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- Medically Reviewed by Mr Mfazo Hove Consultant Ophthalmologist
- Author: Chris Dunnington
- Published: December 16, 2024
Understanding a Rare but Serious Complication of Cataract Surgery
Cataract surgery is one of the most common and successful eye procedures performed worldwide. At Blue Fin Vision® Eye Clinic in London, we pride ourselves on providing exceptional care and achieving excellent outcomes for our patients. Mr Hove has performed over 14,000 cataract surgeries at SpaMedica without a single case of endophthalmitis. However, as with any surgical procedure, there are potential risks and complications that patients should be aware of. One such rare but serious complication is endophthalmitis.
In this comprehensive guide, we’ll explore what endophthalmitis is, its causes, symptoms, and treatment options. Our goal is to provide you with a clear understanding of this condition and reassure you that with proper precautions and prompt treatment, the risk of endophthalmitis can be minimised, and its impact can be effectively managed.
What is Endophthalmitis?
Endophthalmitis is a severe inflammation of the interior of the eye, typically caused by a bacterial or fungal infection. This condition can affect both the anterior (front) and posterior (back) chambers of the eye, including the vitreous and aqueous humours. While endophthalmitis can occur for various reasons, it is most associated with eye surgeries, particularly cataract surgery.
Types of Endophthalmitis
There are two main types of endophthalmitis:
- Exogenous Endophthalmitis: This type occurs when microorganisms enter the eye from an external source. It is the most common form and is often associated with:
- Postoperative complications (especially after cataract surgery)
- Penetrating eye injuries
- Extension of corneal infections
- Endogenous Endophthalmitis: This less common type occurs when infection spreads to the eye through the bloodstream from another part of the body.
Endophthalmitis and Cataract Surgery
While endophthalmitis can occur after various eye procedures, it is most frequently associated with cataract surgery. This is primarily due to the high volume of cataract surgeries performed globally. However, it’s important to note that the incidence of endophthalmitis following cataract surgery is very low, typically occurring in less than 0.1% of cases.
Why Does It Occur After Cataract Surgery?
During cataract surgery, a small incision is made in the eye to remove the cloudy lens and replace it with an artificial intraocular lens. This creates a potential entry point for bacteria or fungi to enter the eye. Despite stringent sterilisation procedures and preventive measures, there’s always a minimal risk of microorganisms entering the eye during or shortly after the surgery.
Causes of Endophthalmitis
Understanding the causes of endophthalmitis is crucial for both prevention and early detection. The primary causes include:
- Bacterial Infection: The most common cause, particularly in postoperative cases. Common bacteria involved include:
- Staphylococcus epidermidis
- Staphylococcus aureus
- Streptococcus species
- Fungal Infection: Less common but can occur, especially in immunocompromised patients or after trauma involving organic matter.
- Contamination During Surgery: Despite rigorous sterilisation protocols, there’s a minimal risk of introducing microorganisms during the surgical procedure.
- Patient’s Own Bacterial Flora: Sometimes, the patient’s own bacteria from the eyelids or surrounding skin can enter the eye during or after surgery.
- Contaminated Surgical Instruments or Intraocular Lenses: Although rare due to strict sterilisation procedures, this remains a potential cause.
- Postoperative Wound Leak: If the surgical incision doesn’t seal properly, it can provide an entry point for bacteria.
- Systemic Infection: In cases of endogenous endophthalmitis, infection from another part of the body spreads to the eye via the bloodstream.
Symptoms of Endophthalmitis
Early recognition of endophthalmitis symptoms is crucial for prompt treatment and better outcomes. If you’ve recently undergone cataract surgery or any other eye procedure, be alert to the following symptoms:
Common Symptoms
- Decreased Vision: A sudden or rapid decline in vision quality is often the first noticeable symptom.
- Eye Pain: Ranging from mild discomfort to severe pain, often worsening over time.
- Redness: The affected eye may appear noticeably red and inflamed.
- Swelling: Both the eyelid and the area around the eye may become swollen.
- Increased Sensitivity to Light: Known as photophobia, this can be quite severe.
- Floaters or Flashes: You may notice an increase in floaters or flashes of light in your vision.
Less Common Symptoms
- Discharge: In some cases, there may be a purulent (pus-like) discharge from the eye.
- Fever: Although not always present, some patients may develop a fever, especially in cases of endogenous endophthalmitis.
- Headache: Some patients report headaches associated with the eye pain.
Timing of Symptoms
The onset of symptoms can vary:
- Acute Postoperative Endophthalmitis: Symptoms typically appear within the first week after surgery, often within 2-5 days.
- Chronic Postoperative Endophthalmitis: Symptoms may develop more gradually, sometimes weeks or even months after surgery.
- Endogenous Endophthalmitis: The onset can be more variable and may coincide with symptoms of systemic infection.
Diagnosis of Endophthalmitis
If endophthalmitis is suspected, prompt diagnosis is crucial. At Blue Fin Vision® Eye Clinic, we employ a comprehensive approach to diagnose this condition:
Clinical Examination
- Visual Acuity Test: To assess the extent of vision loss.
- Slit-Lamp Examination: This allows for a detailed view of the eye’s structures, including:
- The presence of hypopyon (pus in the anterior chamber)
- Corneal clarity
- Anterior chamber and vitreous inflammation
Imaging Studies
- Ultrasound: Particularly useful if the interior of the eye cannot be visualised due to severe inflammation.
- Optical Coherence Tomography (OCT): Can help assess retinal involvement.
Microbiological Testing
- Vitreous Tap: A sample of vitreous fluid is collected for culture and sensitivity testing.
- Aqueous Tap: In some cases, a sample from the anterior chamber may also be taken.
Blood Tests
- In cases of suspected endogenous endophthalmitis, blood cultures may be performed to identify any systemic infection.
Differential Diagnosis
It’s important to rule out other conditions that may present similarly, such as:
- Toxic Anterior Segment Syndrome (TASS)
- Sterile endophthalmitis
- Severe postoperative inflammation
Treatment of Endophthalmitis
The treatment of endophthalmitis is a medical emergency requiring immediate intervention. The goal is to quickly control the infection and inflammation to preserve vision. At Blue Fin Vision® Eye Clinic, we follow evidence-based protocols for managing endophthalmitis:
Immediate Interventions
- Intravitreal Antibiotics: The mainstay of treatment involves injecting antibiotics directly into the vitreous. Common choices include:
- Vancomycin (for Gram-positive coverage)
- Ceftazidime or Amikacin (for Gram-negative coverage)
- Vitreous Tap and Inject: In less severe cases, a sample of vitreous is taken for culture, followed by antibiotic injection.
- Vitrectomy: For severe cases or those not responding to initial treatment, a vitrectomy (surgical removal of infected vitreous) may be performed. This procedure:
- Removes infected material
- Allows for better distribution of antibiotics
- Provides a larger sample for culture
Adjunctive Treatments
- Systemic Antibiotics: Intravenous antibiotics may be used, especially in cases of endogenous endophthalmitis.
- Topical Antibiotics: Eye drops are often prescribed to treat any surface infection.
- Intravitreal Steroids: May be used to reduce inflammation, but their use is controversial and decided on a case-by-case basis.
- Cycloplegic Agents: To relieve pain and prevent synechiae formation.
Monitoring and Follow-up
- Close monitoring of the patient’s condition is essential.
- Frequent follow-up examinations to assess response to treatment.
- Adjustment of treatment based on culture results and clinical response.
Potential Outcomes
The prognosis for endophthalmitis can vary widely depending on:
- The causative organism
- The timing of diagnosis and treatment
- The severity of the infection at presentation
With prompt and appropriate treatment, many patients can recover useful vision. However, in severe cases, there may be permanent vision loss or even the need for removal of the eye (enucleation) in extreme situations.
Prevention of Endophthalmitis
At Blue Fin Vision® Eye Clinic, we take extensive measures to prevent endophthalmitis. While the risk can never be completely eliminated, the following strategies significantly reduce its occurrence:
Preoperative Measures
- Proper Patient Selection: Identifying and managing risk factors such as blepharitis or systemic infections.
- Preoperative Antibiotics: Topical antibiotics may be prescribed before surgery.
- Proper Skin and Eyelid Preparation: Using povidone-iodine or chlorhexidine to sterilise the surgical area.
Intraoperative Measures
- Strict Aseptic Technique: Adhering to rigorous sterilisation protocols for all instruments and materials.
- Proper Wound Construction: Ensuring watertight closure of surgical incisions.
- Intracameral Antibiotics: Injecting antibiotics into the anterior chamber at the end of surgery.
Postoperative Measures
- Topical Antibiotics: Prescribing antibiotic eye drops for use after surgery.
- Patient Education: Instructing patients on proper postoperative care and signs to watch for.
- Prompt Follow-up: Scheduling early postoperative visits to monitor for any signs of infection.
Conclusion: The Importance of Awareness and Prompt Action
Endophthalmitis, while rare, remains a serious concern in cataract surgery and other eye procedures. At Blue Fin Vision® Eye Clinic in London, we are committed to providing the highest standard of care to minimise the risk of this complication. Our state-of-the-art facilities, experienced surgeons, and adherence to best practices in infection control contribute to our excellent safety record.
However, patient awareness plays a crucial role in early detection and treatment. If you experience any sudden changes in vision, increased pain, or redness following eye surgery, it’s vital to seek immediate medical attention. Remember, early intervention is key to preserving vision and achieving the best possible outcomes.
We hope this guide has provided you with valuable insights into endophthalmitis. Our team at Blue Fin Vision® Eye Clinic is always here to answer your questions and provide the care you need. Your vision is our priority, and we are dedicated to ensuring the best possible outcomes for all our patients.
For more information or to schedule a consultation, please don’t hesitate to contact Blue Fin Vision® Eye Clinic. Your eye health is our passion, and we’re here to guide you every step of the way.
