Study of incidence of endophthalmitis in posttherapeutic keratoplasty patients at a secondary care hospital in Saurashtra Region, India

Kamal R Dodia; Rajesh K Chudasama; Ravi Dharamdasani

doi:10.4103/jmgims.jmgims_32_16

ORIGINAL ARTICLE

Year : 2019 | Volume : 24 | Issue : 2 | Page : 82-86

Study of incidence of endophthalmitis in posttherapeutic keratoplasty patients at a secondary care hospital in Saurashtra Region, India

Kamal R Dodia¹, Rajesh K Chudasama², Ravi Dharamdasani¹
¹ Department of Ophthalmology, P D U Government Medical College, Rajkot, Gujarat, India
² Department of Community Medicine, P D U Government Medical College, Rajkot, Gujarat, India

Date of Web Publication

17-Sep-2019

Correspondence Address:
Dr. Rajesh K Chudasama
Vandana Embroidary, Mato Shree Complex, Sardar Nagar Main Road, Rajkot - 360 001, Gujarat
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jmgims.jmgims_32_16

Abstract

Background: Endophthalmitis is an infrequent but devastating intraocular infection. The objective of the present study was to detect the incidence of endophthalmitis in posttherapeutic keratoplasty patients. Materials and Methods: The study was conducted at a secondary-level government eye care center at Rajkot, Gujarat. The study included 71 eyes of 71 patients prospectively from January 2013 to December 2014. All the patients who underwent therapeutic keratoplasty for suppurative keratitis and descemetocele were included in this study. The study excluded all the patients who underwent optical penetrating keratoplasty and posttraumatic keratoplasty. The patients were followed up on the 1^st, 7^th, 15^th, and 45^th postoperative days for signs and symptoms of endophthalmitis. Results: There were 71 eyes of 71 patients including 44 (62.0%) males and 27 (38.0%) females. The mean age of the patients was 53.4 ± 18.9 years (range: 8–98 years). Out of the 71 eyes, 51 had preoperative ocular history including foreign body fall (15 [21.1%]), vegetative material trauma (20 [28.2%]), nonvegetative material trauma (11 [15.5%]), and previous keratoplasty (5 [7.0%]). Predominantly, bacterial infection was reported in 28 (39.4%) patients. Iritis was reported in all patients after keratoplasty followed by conjunctivitis (9.9%) and vitritis (7.0%). During follow-up examination on the 1^st, 7^th, 15^th, and 45^th postoperative days, zero incidence of endophthalmitis was reported. Conclusion: The present study reported zero incidence of endophthalmitis in therapeutic penetrating keratoplasty patients. Therapeutic penetrating keratoplasty is effective in the management of eye with suppurative keratitis and descematocoele.

Keywords: Endophthalmitis, incidence, secondary care center, therapeutic keratoplasty

How to cite this article:
Dodia KR, Chudasama RK, Dharamdasani R. Study of incidence of endophthalmitis in posttherapeutic keratoplasty patients at a secondary care hospital in Saurashtra Region, India. J Mahatma Gandhi Inst Med Sci 2019;24:82-6

How to cite this URL:
Dodia KR, Chudasama RK, Dharamdasani R. Study of incidence of endophthalmitis in posttherapeutic keratoplasty patients at a secondary care hospital in Saurashtra Region, India. J Mahatma Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Mar 29];24:82-6. Available from: https://www.jmgims.co.in/text.asp?2019/24/2/82/267006

Introduction

Endophthalmitis is an ocular inflammation resulting from the introduction of an infectious agent into the posterior segment of the eye. It is a sight-threatening condition characterized by inflammation of the intraocular structures usually from infectious organisms^[1] such as bacteria or fungi.^[2] Endophthalmitis is an infrequent but devastating intraocular condition with high potential for ocular morbidity, including permanent severe vision loss.^[3] Infectious agents generally gain access to the posterior segment of the eye by one of the following: (1) as a consequence of intraocular surgery – postoperative, (2) following a penetrating injury to the globe – posttraumatic, (3) from hematogenous spread of organisms to the eye from a distant anatomical site – endogenous, and (4) from spread of organisms from neighboring structures, secondary to microbial keratitis – miscellaneous.^[3],[4],[5]

Endophthalmitis is divided into two main types based on the mode of infection as exogenous and endogenous.^[6] Most cases of endophthalmitis are exogenous and organisms are introduced into the eye via trauma, surgery, or an infected cornea. Endogenous endophthalmitis occurs when the eye is seeded via the bloodstream. Patients usually have symptoms from their underlying systemic infection, but sometimes present only with eye symptoms.^[7] Most cases of endophthalmitis present acutely, with hours to a few days of symptoms. These cases are medical emergencies, as delay in treatment may result in permanent vision loss.^[7]

Postoperative endophthalmitis is one of the most dreaded complications of intraocular surgery.^[1],[8],[9] The reported incidence of postoperative endophthalmitis varies by the specific surgical procedure and across studies, but the overall incidence has been declining since the late 19^th century.^[8] The incidence of endophthalmitis following different procedures varies, for cataract from 0.07% to 0.32%,^{[4],[9],[10],[11],[12]} for vitrectomy from 0.03% to 0.07%,^[13],[14] and for posttraumatic <1%.^[15]

Currently, not much information is available for the incidence of endophthalmitis among posttherapeutic penetrating keratoplasty patients in India. Hence, the present study was conducted with the objective to detect the incidence of endophthalmitis among the patients of posttherapeutic penetrating keratoplasty at a secondary care center in Rajkot, Gujarat state, India.

Materials and Methods

This study was conducted at the Ophthalmic Department, P D U Government Medical College and Civil Hospital, Rajkot, a secondary-level center to detect the incidence of endophthalmitis among patients who underwent therapeutic penetrating keratoplasty. A prospective study was conducted over a period of 2 years from January 2013 to December 2014. The secondary eye center has a working operation theater and the facility to conduct cataract surgery in the study area. The present center is attached to the Government Medical College and equipped with various instruments such as high-class surgical microscope, phaco-emulsification machine, A-scan, B-scan, fundus camera, YAG laser machine, and anesthesia trolley to perform highly complex surgery and manage related potential complications. A total of 71 eyes of 71 patients enrolled prospectively in hospital matching inclusion criteria were selected during the study period of 2 years. The study was conducted after getting the ethical clearance from the Institutional Ethical Committee.

All the patients who underwent therapeutic keratoplasty for suppurative keratitis and descematocoele were included in this study. The study excluded all the patients who underwent optical penetrating keratoplasty and posttraumatic keratoplasty. Informed written consent was taken at the time of admission, and age, sex, eye, indication of therapeutic keratoplasty, detailed ocular history, and systemic history were collected in a predesigned pro forma.

After admission, patients underwent investigations such as blood pressure recording; blood sugar, blood urea level, serum creatinine, and other routine blood and urine investigations; chest X-ray posteroanterior view; Gram stain; potassium hydroxide (KOH) and culture of corneal scrapings; and the sac is tested for patency. Visual acuity and slit-lamp examinations were done, and B-scan was done if needed. Preoperative preparations in each patient included lid preparation, injection Tetanus toxoid, tablet acetazolamide 2 stat, injection cefotaxime and injection amikacin as per body weight, and injection atropine and xylocaine test dose just before the surgery. The patient was examined on slit lamp before the surgery for estimation of graft size. Depending on the ulcer size, donor and recipient corneal button size was estimated. Povidone-iodine 5% was instilled into the operative eye and painting in peri-ocular area was done. After that, peribulbar anesthetic block was given.

Donor button was then harvested from the donor eyeball under aseptic precautions and kept in Teflon block with endothelial side up, with the predecided trephine size. It was followed by painitng, draping, and punctum cautery was done if there was nasolacrimal duct blockage. Injection mannitol was kept ready and given if rise in intraocular pressure was found peroperatively. Superior rectus bridle suture was passed, and then the infected button was excised and sent for Gram stain, KOH, and culture sensitivity. Simultaneous cataract surgery with intraocular lens was done if required. Donor button was then sutured over the recipient eye. The first four primary sutures were taken at 12, 3, 6, and 9 o' clock positions followed by the remaining sutures. Knots were buried, anterior-chamber wash was done, and air bubble was injected. At the end of procedure, betadine wash was done. Subconjunctival injection of amikacin was given. Antibiotic ointment was put followed by pad and bandage of the operated eye.

For all the study participants, postoperative assessments were done first by the resident doctor followed by the consultant ophthalmologist. Postoperatively, the patients were given injection cefotaxime 1 g intravenously (IV) 12 hourly and injection amikacin 500 mg IV 12 hourly for 5 days. Oral tablet acetazolamide 250 mg qds, tablet dicolfenac 50 mg bd, tablet B-complex vitamins 1 bd, and tablet Vitamin C 1 od were also given. From the 1^st postoperative day, antibiotic drops of moxifloxacin, tobramycin, or natamycin were also given if fungal etiology was suspected. The patients were followed up on the 1^st, 7^th, 15^th, and 45^th postoperative days for signs and symptoms of endophthalmitis, and detailed examination such as visual acuity, slit-lamp examination, and B-scan was done if required. Steroids were started with minimal tapering doses when there were no signs suggestive of infection after 30 days of the surgery. Statistical analysis was made with Epi Info version 3.5.1 statistical software (CDC, Atlanta, GA, USA).^[16]

Results

A total of 71 cases were admitted during the study period of 2 years who underwent therapeutic endophthalmitis at a secondary care center, Rajkot. There were 71 eyes of 71 patients including 44 (62.0%) males and 27 (38.0%) females [Table 1]. The mean age of patients was 53.4 ± 18.9 years (range: 8–98 years) with little high female predominance (57.0 ± 19.2 years, range: 20–98 years). More than half (53.5%) of the patients were from 46 to 65 years' age group. There were 38 (53.5%) right eyes and 33 (46.5%) left eyes. Hypertension (14.1%) and diabetes mellitus (12.7%) were diagnosed mainly among the patients, followed by bronchial asthma (4.2%).

Table 1: Basic characteristics of patients who underwent therapeutic keratoplasty at Rajkot

Click here to view

More than three-fourth, i.e. 56 (78.9%) eyes had phakic lens, followed by 10 (14.1%) with pseudophakic lens and 5 (7.0%) with aphakic [Table 2]. Out of the 71 eyes, 51 had preoperative ocular history including foreign body fall (15 [21.1%]), vegetative material trauma (20 [28.2%]), nonvegetative material trauma (11 [15.5%]), and previous keratoplasty (5 [7.0%]). Bacterial infection was predominantly reported in 28 (39.4%) patients followed by fungal in 15 (21.2%) patients. Iritis was reported in all patients after keratoplasty followed by conjunctivitis (9.9%) and vitritis (7.0%).

Table 2: Ophthalmic characteristics of patients who underwent therapeutic keratoplasty at Rajkot

Click here to view

Follow-up examination of all patients operated for therapeutic keratoplasty was conducted on the 1^st, 7^th, 15^th, and 45^th postoperative days. All patients were examined to detect signs of endophthalmitis during all follow-up visits, but zero incidence was reported even after 45^th postoperative day in the present study.

Discussion

The primary purpose of therapeutic penetrating keratoplasty is to restore the structural integrity of the eye or to resolve infectious or inflammatory keratitis that is refractory to conventional medical therapy, and often both these indications are present.^[17],[18] When corneal infection does not respond to medical therapy, the only remaining option for treatment may be surgical excision of the infected tissue and replacement with a donor cornea. Therapeutic keratoplasty offers surgical debridement of an infectious process.^[17] If there is active infection without perforation, keratoplasty can be undertaken because perforation is a threatening condition. Corneal perforation increases the risk of endophthalmitis and infectious scleritis and should be avoided because of severe morbidity of the condition.^{[17],[18],[19],[20],[21]} Penetrating keratoplasty is the final therapeutic option in the management of refractory corneal disease after conventional medical therapy fails to prevent corneal perforation.^[17]

The overall pooled estimate of incidence of acute endophthalmitis from 1972 to 2002 after penetrating keratoplasty was 0.382%, with varying rates for each decade at 0.142% in the 1970s, 0.376% in the 1980s, 0.453% in the 1990s, and 0.200% during 2000 and beyond.^[8] It indicates that the overall incidence of endophthalmitis is decreasing in the last decade. Overall, the rate of endophthalmitis following penetrating keratoplasty was higher (0.382%) than that following cataract surgery (0128%),^[22] but it was changed during the last decade.^[23]

The present study reported zero incidence of endophthalmitis following therapeutic penetrating keratoplasty after the 45^th day postoperatively. Similar findings of zero endophthalmitis after therapeutic penetrating keratoplasty were reported in Turkey,^[17] a decade before. However, we were not able to find any other study reporting the same in the last 10 years, indicating the scope of further studies in the future to support the above findings. The trend of previous decades suggested that the incidence of endophthalmitis is decreasing and the present study reports zero incidence, supporting the same findings reported previously.^[8]

Different studies reported the incidence of endophthalmitis after penetrating keratoplasty from lower incidence of 0.11%,^[24] 0.18%,^[25] and 0.194%^[26] to higher incidence of 0.5%.^[9] The higher incidence was probably due to the inadequate clearance of the bacterial load in the donor cornea during preservation. Several explanations exist for the decreasing incidence of endophthalmitis including increasingly widespread use of povidone-iodine to disinfect the ocular surface at the time of postmortem harvesting of the donor tissue,^[27] could account intraoperatively for less bacterial contamination of donor tissue,^[28],[29] less risk of infection from organisms present on the recipient's ocular surface, evolution of eye banking techniques, availability of newer antibiotics,^[8] periodic monitoring of operation theaters for microbial load, and maintenance of proper functioning of autoclaves and other sterilizers.^[8] Many of the above factors are already been in practice in the present study institute and that was also among the reasons of zero incidence for endophthalmitis.

Conclusion

The present study reported zero incidence of endophthalmitis in therapeutic penetrating keratoplasty patients supporting the decreasing incidence of endophthalmitis in the last decade. Therapeutic penetrating keratoplasty is effective in the management of eyes with suppurative keratitis and descematocoele.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Uhumwangho OM, Akpata EP. Endophthalmitis in a tertiary centre in Nigeria. Sahel Med J 2015;18:74-7. [Full text]
2.	Aydin S, Ertugrul B, Gultekin B, Uyar G, Kir E. Treatment of two postoperative endophthalmitis cases due to Aspergillus flavus and Scopulariopsis spp. With local and systematic antifungal therapy. BMC Infect Dis 2007;7:87. [Doi. 10.1186/1471-2334-7-87].
3.	Kresloff MS, Castellarin AA, Zarbin MA. Endophthalmitis. Surv Ophthalmol 1998;43:193-224.
4.	Connell PP, O'Neill EC, Fabinyi D, Islam FM, Buttery R, McCombe M, et al. Endogenous endophthalmitis: 10-year experience at a tertiary referral centre. Eye (Lond) 2011;25:66-72.
5.	Rachitskaya AV, Flynn HW Jr., Fisher YL, Ayres B. Correlation between baseline echographic features of endophthalmitis, microbiological isolates and visual outcomes. Clin Ophthalmol 2013;7:779-85.
6.	Pahuja S, Narula R. Endophthalmitis. Delhi J Ophthalmol 2011;21:4-8.
7.	Durand ML. Endophthalmitis. Clin Microbiol Infect 2013;19:227-34.
8.	Taban M, Behrens A, Newcomb RL, Nobe MY, McDonnell PJ. Incidence of acute endophthalmitis following penetrating keratoplasty: A systematic review. Arch Ophthalmol 2005;123:605-9.
9.	Jambulingam M, Parameswaran SK, Lysa S, Selvaraj M, Madhavan HN. A study on the incidence, microbiological analysis and investigations on the source of infection of postoperative infectious endophthalmitis in a tertiary care ophthalmic hospital: An 8-year study. Indian J Ophthalmol 2010;58:297-302. [PUBMED] [Full text]
10.	Wong TY, Chee SP. The epidemiology of acute endophthalmitis after cataract surgery in an Asian population. Ophthalmology 2004;111:699-705.
11.	Keay L, Gower EW, Cassard SD, Tielsch JM, Schein OD. Postcataract surgery endophthalmitis in the United States: Analysis of the complete 2003 to 2004 medicare database of cataract surgeries. Ophthalmology 2012;119:914-22.
12.	Lalitha P, Rajagopalan J, Prakash K, Ramasamy K, Prajna NV, Srinivasan M, et al. Postcataract endophthalmitis in South India incidence and outcome. Ophthalmology 2005;112:1884-9.
13.	Cohen SM, Flynn HW Jr. Murray TG, Smiddy WE. Endophthalmitis after pars plana vitrectomy. The postvitrectomy endophthalmitis study group. Ophthalmology 1995;102:705-12.
14.	Eifrig CW, Scott IU, Flynn HW Jr., Smiddy WE, Newton J. Endophthalmitis after pars plana vitrectomy: Incidence, causative organisms, and visual acuity outcomes. Am J Ophthalmol 2004;138:799-802.
15.	Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML, et al. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol 2009;147:601-800.
16.	Centers for Disease Control and Prevention. Epi Info version 3.5.1; 2008. Available from: http://www.cdc.gov/epiinfo/. [Last accessed on 2011 Aug 15].
17.	Nurözler AB, Salvarli S, Budak K, Onat M, Duman S. Results of therapeutic penetrating keratoplasty. Jpn J Ophthalmol 2004;48:368-71.
18.	Killingsworth DW, Stern GA, Driebe WT, Knapp A, Dragon DM. Results of therapeutic penetrating keratoplasty. Ophthalmology 1993;100:534-41.
19.	Cavanaugh TB, Gottsch JD. Infectious keratitis and cyanoacrylate adhesive. Am J Ophthalmol 1991;111:466-72.
20.	Arentsen JJ, Laibson PR, Cohen EJ. Management of corneal descemetoceles and perforations. Ophthalmic Surg 1985;16:29-33.
21.	Hill JC. Use of penetrating keratoplasty in acute bacterial keratitis. Br J Ophthalmol 1986;70:502-6.
22.	Aiello LP, Javitt JC, Canner JK. National outcomes of penetrating keratoplasty. Risks of endophthalmitis and retinal detachment. Arch Ophthalmol 1993;111:509-13.
23.	Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, et al. Acute endophthalmitis following cataract surgery: A systematic review of the literature. Arch Ophthalmol 2005;123:613-20.
24.	Kattan HM, Flynn HW Jr., Pflugfelder SC, Robertson C, Forster RK. Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery. Ophthalmology 1991;98:227-38.
25.	Alshihry AM. Epidemiology of postoperative endophthalmitis (POE) in a specialized eye hospital. Epidemiol 2014;4:145. [Doi: 10.4172/2161-1165.1000145].
26.	Aaberg TM Jr. Flynn HW Jr., Schiffman J, Newton J. Nosocomial acute-onset postoperative endophthalmitis survey. A 10-year review of incidence and outcomes. Ophthalmology 1998;105:1004-10.
27.	Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: An evidence-based update. Ophthalmology 2002;109:13-24.
28.	Ferguson AW, Scott JA, McGavigan J, Elton RA, McLean J, Schmidt U, et al. Comparison of 5% povidone-iodine solution against 1% povidone-iodine solution in preoperative cataract surgery antisepsis: A prospective randomised double blind study. Br J Ophthalmol 2003;87:163-7.
29.	Adenis JP, Robert PY. Local antimicrobial prophylaxis in cataract surgery: Recent controversies and clinical guidelines. Ophthalmologica 1997;211 Suppl 1:77-80.