given, and final VA. Patients who underwent manual small incision cataract surgery only were selected.

The patients who presented with suspected endopthalmitis within 6 weeks following surgery were included in the study group. Endophthalmitis is defined as intraocular inflammation involving both the vitreous and the anterior chamber. The diagnosis of endophthalmitis was based on patients presenting with symptoms of pain, redness, diminution of vision and signs of circumcorneal congestion, anterior chamber reaction, hypopyon, corneal infiltrations, vitritis, and loss of red reflex. Direct vitreous and aqueous samples were obtained in all cases using 26 gauge needles and sent to the microbiology laboratory for culture and sensitivity testing. In addition to Gram stain microscopy, the samples were inoculated directly onto Blood Agar and Sabouraud Dextrose Agar. The patients diagnosed with endophthamitis were treated with intravitreal antibiotics and sutureless vitrectomy. Patients presenting with corneal infiltrate were treated with corneal patch graft and therapeutic penetrating keratoplasty along with intravitreal antibiotic injection. The incised corneal button was sent for microbiological assessment. The final VA at 3 months and ocular status was recorded.

The intravitreal antibiotics administered were Inj. vancomycin (1 mg in 0.1 ml) and Inj. cefotaxime (2.25 mg in 0.1 ml).

  Results Top

The total number of patients, who underwent manual small incision cataract surgery from April 2010 to October 2012, was 64,926. Thirty-one cases presented with suspected endopthalmitis after the surgery. There were 18 males and 13 females. Eleven patients presented immediately or within a week after surgery while 18 patients presented within 6 weeks and 2 patients after 6 weeks. The two patients who came after 6 weeks were included in the study because diagnosis was made at 4 weeks follow up at camp, but the patients reported late to the base hospital.

On reviewing the operative notes of endophthalmitis patient, 25 patients had uneventful cataract surgery while 3 patients had posterior capsular rent (PCR), 2 patients had zonular dialysis (ZD), and 1 went for repeat surgery on first postoperative day for section suturing. In PCR and ZD cases, anterior vitrectomy was done and intraocular lens (IOL) was placed in Sulcus (in PCR cases) and in the bag (in ZD cases), respectively. There were no cluster cases of endophthalmitis.

The culture report of the patients showed that 18 patients were culture negative, 8 patients showed growth of Nocardia, and 1 patient each for Beta Hemolytic Streptococcus, Alpha Hemolytic Streptococcus, Coagulase Negative Staphylococcus, Streptococcus pyogenes, and Streptococcus pneumoneae. The treatment given to the patient and the final VA is recorded in [Table 1].
Table 1: Patient demography, systemic condition, visual acuity at presentation, fi nal visual acuity, treatment given, and culture pattern

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  Discussion Top

Cataract surgery is the most common ocular surgical procedure performed and majority of the cases of postsurgical endophthalmitis follows cataract surgery. Endophthalmitis is a rare but devastating infection, caused by diverse organisms but predominantly by bacteria.

In recent years, there has been an improvement in prognosis of postsurgical endophthalmitis due to better understanding of aetio-pathogenesis, improvement in diagnostic techniques like polymerase chain reaction, availability of broad spectrum antibiotics and finer vitrectomy instrumentation. There is no consensus on the prophylactic measure to prevent the incidence of endopthalmitis but instillation of povidone iodine 5% solution in the conjunctival sac for 2 min before surgery is the most widely accepted intervention. [3] There has been a recent interest in the use of intracameral moxifloxacin and cefuroxime to reduce the rate of endophthalmitis. [4],[5] The other modalities advocated to lower the rate of postoperative endophthalmitis include proper wound construction, good sterilization protocol, minimal instrument handling, and educated operation theater staff.

The visual outcome after endophthalmitis is generally poor but aggressive and appropriate treatment can improve the visual outcome. Although our results showed that standard interventions led to improvement in VA, only a minority of patients achieved final VA of ≥6/60.

The incidence of endophthamitis in our study was 0.048%. On comparing with a similar study by Ravindran et al., the rate of endophthalmitis in surgeries performed by residents, fellows, and mini-fellowship trainees was 0.13%. [6]

In our study, the rate of culture positivity was 41.94%, which is less than that of reported in the endophthalmitis vitrectomy study (EVS) (67%). [7] Another study by Das et al. reported a culture positivity of 58.06%. [8] Causative organism is a major determinant in the final outcome of endophthalmitis. In a recent study by Schimel et al., the most common organisms identified were Staphylococcus epidermidis in 30.1% and Streptococcus viridians group in 10.9% cases. Overall, 72.9% isolates were Gram-positive organisms, 10.7% isolates were Gram-negative organisms, 15.8% were fungi, and 0.4% isolates were viruses. [9]

In India, Anand et al. noted that Gram-negative bacteria accounted for 41.7% of postoperative endophthalmitis followed by Gram-positive bacteria (37.6%) and fungi (21.8%). [10] In a study by Gupta et al. for spectrum and clinical profile of postcataract surgery endophthalmitis in North India, 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. [11],[12],[13] In our study, there was a majority of Nocardia positive cases (61.54%) while the rest were Gram-positive bacteria (38.46%). There was no fungal isolate in our study. The increased Nocardia isolates may be attributed to patient's exposure to soil as majority of the patients belong to a rural background. [14] Nocardia positive patients had the worst visual outcome even after aggressive treatment. The poor prognosis in Nocardia endophthalmitis is due to severe intraocular inflammation, which may lead to phthisis. [15] The poor visual outcome of other endophthalmitis patients can also be attributed to the rural background of the patients, late presentation, and virulence of the causative organism.

Endophthalmitis is a grave disease that requires aggressive and prompt management. The treatment should be individualized and the prognosis depends on variable factors, including causative organism and time interval between presentation and commencement of treatment. In our study, the incidence of endophthalmitis was 0.048%, which is in accordance with other studies. [16] The final VA of majority of the patients, even after aggressive treatment, was less than 6/60, which indicates the poor prognosis of this disease.

  References Top

1.Quillen DA. Common causes of vision loss in elderly patients. Am Fam Physician 1999;60:99-108.  Back to cited text no. 1
2.Haddadin A, Ereifej I, Zawaida F, Haddadin H. Causes of visual impairment and blindness among the middle-aged and elderly in northern Jordan. East Mediterr Health J 2002;8:404-8.  Back to cited text no. 2
3.Yu CQ, Ta CN. Prevention of postcataract endophthalmitis: Evidence-based medicine. Curr Opin Ophthalmol 2012;23:19-25.  Back to cited text no. 3
4.Ekinci Koktekir B, Aslan BS. Safety of prophylactic intracameral moxifloxacin use in cataract surgery. J Ocul Pharmacol Ther 2012;28:278-82.  Back to cited text no. 4
5.Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW. ESCRS Endophthalmitis 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;32:407-10.  Back to cited text no. 5
6.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 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg 2009;35:629-36.  Back to cited text no. 6
7.Doft BH, Barza M. Optimal management of postoperative endophthalmitis and results of the Endophthalmitis Vitrectomy Study. Curr Opin Ophthalmol 1996;7:84-94.  Back to cited text no. 7
8.Das T, Hussain A, Naduvilath T, Sharma S, Jalali S, Majji AB. Case control analyses of acute endophthalmitis after cataract surgery in South India associated with technique, patient care, and socioeconomic status. J Ophthalmol 2012;2012:298459.  Back to cited text no. 8
9.Schimel AM, Miller D, Flynn HW Jr. Endophthalmitis isolates and antibiotic susceptibilities: A 10-year review of culture-proven cases. Am J Ophthalmol 2013;156:50-52.e1.  Back to cited text no. 9
10.Anand AR, Therese KL, Madhavan HN. Spectrum of aetiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol 2000;48:123-8.  Back to cited text no. 10
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11.Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P, et al. Spectrum and clinical profile of post cataract surgery endophthalmitis in north India. Indian J Ophthalmol 2003;51:139-45.  Back to cited text no. 11
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12.Han DP, Wisniewski SR, Wilson LA, Barza M, Vine AK, Doft BH, et al. Spectrum and susceptibilities of microbiologic isolates in the Endophthalmitis Vitrectomy Study. Am J Ophthalmol 1996;122:1-17.  Back to cited text no. 12
13.Puliafito CA, Baker AS, Haaf J, Foster CS. Infectious endophthalmitis Review of 36 cases. Ophthalmology 1982;89:921-9.  Back to cited text no. 13
14.Haripriya A, Syeda TS. A case of endophthalmitis associated with limbal relaxing incision. Indian J Ophthalmol 2012;60:223-5.  Back to cited text no. 14
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15.Pradhan ZS, Jacob P, Korah S. Management of post-operative Nocardia endophthalmitis. Indian J Med Microbiol 2012;30:359-61.  Back to cited text no. 15
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16.Lalitha P, Rajagopalan J, Prakash K, Ramasamy K, Prajna NV, Srinivasan M. Postcataract endophthalmitis in South India incidence and outcome. Ophthalmology 2005;112:1884-9.  Back to cited text no. 16


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