By Byron H. Demorest, MD, and Jerome W. Bettman Sr., MD
[Argus, January 1997]
Abnormal Postoperative Inflammation is Endophthalmitis Until Proven Otherwise
Endophthalmitis has been and probably always will be the most serious risk for patients undergoing cataract surgery. Although all preop cataract patients are routinely informed of the known risks of surgery, including endophthalmitis, patients still may sue their ophthalmologist if they lose vision from an unexpected infection. Patients usually are warned of infection and possible loss of the eye, but they often do not recall this information.
The 1995 Endophthalmitis Vitrectomy study developed diagnostic and therapeutic recommendations that are helpful for risk management. Pain, redness and loss of vision were identified as the most significant symptoms of endophthalmitis, although the study noted that a surprising 25% of patients with endophthalmitis did not complain of much pain. Loss of vision, on the other hand, is extremely significant, particularly when the patient notes a decrease in vision from the day before. Other factors to consider include the presence of a corneal infiltrate, an absent red retinal reflex, and vision reduced to light perception.
These signs and symptoms must be contrasted with the normal sterile inflammatory reaction following cataract surgery that in some cases may produce a severe uveitis. Some eyes react more violently to retained lens material than others. A postoperative intraocular hemorrhage may also confuse the issue. When a patient is seen with a postoperative inflammatory response, it is wise to consider seeing the patient again within eight to 12 hours after increasing topical steroids. Some types of endophthalmitis may improve slightly with steroids, although usually not to the same extent as a postoperative inflammatory reaction. Additionally, although some cells may be seen in the anterior chamber with uveitis, there are usually far more cells and debris in the anterior and posterior chambers with an endophthalmitis.
A great risk to the patient is an endophthalmitis that develops over the weekend. Often the patient is reluctant to call or "bother" the surgeon, and sometimes another ophthalmologist is covering for the weekend. The on-call physician may not see the patient or, if seen, may not have all the relevant records regarding the patient's prior postop exams. This can be a tragic situation. In one OMIC case where the covering ophthalmologist was taking weekend call for his group, he saw a three-day postop cataract patient on Sunday afternoon. Although he performed a thorough examination, he did not have access to Friday's record of the patient's first-day postop exam, which indicated VA 20/200. [For security reasons, this group locked up patient records over the weekend.] By Sunday, when the patient was seen by the covering physician, vision had decreased to hand motion. He diagnosed suture inflammation and told the patient to call back if the pain got worse. The next morning when the patient returned, there was an overwhelming endophthalmitis with eventual loss of the eye. The plaintiff's expert witness testified at trial that if the covering physician had had access to the chart with the Friday exam findings he would have noted the decrease in vision and been better able to diagnose the endophthalmitis. The plaintiff was awarded a large indemnity. OMIC has been able to successfully defend other endophthalmitis cases even when there was significant vision loss but only when the endophthalmitis was recognized early and treated appropriately, albeit unsuccessfully.
Proven treatment recommendations for endophthalmitis include obtaining aqueous and vitreous samples for culturing on blood agar, chocolate agar, and liquid thioglycollate. When a late infection is seen, Sabouraud's agar should be used for fungus. Gram staining with microscopic examination of both anterior chamber and vitreous specimens is advisable. Once the vitreous tap has been taken, Vancomycin plus Amikacin should be injected intravitreally. Systemic antibiotics are now felt to be of no or minimal value.
Chronic endophthalmitis with a late onset may be caused by proprionobacterium acne, which often proliferates within the capsular bag. Such infections can be deceptive as they may become quiescent after steroid therapy, only to recur.
In summary, whenever a patient has an ocular inflammatory response following cataract surgery, the ophthalmologist should suspect endophthalmitis and treat it as such until proven otherwise. Proper treatment is good risk management and may save the patient's eye.
