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Case report

Bilateral endophthalmitis after bilateral sequential phacoemulsification

Puvanachandra, Narman MB, BChir, MA, MRCOphth; Humphry, Roger C. MD, FRCOphth, FRCS

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Journal of Cataract & Refractive Surgery: June 2008 - Volume 34 - Issue 6 - p 1036-1037
doi: 10.1016/j.jcrs.2008.01.032
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Bilateral sequential phacoemulsification is increasingly practiced worldwide. Advocates of this technique propose that it offers significant advantages over the traditional 2-stage procedure. They also claim low bilateral complication rates, particularly bilateral postoperative endophthalmitis. We present a case in which bilateral culture-positive endophthalmitis developed after bilateral sequential phacoemulsification. To our knowledge, this is the third reported case after phacoemulsification.


Bilateral sequential phacoemulsification surgery was performed in an 81-year-old woman. Preoperatively, the patient was fully counseled about the risks of such surgery. No preoperative ocular comorbidity existed. The patient was systemically well according to her general practitioner and was not taking any medication.

After satisfactory draping, surgery was performed by a single surgeon under topical anesthesia using on-axis clear corneal temporal incisions. After uneventful phacoemulsification in the right eye, a 3-piece acrylic intraocular lens (IOL) was inserted and intracameral cefuroxime instilled. Between eyes, complete rescrubbing and redraping occurred with fresh povidone–iodine. Different equipment from the same sterilization cycle and fresh irrigating fluid was used for phacoemulsification in the left eye, which was also uneventful and identical to that in the right eye. The acrylic IOL was from a separate batch. Postoperatively, the patient used tobramycin drops 4 times a day with apparent good compliance.

Four days postoperatively, the patient presented with rapid onset of bilateral ocular pain and significant reduction in vision over the preceding 24 hours. The visual acuity was hand movements in the right eye and 6/24 in the left eye. She had bilateral fibrinous anterior uveitis with hypopyon and pupillary membrane on the right and bilateral vitritis obscuring fundus details.

The patient was managed with bilateral vitreous taps and administration of intravitreal antibiotic agents: 2 mg vancomycin (0.1 mL of 20 mg/mL) and 0.4 mg amikacin (0.1 mL of 4 mg/mL). The initial Gram stain revealed gram-positive cocci, based on which topical ciprofloxacin, gentamicin, and oral ciprofloxacin were initiated. Within 2 days, the patient showed signs of improvement and steroids were added topically and systemically. Bilateral culture results from both eyes at 48 hours revealed Staphylococcus epidermidis, sensitive to gentamicin, ciprofloxacin, and vancomycin. The progress was steady, and after 2 months, the visual acuity had improved to 6/9 bilaterally.


Bilateral sequential phacoemulsification has many social, clinical, and economic advantages.1,2 There is the overall convenience for the patient, with fewer hospital visits, quicker visual rehabilitation, and a single operation. Also, when local anesthesia is undesirable, general anesthesia is necessary only once. Increasing the productivity of an eye unit through fewer patient episodes and faster operating room turnover reduces hospital waiting lists and, potentially, the overall economic burden of disease.

The principal concerns with such surgery are bilateral complications leading to bilateral visual loss. The current literature has small retrospective series3,4 with insufficient numbers to comment on the risk for endophthalmitis, whose incidence after unilateral cataract surgery is only 0.07%. There are only 2 reported cases5,6 of bilateral endophthalmitis after sequential phacoemulsification. Critics emphasize the use of only flash sterilization in the first case and no sterilization between eyes in the second case. It is important to stress that full reprepping with povidone–iodine, redraping, rescrubbing by staff, and change of equipment, including irrigating fluids, occurred between eyes in our case.

Our unit performs infrequent cases of bilateral sequential phacoemulsification infrequently when there is a strong patient preference for this. We abide by strict exclusion criteria, including ocular surface disease, previous refractive surgery, corneal decompensation risk, glaucoma, uveitis, and an immunocompromised patient. There is a policy of not proceeding to the second eye in the event of a complicated or prolonged first procedure. The rate of endophthalmitis after phacoemulsification in our unit is low (less than 0.07%).

Bilateral sequential phacoemulsification may have a limited role in select scenarios once careful preoperative counseling has been provided and appropriate exclusion criteria applied. As a profession, ophthalmology must still decide the ethical dilemma of exposing an individual to bilateral sight-threatening complications for an electively managed benign condition.


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3. Johansson BA, Lundh BL. Bilateral same day phacoemulsification: 220 cases retrospectively reviewed. Br J Ophthalmol. 2003;87:285-290.
4. Arshinoff SA, Strube YNJ, Yagev R. Simultaneous bilateral cataract surgery. J Cataract Refract Surg. 2003;29:1281-1291.
5. Özdek Ş.C, Onaran Z, Gürelik G, Konuk O, Tekinşen A, Hasanreisoğlu B. Bilateral endophthalmitis after simultaneous bilateral cataract surgery. J Cataract Refract Surg. 2005;31:1261-1262.
6. Kashkouli MB, Salimi S, Aghaee H, Naseripour M. Bilateral pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery. Indian J Ophthalmol. 55. 2007. 374-375. Available at: Accessed March 11, 2008.
© 2008 by Lippincott Williams & Wilkins, Inc.