Journal of Pediatric Ophthalmology and Strabismus

Review Article 

Extraocular and Intraocular Infections Following Strabismus Surgery: A Review

Malcolm R. Ing, MD, FACS; Justin Shortell, MD; Jamie Golez, BS

Abstract

An extensive literature review of various types of infections following strabismus surgery was facilitated by using the search engines PubMed and Google Scholar. In both search engines, the phrases “infection following strabismus surgery,” “infection strabismus surgery,” “complications of strabismus surgery,” “endophthalmitis strabismus surgery,” and “strabismus scleral perforation” were used for the review. The type of infection, surface involved, and site of the infection determined the type of therapy. Infections involving deeper tissues, such as periocular infection or orbital cellulitis, required systemic therapy. Sub-Tenon's abscesses required incision and drainage, as well as systemic antibiotics. The development of endophthalmitis following strabismus surgery was rare, but was usually devastating to the visual result. Symptoms of an adverse intraocular condition began by mean postoperative day 3, but the definitive diagnosis and treatment of endophthalmitis was not made until mean postoperative day 6. Despite early detection of this latter type of infection and early surgical intervention with vitreous paracentesis and intraocular injection of antibiotics, the visual result was extremely poor in more than two-thirds of the reported cases. Although there is no known way to truly prevent all infections following strabismus surgery, several techniques may be prudent for the strabismus surgeon to adopt to decrease the bacterial load and minimize the risk of infection. The surgeon should be encouraged to consider preoperative use of povidone-iodine on the operative field and avoid scleral perforation during surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(4):214–221.]

Abstract

An extensive literature review of various types of infections following strabismus surgery was facilitated by using the search engines PubMed and Google Scholar. In both search engines, the phrases “infection following strabismus surgery,” “infection strabismus surgery,” “complications of strabismus surgery,” “endophthalmitis strabismus surgery,” and “strabismus scleral perforation” were used for the review. The type of infection, surface involved, and site of the infection determined the type of therapy. Infections involving deeper tissues, such as periocular infection or orbital cellulitis, required systemic therapy. Sub-Tenon's abscesses required incision and drainage, as well as systemic antibiotics. The development of endophthalmitis following strabismus surgery was rare, but was usually devastating to the visual result. Symptoms of an adverse intraocular condition began by mean postoperative day 3, but the definitive diagnosis and treatment of endophthalmitis was not made until mean postoperative day 6. Despite early detection of this latter type of infection and early surgical intervention with vitreous paracentesis and intraocular injection of antibiotics, the visual result was extremely poor in more than two-thirds of the reported cases. Although there is no known way to truly prevent all infections following strabismus surgery, several techniques may be prudent for the strabismus surgeon to adopt to decrease the bacterial load and minimize the risk of infection. The surgeon should be encouraged to consider preoperative use of povidone-iodine on the operative field and avoid scleral perforation during surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(4):214–221.]

Introduction

This review article discusses the various types of infection following strabismus surgery. The severity of the infection was determined by its location. Surface infections such as conjunctivitis were treated by topical antibiotics, whereas deeper infections such as periorbital or orbital cellulitis required topical and systemic antibiotics in attempts at resolution. Sub-Tenon's abscesses required incision and drainage, as well as systemic antibiotics. Endophthalmitis, the most serious type of ocular infection, required intravitreal injections of antibiotics. The incidence, method of diagnosis, treatment, and prognosis of each of the types of infection are reported.

Extraocular Infection

Conjunctivitis

The true incidence of superficial infections such as blepharitis and conjunctivitis is hard to determine. In a retrospective study of 1,603 patients, Koederitz et al.1 reported approximately 3% of their cases developed clinical signs of conjunctivitis following strabismus surgery. These investigators also discovered a significantly higher incidence of infection following reoperations and limbal incisions compared with fornix incisions. Superficial infections were treated by topical antibiotics with resolution. The outcome of the strabismus surgery was not affected by the surface infection.

The practice of routinely using antibiotic/steroid medication postoperatively has been called into question by Wilson.2 Ing's survey of the Costenbader Alumni3 reported that the incidence of postoperative infection in patients of 12 surgeons who did not use antibiotics was not greater than the incidence of infection reported by 51 surgeons who included antibiotics in the postoperative regimen for their patients. In a masked study of antibiotic steroid drops, Wortham et al.4 also questioned the necessity of routinely using postoperative antibiotic steroid drops following strabismus surgery. Kearns and Cullen5 found that the occurrence of severe conjunctivitis following strabismus surgery was too frequent to recommend not using antibiotic drops in both eyes following surgery. Despite the question of the scientific basis for using topical antibiotics by some investigators, Wilson2 noted that many strabismologists recommend the use of antibiotic or antibiotic-steroid topical medication during the immediate postoperative period.

Sub-Tenon's Abscess

Formation of a sub-Tenon's abscess is another extraocular infection identified following strabismus surgery. There are scant numbers of cases of sub-Tenon's abscess formation reported in the literature and these are listed in Table 1.6–11

Sub-Tenon's Abscess Literature Review

Table 1:

Sub-Tenon's Abscess Literature Review

An analysis of the 6 reported cases of this type of infection reveals that preoperative povidone-iodine was used in 4 of the cases, with no report of use in the other 2 cases. The use of postoperative antibiotic drops was reported in 2 cases, but unreported in the other 4 cases. The cases were diagnosed by the observation of a localized edema, pain, and redness adjacent to an extraocular muscle involved. Systemic antibiotics were started on the day of diagnosis, which ranged from postoperative day 1 through postoperative day 10. Significant clinical improvement occurred after surgical drainage of the abscess.

The study of these 6 cases of sub-Tenon's abscesses reveals that the use of neither preoperative povidone-iodine nor postoperative antibiotic drops was entirely preventative of this type of complication following strabismus surgery. It was notable that the visual acuity in all of these cases was not adversely affected by this complication if the diagnosis was made in a timely manner. Indeed, the desired alignment result was achieved by early and effective management of the extraocular infection in all of these cases.

Orbital Cellulitis

The incidence of orbital cellulitis is low. This extraocular complication was reported as 12 cases in a large series of 12,263 patients or approximately 1 per 1,000 cases treated at the Columbia Presbyterian Hospital in New York.12 Ing3 found a similar incidence of 1 per 1,000 to 1 per 1,900 cases.

Because the incidence of orbital cellulitis is so infrequent, it may be instructive to analyze a group experience such as that reported by Kivlin and Wilson13 for the Periocular Infection Study Group. In their survey of 308 pediatric ophthalmologists, 25 patients were reported to have orbital cellulitis with evidence of infection deep to the conjunctiva. The diagnosis was made on clinical signs of edema of the eyelids and conjunctiva with proptosis, restricted motion, and pain. One-half of the patients exhibited systemic signs of lethargy and loss of appetite. Ten of the 25 cases had supportive diagnostic evidence provided by computed tomography or magnetic resonance imaging scan. Unsuspected sinus infection was found in 3 cases. One-third of the conjunctival cultures were negative and only one patient had a positive blood culture. The most common offending organism was found to be Staphylococcus aureus.

Oral antibiotics were given in 11 cases, but this route of administration was thought to be effective in only 3 of the patients. Most of the cases were successfully managed by hospitalization, intravenous cefuroxime, and intravenous ceftriaxone. Because of serious complications of meningitis and death with advanced orbital cellulitis, Kivlin and Wilson13 recommended hospitalization and examination of the cerebrospinal fluid, especially in infants and children younger than 5 years. The diagnosis was made in two-thirds of the patients by the second postoperative day. However, it should also be noted that the diagnosis was not made until later in the postoperative period in one-third of the cases.

These findings suggest that the strabismologist needs to emphasize to the patient or parents that, if any significant changes in appearance, pain, or loss of appetite should develop later in the postoperative course, the patient should contact the surgeon for emergency follow-up care as soon as possible. Out-of-town patients may contact the surgeon by phone and send progress photographs. An examination should occur in suspicious cases later in the postoperative period, despite a satisfactory initial postoperative examination. With prompt diagnosis and appropriate systemic antibiotic treatment, the prognosis for orbital cellulitis was relatively good, with 72% of the patients achieving the surgeon's alignment goal without vision loss.

Intraocular Infections

Endophthalmitis

Undoubtedly, the most dreaded infection following strabismus surgery is endophthalmitis. However, the incidence of this intraocular infection is extremely low, estimated as 1 per 30,000 by Ing3 to 1 per 185,000 cases by Simonsz.14 Our survey of 22 reported cases of endophthalmitis following strabismus surgery is reported in Table 2.15–28

Endophthalmitis Literature ReviewEndophthalmitis Literature Review

Table 2:

Endophthalmitis Literature Review

Although rare, the complication of endophthalmitis following strabismus surgery is accompanied by a poor prognosis. Only 8 of the 22 (36%) reported cases retained normal vision. Four eyes that did not respond to treatment were enucleated, 4 eyes had the diagnosis of phthisis, and 8 were declared to be legally blind. The onset of symptoms, such as lethargy, loss of appetite, and asymmetric swelling of the orbit and eyelids, occurred on postoperative days 1 to 10 (mean: day 3). Definitive diagnosis of intraocular infection was made on days 2 to 14, (mean: day 6). Causative organisms were found to be gram-positive methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, and gram-negative organisms such as Streptococcus pneumoniae and Haemophilus influenzae.12 Two patients with subretinal abscesses progressed to endophthalmitis.27,28 One patient suffered anterior segment ischemia with the concurrent development of endophthalmitis.26

All 8 of the eyes that demonstrated recovery of normal vision were treated by intravitreal antibiotics, usually vancomycin. However, it should be acknowledged that almost all of the 14 cases with poor outcomes were also treated with intravitreal antibiotics. The cases in which there was resolution of endophthalmitis received the intravitreal injection of antibiotics on postoperative days 3 to 7 (mean: day 6). The cases that did not respond to intravitreal antibiotics had the injection administered on postoperative days 2 to 14 (mean: day 7). Thus, despite the majority of patients receiving intravitreal antibiotics within the first week following surgery, only 8 of 22 had a satisfactory outcome.

Prevention of Infection and Risk Factors

The Issue of Scleral Penetration

Penetration of the sclera, with or without perforation of the retina, is believed to be the avenue of entry of bacteria in endophthalmitis following strabismus surgery. Despite the assumption of this bacterial portal of entry, a perforation of the retina was recognized in only 4 of the 22 cases. In all other cases, a scleral penetration was either not recognized or, perhaps, did not occur at the time of surgery. It was reported that, prior to the 1990s, occult perforations occurred in 9% to 12% of all strabismus surgeries.29,30 Recognized scleral perforation during eye muscle surgery is said to occur in 1.3 of 1,000 cases.31 The incidence of inadvertent penetration of the sclera was 2% in a study by Cibis in 1992.32 In a prospective study by Noel et al.,33 the incidence of scleral penetration and retinal perforation was 1.4% and 0.4%, respectively, in 2,055 extraocular muscle procedures.

Subsequent studies, such as the prospective study in 2004 by Dang et al.,34 found that scleral penetration occurred in 5.1% and perforation of the retina occurred in 2.8%. Penetrations of the sclera are believed to occur less often with the use of a scleral spatula needle than with a reverse cutting needle. Nevertheless, Dang et al. reported that the most commonly used needle to be associated with a penetration was just that type, namely, the S-24 needle. It should be noted that the high incidence of penetration with this needle in the authors' series may represent the fact that surgeons are more commonly using this type of needle than any other type. Dang et al. also found that penetrations were more likely to be associated with recessions rather than resections, perhaps due to the fact that the sclera is thinner at the areas that are used in recession, posterior to the original insertion, versus the original thicker insertion area that is used in resections. This report found that penetrations of the sclera or perforations of the retina were most likely to occur with horizontal rectus muscle surgery when compared to vertical muscle surgery. Because the incidence of endophthalmitis is much lower than the incidence of known scleral penetration, it is evident that endophthalmitis did not develop in the majority of patients with a known scleral break.

Surgeons should try to avoid penetration of the sclera, but understand that occult penetrations have been documented in prospective studies. Surgeons who suspect penetration during the eye muscle reattachment phase of the surgery should examine the retina with a dilated pupil and an indirect ophthalmoscope in the operating room. It would also be prudent to perform frequent postoperative examinations for patients in whom a penetration is found. It is notable, however, that endophthalmitis has been found to develop in patients without known scleral penetration (Table 2).

Use of Preoperative Povidone-Iodine

Although we have no good data on the use of povidone-iodine in preventing endophthalmitis following strabismus surgery, the administration of topical drops of povidone-iodine in the cul-de-sac prior to surgical incision has been found to reduce the bacteria in the cul-de-sac.35,36 In addition, the incidence of endophthalmitis following cataract surgery has been shown to be reduced by instillation of povidone-iodine in the cul-de-sac prior to surgery.37

The conjunctival cul-de-sac was the most common area of contamination, and povidone-iodine has been found to be useful in reducing bacteria in the cul-de-sac in ocular surgery.35,36 Olitsky et al.38 found that the needles were culture positive in 15% of cases even after pretreatment of the cul-de-sac with 5% povidone-iodine. Furthermore, Carothers et al.39 found that 19% of needles and 25% of sutures were culture positive despite preoperative povidone-iodine preparation. Eustis and Rhodes40 also found that 28% of sutures used in strabismus surgery were culture positive despite the preoperative use of povidone-iodine in the cul-de-sac. However, these same authors found that the contamination rate could be reduced to 9% if the sutures used in strabismus surgery were presoaked in 5% povidone-iodine. Furthermore, Levinson et al.41 demonstrated in a recent study of povidone-iodine applied to the cul-de-sac before intravitreal injections that the bacterial count was more effectively reduced by the reapplication of povidone-iodine after the insertion of the speculum. In addition, Benson et al.42 found that the 25% contamination rate of the surgical site and sutures was reduced to a 10% contamination rate by the dual application of povidone-iodine, which included the second application after the insertion of the speculum.

Although infection after strabismus surgery is not completely preventable, the use of povidone-iodine in the manner discussed above is worthwhile to consider.43

Conclusion

Despite the most meticulous surgery and preparation, an infection following strabismus surgery may still occur. A normal examination early in the postoperative period does not preclude the development of an infection later in the postoperative period. Therefore, an examination or contacting the out-of-town patients or parents by phone and/or requesting photographs later in the postoperative period may be the best way to detect possible infections that jeopardize the visual result. Additionally, families should be made aware of the signs and symptoms of infection and urged to contact the surgeon at the earliest appearance of these possible complications.

References

  1. Koederitz NM, Neely DF, Plager DA, et al. Postoperative povidone-iodine prophylaxis in strabismus surgery. J AAPOS. 2008;12:396–400. doi:10.1016/j.jaapos.2007.10.005 [CrossRef]
  2. Wilson ME. Topical antibiotic/steroid medication for infection prophylaxis after strabismus surgery: is it custom or science?J AAPOS. 2008;12:321. doi:10.1016/j.jaapos.2008.06.003 [CrossRef]
  3. Ing MR. Infection following strabismus surgery. Ophthalmic Surg. 1991;22:41–43.
  4. Wortham EV, Anandakrishnan I, Kraft SP, Smith D, Morin JD. Are antibiotic-steroid drops necessary following strabismus surgery? A prospective, randomized, masked trial. J Pediatr Ophthalmol Strabismus. 1990;27:205–207.
  5. Kearns PP, Cullen JF. Fucithalmic, chloramphenicol or no treatment after squint surgery in children: a single blind randomized study. Acta Ophthalmol. 1992;70:132–134. doi:10.1111/j.1755-3768.1992.tb02105.x [CrossRef]
  6. Batur M, Seven E, Gül A, Caglar C, Yasar T. A case: abscess formation in the sub-Tenon's space after strabismus surgery. East J Med. 2017;22:211–213. doi:10.5505/ejm.2017.02996 [CrossRef]
  7. Brenner C, Ashwin M, Smith D, Blaser S. Sub-Tenon's space abscess after strabismus surgery. J AAPOS. 2009;13:198–199. doi:10.1016/j.jaapos.2008.10.010 [CrossRef]
  8. Chang MY, Liu W, Glasgow BJ, Isenberg SJ, Velez FG. Necrotizing Tenon's capsule infection in a lymphopenic down syndrome patient following strabismus surgery. J AAPOS. 2017;21:333–335. doi:10.1016/j.jaapos.2017.06.006 [CrossRef]
  9. Dhrami-Gavazi E, Lee W, Garg A, Garibaldi DC, Leibert M, Kazim M. Bilateral orbital abscesses after strabismus surgery. Ophthalmic Plast Reconstr Surg. 2015;31:e141–e142. doi:10.1097/IOP.0000000000000182 [CrossRef]
  10. Kothari M., Sukri N. Bilateral staphylococcus aureus sub-tenon's abscess following strabismus surgery in a child. J AAPOS. 2010;14:193–195. doi:10.1016/j.jaapos.2009.11.023 [CrossRef]
  11. Yau GL, Warder D, Farmer JP, Urton T, Strube YN. A child with rapidly progressive necrotizing group a streptococcal Tenon's capsule infection one day after strabismus surgery. J AAPOS. 2015;19:470–473. doi:10.1016/j.jaapos.2015.05.019 [CrossRef]
  12. Locatcher-Khorazo D, Seegal BC, Gutierrez EH. Postoperative infections of the eye. In: Locatcher-Khorazo D, Seegal BC, eds. Microbiology of the Eye. St. Louis, MO: C.V. Mosby; 1972:80–82.
  13. Kivlin JD, Wilson ME. Periocular infection after strabismus surgery: The Periocular Infection Study Group. J Pediatr Ophthalmol Strabismus. 1995;32:42–49.
  14. Simonsz HJ. Endophthalmitis After Strabismus Surgery. Dublin: World Society of Paediatric Ophthalmology and Strabismus; 2016.
  15. Alniemi ST, Bakri SJ, Cherfan C, Mohney BG. Successfully managed endophthalmitis following strabismus surgery. J AAPOS. 2016;20:263–266. doi:10.1016/j.jaapos.2016.01.008 [CrossRef]
  16. Recchia FM, Baumal CR, Sivalingam A, Kleiner R, Duker JS, Vrabec TR. Endophthalmitis after pediatric strabismus surgery. Arch Ophthalmol. 2000;118:939–944.
  17. Thomas JW, Hamill MB, Lambert HM. Streptococcus pneumonia endophthalmitis following strabismus surgery. Arch Ophthalmol. 1993;111:1171–1172. doi:10.1001/archopht.1993.01090090022010 [CrossRef]
  18. Uniat LM, Olk RJ, Kenneally CZ, Windsor CE. Endophthalmitis after strabismus surgery with a good visual result. Ophthalmic Surg. 1988;19:42–43.
  19. Patel SB, Reddy N, Hogan RN, Cao JH. A case of endophthalmitis after bilateral medial rectus recession. J Pediatr Ophthalmol Strabismus. 2017;29:e37–e41.
  20. Thorne JE, Maguire AM. Hemophilus aegyptius endophthalmitis following strabismus surgery. J Pediatr Ophthalmol Strabismus. 2000;37:52–53.
  21. Walton RC, Cohen AS. Staphylococcus epidermidis endophthalmitis following strabismus surgery. JAAPOS. 2004;8:592–593.
  22. Lenahan DS, Kutschke PJ, Scott WE. Endophthalmitis following pediatric strabismus surgery with good visual result. Am Orthopt J. 2004;54:152–154. doi:10.3368/aoj.54.1.152 [CrossRef]
  23. Ruby A, Shaikh S, Khammar AJ, Trese M. Suprachoroidal septic effusion leading to panophthalmitis following strabismus surgery. J Pediatr Ophthalmol Strabismus. 2005;42:250–252.
  24. Kushner BJ, Meyers FL. Good visual outcome after endophthalmitis in an eye previously treated successfully for amblyopia. J Pediatr Ophthalmol Strabismus. 1989;26:69–71.
  25. Salamon SM, Friberg TR, Luxenberg MN. Endophthalmitis after strabismus surgery. Am J Ophthalmol. 1982;93:39–41. doi:10.1016/0002-9394(82)90696-1 [CrossRef]
  26. Smith JM, Hwang RY, Siringo F, et al. Concurrent endophthalmitis and anterior segment ischemia after strabismus surgery. Retin Cases Brief Rep. 2017;11:148–151. doi:10.1097/ICB.0000000000000315 [CrossRef]
  27. Mak MY, Chiu HH, Smith DR, Muni RH. Subretinal abscess following strabismus surgery. Ophthalmol Retina. 2018;2:511–513. doi:10.1016/j.oret.2017.12.005 [CrossRef]
  28. Patel CC, Goldenberg DT, Trese MT, Walsh MK, O'Malley ER. Subretinal abscess after strabismus surgery: case report and literature review. Retin Cases Brief Rep. 2011;5:6–9. doi:10.1097/ICB.0b013e3181babedb [CrossRef]
  29. Gottlieb F, Castro JL. Perforation of the globe during strabismus surgery. Arch Ophthalmol. 1970;84:151–157. doi:10.1001/archopht.1970.00990040153006 [CrossRef]
  30. Morris RJ, Rosner PH, Fells MP. Incidence of inadvertent globe perforation during strabismus surgery. Br J Ophthalmol. 1990;74:490–493. doi:10.1136/bjo.74.8.490 [CrossRef]
  31. Simon JW, Leninger LL, Scheraga JL. Recognized scleral perforation during eye muscle surgery, incidence and sequelae. J Pediatr Ophthalmol Strabismus. 1992;29:273–275.
  32. Cibis GW. Incidence of inadvertent perforation in strabismus surgery. Ophthalmic Surg. 1992;23:360–361.
  33. Noel LP, Bloom JN, Clark WN, Bawazeer A. Retinal perforation in strabismus surgery. J Pediatr Ophthalmol Strabismus. 1997;34:115–117.
  34. Dang Y, Racu C, Isenberg SJ. Scleral penetrations and perforations in strabismus surgery and associated risk factors. J AAPOS. 2004;8:325–331. doi:10.1016/j.jaapos.2004.03.003 [CrossRef]
  35. Apt L, Isenberg SI, Yoshimori R, Spierer A. Outpatient topical use of povidone iodine in preparing the eye for surgery. Ophthalmology. 1989;96:289–292. doi:10.1016/S0161-6420(89)32897-1 [CrossRef]
  36. Isenberg SI, Apt L, Yoshimori R, Khwarg S. Chemical preparation of the eye in ophthalmic surgery: IV. Comparison of povidone-iodine on the conjunctiva with a prophylactic antibiotic. Arch Ophthalmol. 1985;103:1340–1342. doi:10.1001/archopht.1985.01050090092039 [CrossRef]
  37. Speaker MG, Menikoff IA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology. 1991;98:1769–1775. doi:10.1016/S0161-6420(91)32052-9 [CrossRef]
  38. Olitsky SE, Vilardo M, Awneer S, Reynolds JD. Needle sterility during strabismus surgery. J AAPOS. 1998;182:151–152. doi:10.1016/S1091-8531(98)90006-4 [CrossRef]
  39. Carothers TS, Coats DK, McCreery KM, et al. Quantification of incidental needle and suture contamination during strabismus surgery. Binocul Vis Strabismus Q. 2003;18:75–79.
  40. Eustis HS, Rhodes A. Suture contamination in strabismus surgery. J Pediatr Ophthamol Strabismus. 2012;49:206–209. doi:10.3928/01913913-20110920-01 [CrossRef]
  41. Levinson JD, Garfinkel RA, Berinstein DM, et al. Timing of povidone iodine application to reduce the risk of endophthalmitis after intravitreal injections. Ophthalmology Retina. 2018;2:654–658. doi:10.1016/j.oret.2017.06.004 [CrossRef]
  42. Benson CE, Rogers KL, Suh DW. Dual application versus single application of povidone-iodine in reducing surgical site contamination during strabismus surgery. J AAPOS. 2014;18:347–350. doi:10.1016/j.jaapos.2014.02.014 [CrossRef]
  43. Schnall BM, Feingold A. Infection following strabismus surgery. Curr Opin Ophthalmol. 2018;29:407–411.

Sub-Tenon's Abscess Literature Review

Case No.Preop Povidone-IodinePostop Abx/Steroid RegimenPOD Symptoms 1st AppearedPOD Case Diagnosed & Abx StartedPOD I&D PerformedLength of Abx TreatmentPreop VA and AlignmentPostop VA and Alignment
1 (Batur)YesOfloxacin, dexamethasone7 (vague)710IV abx duration NRExotropia in right eye; OD: 20/25, OS: 20/20Orthophoric; EOMI; OD: 20/25, OS: 20/20
2 (Brenner)YesNeomycin, polymyxin B, dexamethasone3 (vague)337 days of IV abx; duration of oral abx NR40 PD esotropia at distance and near without correction; VA NROrthophoric; EOMI; VA NR
3 (Chang)aYesGentamicin, prednisolone acetate667 to 9b2 days of IV abx; duration of oral abx NREsotropia and nystagmusOrthotropic and improvement in nystagmus; VA NR
4 (Dhrami-Gavazi)cNRUnspecified topical combination steroid/abx1373 days IV abx; 1 day oral abx; 3 days IV abx; 7 days oral abxNR, but VA 20/25 on presentation with infectionOrthophoric; EOMI; VA NR
5 (Kothari)dNRGatifloxacin, dexamethasone355Duration of oral abx NRV-pattern infantile esotropia; VA NROrthotropic; EOMI; VA NR
6 (Yau)YesGatifloxacin, tobramycin, dexamethasone0112 week course IV abx; 10 days oral abxEsotropia 25 PD at distance and 35 PD at near withoutcorrection, small left hypertropia and 2+ left inferior oblique overactionResidual intermittent esotropia of 12 PD at distance and 5 PD at near through bifocal; OD: 20/40, OS: 20/40

Endophthalmitis Literature Review

Case No.Preop P-IPostop Abx/Steroid RegimenPostop PerforationPOD Symptoms 1st AppearedPOD Case Diagnosed & Abx StartedPOD I&D PerformedLength of Abx TreatmentPreop VA & AlignmentPostop VA & Outcome
1 (Alniemi #1)YesTob+DexNo globe perforation; scleral perforation found POD 135 (right upper eyelid swelling)13 + IV abx131 day duration IV abxOD: 20/20, OS: 20/20OD: 20/20 24 months postop
2 (Alniemi #2)YesTob+DexNone3 (mild discharge, dull retinoscopy reflex of right eye)3 + IV abxNone performed (scleral cut-down, anterior tap POD 3)4 days' duration of IV abx; oral abx duration NRNR“normal & equal vision with moderate myopia & large angle esotropia” 1.5 years postop
3 (Alniemi #3)aYesTob+DexNone8 (OS eye pain, redness, slightly decreased vision)8 + IV abxNone performed (scleral cut-down, vitreal tap, choroidal abscess drainage POD 8)2 weeks' duration of IV abx; 4 weeks' duration oral abxOD: 20/40, OS: 20/400OS: 20/400 (baseline), 11 weeks postop
4 (Recchia #1)NRDex, neo sulf, poly BNone3 (lethargy, asymmetric eyelid swelling, asymmetric redness)7 + IV abxPPV & PPL; POD NRDuration of IV abx NRNROS: Enucleated
5 (Recchia #2)NRCombinationNone1 (lethargy, asymmetric redness, fever)6 + IV abxPPV; POD NRDuration of IV abx NRNROS: Enucleated
6 (Recchia #3)NRPred, sulfacetamide sodiumNone1 (lethargy, asymmetric redness)8 + IV abxPPV; PPL, cyclocryotherapy; POD NRDuration of IV abx NRNROS: Phthisis
7 (Recchia #4)NRCombinationNone3 (asymmetric redness)5 + IV abxPPV & PPL; POD NRDuration of IV abx NRNROD: Enucleated
8 (Recchia #5)NRPred, sulfacetamide sodiumNone3 (lethargy, asymmetric redness, pain)8 + IV abxPPV & PPL; POD NRDuration of IV abx NRNROS: Phthisis
9 (Recchia #6)NRDex, neo sulf, poly BNone2 (lethargy, asymmetric eyelid swelling, asymmetric redness)4 + IV abxNoneDuration of IV abx NRNROS: Phthisis
10 (Thomas)YesPoly B, bacitracin zinc, neo sulf, hydrocortisoneNone2 to 4b (increased tearing, swelling OD)5 + IV abxAnterior chamber paracentesis & removal of fibrin clots & limited core vitrectomy; POD NRDuration of IV abx NRNROD: NLP
11 (Uniat)aNRDex, neo sulf, poly B+ scleral perforation, followed by transscleral retinocryopexy3 (pain, irritation OS, decreased vision)3 + IV abx3IV abx 5 daysOD: 20/20, OS: 20/30OS: 20/20 at 5 month postop
12 (Patel SB)NRMoxifloxacinNo globe perforation; scleral perforation on histopathology OS & possible scleral perforation OD on exam7 (conjunctival swelling, redness)> 14b IV abx NRNoneIV abx duration NRNROS: Enucleation
13 (Thorne)NRNRNone4 (pain, decreased vision OD)4 + IV abxPPV; POD NRIV abx 4 days followed by oral abx 7 daysOD: 20/20, OS: 20/20NR (reported necrotic retina OD)
14 (Walton)aYesNR+ scleral perforation2 (pain, decreased vision)2 + IV abxNoneIV abx 1 weekOD: 20/20, OS: 20/40OS: 20/40−2 at 5 weeks postop
15 (Lenahan)NRCombinationNR6 (increased redness, swelling, discharge, pain OS)7 + IV abx7 PPV & PPLIV abx 3 days, oral abx duration NRNROD: 20/20, OS: 20/30 at 4 years postop
16 (Ruby)NRTob+DexNR5 (upper eyelid swelling, redness, epiphoria OS)14 IV abx NRNoneIV abx 7 days, oral abx NRNROS: NLP
17 (Kushner)cNRNRNR immediately after procedure; none detected POD 97 (discomfort, conjunctival erythema OD)9 + IV abx9NROD 20/30OD: 20/40−2 1 months postop
18 (Salamon #1)aNRGentamicin sulfate & pred+ scleral perforation noted & involved suture removed; treated with cryopexy1 (pain, slightly diminished vision)2 + IV abx5IV abx 2 daysOD: 20/60, OS: 20/20OD: LP 6 months postop
19 (Salamon #2)NRNRNone10 (pain, decreased vision OS)10 IV abx NRNoneOral abx 17 daysOD: 20/15, OS: 20/15OS: Phthisis, enucleated 8 years postop
20 (Smith)a,dNRNRNone4 (pain, decreased vision OS)6 + IV abx6 PPVIV abx duration NRNROS: 20/200 at 1 week f/u
21 (Mak)eNRNRNone2 (difficulty opening OD)2 + IV abx4 PPVIV abx duration NRNROD: 20/25
22 (Patel CC)eNRNRNone9 (difficulty opening OS, increased conjunctival redness)9 + IV abx9 core vitrectomyOral abx duration NRNot available due to poor patient cooperationAble to fix and follow with each eye at 1 month f/u
Authors

From University of Hawai'i at Manoa, John A. Burns School of Medicine, Honolulu, Hawaii.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Malcolm R. Ing, MD, FACS, Department of Ophthalmology, University of Hawai'i at Manoa, John A. Burns School of Medicine, 1330 Ala Moana Blvd., Suite 10, Honolulu, HI 96814. E-mail: malcolmingmd@hotmail.com

Received: January 14, 2019
Accepted: April 15, 2019

10.3928/01913913-20190425-01

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