Unilateral endophthalmitis after immediate sequential bilateral cataract surgery in a cognitively impaired patient: diagnosis and treatment

Abstract

Introduction: 

Immediate sequential bilateral cataract surgery (ISBCS) is a reasonable approach for cataract surgery in patients needing general anesthesia, such as those with cognitive impairment. To our knowledge, this is the first reported case of unilateral acute-onset postoperative endophthalmitis in a patient with cognitive impairment after ISBCS, with emphasis on diagnostic and treatment challenges.

Patient and Clinical Findings: 

A 64-year-old woman with a history of cognitive impairment, seizure disorder, and no prior ocular surgery presented with dense visually significant cataracts and visual acuity of fix and follows in both eyes.

Diagnosis, Intervention, and Outcomes: 

Patient underwent ISBCS under general anesthesia and without intracameral antibiotics or corneal sutures. The patient returned with unilateral acute-onset endophthalmitis 2 weeks postoperatively. Because of the patient's limited ability to comply with treatment, and lack of emergency general anesthesia needed for vitreous cultures, intravitreal vancomycin injection (1 mg/0.1 mL) was empirically given, with clinical resolution of the infection and visual acuity of fix and follows.

Conclusions: 

Acute-onset postoperative endophthalmitis in the setting of cognitive impairment is challenging because emergency general anesthesia may not be available, and the patient can tolerate only limited interventions. In this patient, empiric intravitreal vancomycin injection without cultures led to a satisfactory clinical outcome.

Cataract surgery is one of the most commonly performed surgeries worldwide.¹ It is reported that cataracts occur in 8% to 14% of adults with mental disability, and between 34% and 72% of these individuals undergo surgery.^2,3 Cataract surgery may be more difficult in the setting of cognitive impairment due to inability to cooperate with treatment under topical or local anesthesia.² An option for these patients is immediate sequential bilateral cataract surgery (ISBCS) under general anesthesia.

Endophthalmitis is a rare but serious postoperative complication of cataract surgery.⁴ The incidence of endophthalmitis after ISBCS has been reported at 0.029%.⁵ Among these cases, the most common organisms were staphylococci; streptococci were associated with poorer visual outcomes.⁶ This report describes a patient with cognitive impairment who developed unilateral acute-onset postoperative endophthalmitis after ISBCS. The patient was treated with empiric intravitreal vancomycin 1 mg/0.1 mL without cultures, with favorable clinical outcome.

This case demonstrates a challenging situation after ISBCS. The patient was treated with 1 dose of intravitreal vancomycin which achieved a good clinical outcome without requiring a second general anesthetic or a more involved procedure under topical or local anesthesia.

Patient Consent Statement

The study was conducted in accordance with the tenets of the Declaration of Helsinki and the Health Insurance Portability and Accountability Act. It was deemed exempt from review by the University of Miami Institutional Review Board, given it fulfilled criteria for a case report. The patient was unable to provide written consent. The healthcare proxy provided written informed consent.

CASE REPORT

A 64-year-old nonverbal woman with a history of cognitive impairment since birth and seizure disorder, and without any past ocular history, presented for evaluation. The patient was institutionalized and dependent on assistance by caretakers to complete activities of daily living. On examination, corrected distance visual acuity was fix and follows in both eyes. Portable slitlamp examination revealed a clear cornea and dense nuclear and cortical cataracts, with no view to the fundus in both eyes. B-scan echography revealed a normal posterior segment in both eyes. Because the patient could not cooperate with surgery under local or topical anesthesia, it was decided to perform ISBCS under general anesthesia. The patient presented to an academic satellite facility located approximately 50 miles from her living facility, and the surgery was performed at the main eye center, located approximately 180 miles from the patient's living facility.

The patient underwent phacoemulsification using a standard technique starting with the right eye. First, 1 clear corneal side port of 0.9 mm in size was made, and a temporal Triplanar clear corneal incision was made using a 2.5 mm keratome. Then, after phacoemulsification, a hydrophobic acrylic single-piece intraocular lens (IOL) was implanted in the bag followed by stromal hydration (hydroclosure) of all ports (sides and roof). At the end of the procedure, surgical wounds were deemed to be water-tight and without leaking using a sterile fluorescein strip (Seidel test) near the incisions. No corneal sutures were used. Then, the second eye (left eye) was prepped and draped as a new case with exchange for a new sterile instrument tray, phacoemulsification machine disposables (eg, probe, tubing, and cassette), and new set of gowns and gloves for the surgeon. After the end of both surgeries, the patient was prescribed topical moxifloxacin 4 times a day, and prednisolone acetate 1% 4 times a day in both eyes. Intracameral antibiotics were not used in either eye.

The postoperative day 1 examination was unremarkable. On postoperative day 15, the patient returned to clinic because the caregiver noted conjunctival hyperemia and apparent light sensitivity in the right eye (Figure 1, A). On examination, there were conjunctival injection, corneal haze with no corneal staining, and hypopyon in the right eye (Figure 1, A). B-scan echography showed new vitreous opacities in the right eye compared with the preoperative examination (Figure 1, B). The examination of the left eye was that of a quiet pseudophakic eye. Acute-onset postoperative endophthalmitis in the right eye was diagnosed.

Figure 1.: External photos examination of the right eye 15 days postoperatively showing conjunctival injection, hazy cornea, hypopyon, and without signs of corneal staining (A). B-scan evaluation of the right eye showing diffuse vitreous opacities, but with no evidence of retinal detachment (B).

Given the satellite location and the inability to obtain emergency general anesthesia, it was decided to perform empiric intravitreal injection of vancomycin 1 mg/0.1 mL in the right eye without obtaining cultures. The patient was prescribed topical moxifloxacin every 2 hours, prednisolone acetate 1% 4 times a day, and atropine 1% once a day in the right eye.

Three days after the intravitreal injection in the right eye, the inflammation in the conjunctiva was improved and there was approximately 90% resolution of the hypopyon (Figure 2, A). The patient was observed weekly for 6 weeks, with continued improvement (Figure 2, B). Topical therapy was discontinued. Four months postoperatively, there were no clinical signs of infection in the right eye and B-scan echography showed a normal posterior segment (Figure 2, C). The patient's visual acuity remained fix and follows after resolution of the infection. The fellow of the left eye remained without clinical signs of infection.

Figure 2.: EPE of the right eye 3 days after intravitreal vancomycin injection showing clinical improvement of conjunctival inflammation and 90% reduction of hypopyon (A). EPE 1 month after intravitreal injection (B). EPE 4 months after intravitreal injection with clinical resolution of the infection (C). EPE = external photos examination.

DISCUSSION

There are relatively few reports of acute-onset postoperative endophthalmitis in cognitively impaired adults. Wu et al. reported outcomes of patients with cognitive impairment who underwent cataract surgery under general anesthesia, although not using ISBCS (ie, 1 eye at a time). Postoperative surgical complications occurred in 7 (33%) of 21 eyes and included anterior uveitis in 3 (14%) eyes, posterior capsular opacification in 2 (10%) eyes, rhegmatogenous retinal detachment in 1 (5%) eye, dislocated posterior chamber IOL in 1 (5%) eye, pseudophakic bullous keratopathy in 1 (5%) eye, and cystoid macular edema in 1 (5%) eye.² There were no cases of endophthalmitis in this series.² Pershing et al. reported that patients with dementia were more likely to have a longer and more complex cataract surgery lasting over 30 minutes, but with no difference in the likelihood of surgical or postoperative complications when compared with patients without dementia.³

ISBCS is growing in popularity and remains an option for patients who must travel great distances for surgery, those requiring general anesthesia, and those with limited for social support systems in place.^7–9 However, it has been suggested to reserve this technique for patients without ophthalmic risk factors, such as visually significant ocular comorbidities, biometry outliers, dense cataracts, or loose zonular fibers, which can potentially jeopardize the outcome of 1 or both eyes.^8,10

A recent publication using nationwide registry data in Sweden reviewed more than 1.4 million cataract surgeries and more than 92 000 ISBCS cases; the incidence of unilateral endophthalmitis was 0.0299% (1/3334) for unilateral procedures, and 0.0152% (1/6600) for bilateral same day cases, with only 1 ISBCS patient developing bilateral endophthalmitis (1/46 000).⁵ It has been proposed that intracameral antibiotics can reduce the incidence of postoperative endophthalmitis in ISBCS.¹¹

Despite the European experience, many surgeons in the United States do not routinely use intracameral antibiotic prophylaxis. In 2021, the ASCRS surveyed 5052 members and 1205 responded. Of these respondents, 34% reported not using intracameral antibiotics. Among these nonusers, 66% cited compounding risks, 32% cited cost, and 48% were unconvinced of a need (the numbers add to greater than 100% because multiple answers were allowed). In addition, among these nonusers, most responded that they would use a packaged, approved medication if one were available in the United States.¹²

Intracameral antibiotics are not routinely used at our institution. During surgery, both wounds appeared water-tight, and the decision was made not to use corneal sutures. It is possible that corneal sutures might have reduced the risk for infection. However, it would have been very difficult to remove a corneal suture in the postoperative period on this patient and might have required general anesthesia to do so safely. Similarly, a scleral tunnel incision might have been beneficial but would have increased the duration of the surgery and the time under general anesthesia. There is conflicting evidence regarding the rates of endophthalmitis in suture vs suture-less surgeries in both adult and pediatric populations; however, to our knowledge, there is no specific literature comparing these rates in adults with cognitive impairment.^13,14

The current patient, due to her mental status, was very poorly cooperative with examinations and procedures. It was decided to use only a single antibiotic injection because, in the judgment of the treating physician, the patient could not tolerate more than one “stick.” Vancomycin was selected as empiric therapy, given that the most common organisms responsible for endophthalmitis are staphylococci and sensitive to vancomycin.⁶ The decision was made to not try to mix vancomycin with ceftazidime because of concerns of causing precipitation of the solutions.¹⁵ Fortunately, the patient responded very well to this treatment approach. A study of 63 consecutive cases of endophthalmitis after cataract surgery who subsequently underwent a tap and inject procedure showed 84% of them were caused by gram-positive bacteria sensitive to vancomycin.¹⁶ Therefore, it stands to reason that a vancomycin-only treatment approach comes with a 16% risk for not adequately treating the infection.

Furthermore, vitreous cultures were not obtained, again so as not to subject the patient to a second “stick” under difficult circumstances. Moreover, the value of vitreous cultures in the clinical management of endophthalmitis has been called into question. In a series of 111 eyes of 111 patients who developed acute-onset postoperative endophthalmitis after cataract surgery, the management was changed in only 9 of the 111 (8%).¹⁷ In all 9 of these patients, a change in clinical management was prompted by worsening of the clinical appearance, not by the culture results.¹⁷

To our knowledge, this is the first report of unilateral acute-onset postoperative endophthalmitis in a cognitively impaired patient after IBSCS. This patient responded well to empiric intravitreal vancomycin without cultures. As IBSCS gains in popularity, it may be useful to consider quicker, less invasive treatment of postoperative complications. In addition, the use of IBSCS in patients with cognitive impairment comes with additional risks because of the patient's inability to cooperate with procedures in the postoperative period. There may be a rationale to use intracameral antibiotic prophylaxis in these patients, even in institutions (such as ours) which do not routinely use intracameral antibiotics.

WHAT WAS KNOWN

• Immediate sequential bilateral cataract surgery (ISBCS) can be a useful technique to facilitate postoperative care among challenging populations (eg, individuals with cognitive impairment and limited support systems); despite preventive measures, there is a risk for developing acute-onset postoperative endophthalmitis.

WHAT THIS PAPER ADDS

• It is paramount to closely monitor patients undergoing ISBCS, so complications such as endophthalmitis can be promptly managed if they arise during the early postoperative period; however, the specific management should be addressed on case-by-case based on the individual clinical presentation.