From the Guidelines
Infectious endophthalmitis after cataract surgery is a serious emergency requiring immediate intervention with intracameral antibiotic administration, which has been shown to reduce the risk of postoperative bacterial endophthalmitis 1. Treatment should begin with intravitreal antibiotics including vancomycin 1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL, administered by an ophthalmologist as soon as possible after diagnosis. Some key points to consider in the management of infectious endophthalmitis after cataract surgery include:
- Vitreous and aqueous samples should be collected for culture and Gram stain before initiating antibiotics.
- Systemic antibiotics such as fluoroquinolones (e.g., moxifloxacin 400 mg daily) may be added as adjunctive therapy.
- Topical fortified antibiotics like vancomycin 25 mg/mL and tobramycin 14 mg/mL should be administered every hour.
- In severe cases, pars plana vitrectomy may be necessary to remove infected material and improve antibiotic distribution.
- Intravitreal dexamethasone 0.4 mg/0.1 mL can be considered to reduce inflammation once infection is being controlled. Prevention is crucial and includes proper preoperative preparation with povidone-iodine 5% solution, careful sterile technique, and prophylactic antibiotics, such as intracameral injection of 1 mg of cefuroxime after surgery, which has been shown to be effective in reducing the risk of postoperative endophthalmitis 1. Endophthalmitis typically presents within 1-2 weeks after surgery with decreased vision, eye pain, lid swelling, and hypopyon. Early recognition and treatment are essential to prevent permanent vision loss, as the infection can rapidly destroy retinal tissue through inflammatory mediators and bacterial toxins. It is worth noting that the risk of postoperative endophthalmitis can be reduced with the use of intracameral antibiotic administration, and that topical nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce the incidence of early postoperative cystoid macular edema (CME) 1.
From the Research
Infectious Endophthalmitis Post Cataract Surgery
- Infectious endophthalmitis is a serious complication of cataract surgery that occurs in thousands of patients each year 2
- The incidence of postoperative endophthalmitis can be decreased with the use of intracameral antibiotics, such as cefuroxime, moxifloxacin, and vancomycin 2
- A prospective, multicenter, randomized trial demonstrated that intracameral cefuroxime decreases the incidence of postoperative endophthalmitis 2
Risk Factors and Prevention
- Risk factors for the development of endophthalmitis following cataract surgery include patient age, intraoperative surgical complications, and poor wound construction 3
- There are several antibacterial strategies employed to prevent postoperative endophthalmitis, with topical, intracameral, and subconjunctival delivery being the most common 3
- The optimal antibacterial strategy for the prevention of endophthalmitis should be safe, inexpensive, and broad in microbiological activity spectrum, while not requiring patient compliance for its effectiveness 3
Diagnosis and Management
- Infectious endophthalmitis following intraocular surgery is a complication that could cause severe visual loss or loss of the eye 4
- The categorisation of the event that led to intraocular infection will help the clinician to predict the infectious agent and begin appropriate therapy 4
- Intravitreal antibiotic injection remains the gold standard in the management of acute postoperative endophthalmitis 5
- Adjunctive systemic antibiotic therapy for treatment of bacterial endophthalmitis is controversial but common practice due to the severity of the disease 6
Treatment Options
- The best-documented agents achieving therapeutic levels in the vitreous are meropenem, linezolid, and moxifloxacin 6
- Vancomycin, cefazoline, ceftriaxone, ceftazidime, imipenem, and trimethoprim-sulfamethoxazole reach levels justifying their use in specific situations 6
- Available data do not support the use of ciprofloxacin, levofloxacin, aminoglycosides, aminopenicillins, piperacillin, cefepime, and clarithromycin 6