Acute-onset postoperative endophthalmitis is defined as an infection occurring within 6 weeks of the ocular procedure and often occurs after cataract surgery.1 Approximately 70% of post–cataract surgery endophthalmitis cases are caused by coagulase-negative staphylococci, followed by Staphylococcus aureus, accounting for 10%, and streptococci, accounting for 9% of cases.2,3 In the Endophthalmitis Vitrectomy Study (EVS), corneal infiltration or cataract wound abnormality was associated with significant differences in the microbiologic spectrum, such as gram-negative bacteria or gram-positive species other than coagulase-negative micrococci.3
According to the EVS, if the visual acuity (VA) at the initial visit is light perception or below, vitrectomy should be performed early for good prognosis.3 However, it is challenging to choose the optimal time to perform vitrectomy when the corneal pathology, such as corneal infiltration or opacity, hinders the visualization of the posterior pole. In such cases, the Eckardt temporary keratoprosthesis can be used as a tectonic artificial graft because it provides an excellent wide field of vision during vitrectomy. We report the use of Eckardt keratoprosthesis for pars plana vitrectomy (PPV) in a patient with endophthalmitis and suppurative keratitis that developed after cataract surgery.
A 79-year-old woman had laser iridotomy in both eyes due to acute angle-closure glaucoma and was recommended for cataract surgery, but she was lost to follow-up. Two years later, she returned due to decreased VA in the left eye. She had cataract surgery in the left eye at that time, followed by cataract surgery in the right eye 1 month later. During the right eye surgery, zonular weakness was observed at approximately 4 o'clock hours, and a capsular tension ring was inserted. There was no other complication during the surgery.
On the fourth postoperative day, the patient visited the emergency department complaining of decreased VA and right eye pain that had begun 2 days before her visit. The right eye vision was limited to light perception, which was significantly reduced compared with the VA of 20/60 on the first postoperative day. Slitlamp examination revealed corneal ring infiltration with a whitish puffy material in the right eye anterior chamber and lens surface (Figure 1, A). B-scan ultrasonography showed anterior vitreous opacity. No specific findings were observed in the left eye.
The patient's medical history was unremarkable except for hypertension. She used a wheelchair because she had difficulty walking without assistance, and had a habit of frequently wiping her mouth with her hand.
She was diagnosed with acute-onset postoperative endophthalmitis and was hospitalized. She immediately received an intravitreal injection of antibiotics (vancomycin 0.9 mg/0.03 cc, ceftazidime 1.8 mg/0.03 cc, and dexamethasone 150 μg/0.03 cc) after sampling of the cornea, aqueous humor, and vitreous. Systemic antibiotic treatment (ciprofloxacin 400 mg twice daily, linezolid 600 mg 1 time a day, and minocycline 100 mg 2 times a day) was initiated, as well as topical treatment with moxifloxacin every 1 hour and alternating fortified ceftazidime and tobramycin eyedrops every 2 hours. Nevertheless, the right eye condition deteriorated.
On postoperative day 8, intraocular pressure was measured manually and decreased to soft. Slitlamp examination demonstrated a total severe corneal haziness with 360-degree limbal thinning and full exudation in the anterior chamber (Figure 1, B). B-scan ultrasonography showed heterogeneous echogenicity in the whole vitreous that strongly indicated panophthalmic involvement (Figure 1, C). Microbiological analysis later revealed Streptococcus pneumoniae in the corneal scrapping sampled at the initial presentation. The patient was scheduled for emergent vitrectomy using the Eckardt temporary keratoprosthesis and therapeutic keratoplasty using a cryopreserved donor cornea under general anesthesia.
First, a 360-degree conjunctival peritomy at the limbus was performed, and the Flieringa ring was used for globe stabilization. The previous two 10-0 nylon corneoscleral sutures were removed. The Eckardt keratoprosthesis was used, and the recipient cornea was trephined using a 7.0 mm handheld disposable trephine (Katena). Irrigation/aspiration of the anterior chamber was performed, and the intraocular lens with the whitish puffy material was protruded and carefully removed. The Eckardt keratoprosthesis was sutured to the cornea using 6 interrupted Prolene 6-0 sutures (Figure 2, A). A 23-gauge 3-port preparation was set 3.5 mm from the corneal limbus, and the posterior segment was visualized using a BIOM 3 Non-Contact Panoramic Wide-Angle Viewing System (Oculus GmBH). White dense exudative materials were observed on the vitreous base and ciliary body with diffuse vitreous base traction and choroidal and retinal detachment, and proliferative vitreoretinopathy was noted. A series of PPV, retinectomy, endolaser, and silicone oil tamponade were performed using the keratoprosthesis (Figure 2, B).
Because a donor cornea was not available, we used a cryopreserved donor cornea, which was prepared at the eye bank from a whole globe, without any contraindicative features, and was cryopreserved at −80°C for 4 months. After the whole globe was thawed, the corneal button was removed and preserved in Optisol GS (Bausch & Lomb) until surgery. After vitrectomy, the Eckardt keratoprosthesis was removed, and the infected limbal tissue was trimmed. The cryopreserved donor cornea was sutured to the recipient's cornea using an interrupted Ethilon 10-0 suture (Figure 2, C). After keratoplasty completion, a silicone oil injection was administered to supplement the loss of oil during keratoplasty.
During postoperative hospitalization, the patient received moxifloxacin 400 mg by mouth 1 time a day, minocycline 100 mg by mouth 2 times a day, triamcinolone 12 mg by mouth 2 times a day, moxifloxacin eyedrops every 2 hours, and sodium chloride 5% eyedrops 4 times a day. By the end of hospitalization, the transplanted cornea became more edematous, but the anterior chamber remained well formed and no signs of recurrent infection were seen. Corneal edema persisted over the 3-month follow-up period; however, there were no signs of recurrent infection, and the VA increased from light perception to counting fingers at 30 cm.
We present a case of acute-onset postoperative infectious endophthalmitis and suppurative keratitis that was successfully managed by vitrectomy using temporary implantation of a keratoprosthesis, followed by therapeutic keratoplasty with a cryopreserved donor cornea. Over the 3-month follow-up period, there was a residual corneal edema, but there were no signs of recurrent infection and the implanted cornea was maintained stable.
This patient developed endophthalmitis accompanied by suppurative keratitis, and the causative pathogen was found to be S pneumoniae. Endophthalmitis caused by streptococci is known to have worse outcomes than that caused by a staphylococcal infection.4 According to a previous study, in cases of endophthalmitis caused by S pneumoniae, the visual prognosis is generally unfavorable; no light perception was found in 10 (37%) of 27 eyes and 2 (20%) of these eyes were eviscerated.5
In the EVS, if the VA at the initial visit was light perception or below, early vitrectomy was recommended for good prognosis.3 However, in several recent studies regarding the indication of PPV for endophthalmitis, there has been a debate about sticking to the report of the EVS because of the advancement of the surgical technique of vitrectomy.6–10 Several studies reported that vitrectomy as the initial treatment of endophthalmitis could decrease the need for additional intervention to control infection, although there were no benefits of visual outcomes, compared with an intravitreal antibiotic.7,8 Other reports also demonstrated the improvement of vision after initial early vitrectomy (ie, within 1 hour after diagnosis or within 24 hours of onset) in eyes developed infectious endophthalmitis after intraocular surgery.9,10 In particular, as our case, streptococcal endophthalmitis is often associated with poor visual prognosis. Recent report about the predictive factors in the treatment of streptococcal endophthalmitis showed that the only possible predictive factor associated with improved visual outcomes was early vitrectomy within 3 days. Therefore, early diagnosis and vitrectomy are recommended.11
However, as in this case, diffuse corneal infiltration makes it difficult to perform vitrectomy because of poor visualization. Dave et al. reported on a series of 43 eyes that underwent combined keratoplasty and PPV for endophthalmitis with a compromised corneal clarity.12 The most commonly implicated bacteria were Streptococcus species (20.9%), and they used a temporary keratoprosthesis in 22 (51.2%) of the 43 eyes. The anatomical success rate was significantly higher in the group of combined PPV and penetrating keratoplasty with a temporary keratoprosthesis than in the group without a keratoprosthesis. In our case, there was no available donor cornea at the time of the emergent surgery. We decided to use a temporary keratoprosthesis with tectonic keratoplasty using a cryopreserved donor cornea to resolve the infectious process refractory to conventional medical therapy.
Lee et al. reported on 11 patients who had undergone combined corneal allotransplantation and PPV using an Eckardt temporary keratoprosthesis and analyzed the surgical outcome of the corneal allografts.13 In this report, 6 eyes of endophthalmitis and corneal pathology were treated with PPV; corneal graft rejection occurred in the 5 eyes. The presence of an active inflammation at the time of surgery was significantly associated with the graft survival. Therefore, sequential therapeutic keratoplasty with a cryopreserved cornea and optical keratoplasty with fresh corneal tissue can be a treatment option.
Helsen et al. reported on the use of the Eckardt keratoprosthesis as an emergent temporary tectonic seal.14 Similar as in our case, there was no fresh donor cornea available to repair the large corneal defect. The author decided to place the Eckardt keratoprosthesis for 3 weeks until a donor cornea became available and the keratoprosthesis was well tolerated in this period. Presently, temporary keratoprostheses include the Eckardt type and the Landers type.15 In our case, the Eckardt temporary keratoprosthesis was used. Because it has a larger optical cylinder diameter with a smaller vertical length than that of the Landers type, it can better visualize the peripheral retina, making it easier to treat anterior proliferative lesions, as in this case. Unlike the Landers type, which is made of poly(methyl methacrylate), the Eckardt type is made of silicone and it is more flexible. It establishes a close contact with the cornea, preventing leakage of an intraocular infusion even if scleral indentation occurs.
In summary, our patient developed acute-onset infectious endophthalmitis accompanied with suppurative keratitis after cataract surgery, which was caused by highly virulent S pneumoniae and was refractory to medical therapy. We performed an emergent vitrectomy using a temporary keratoprosthesis, followed by therapeutic keratoplasty with a cryopreserved donor cornea to resolve severe infection and achieve anatomical stability. This allowed us the time to plan the sequential optical keratoplasty after infection control was achieved. The Eckardt keratoprosthesis is useful in the treatment of endophthalmitis and suppurative keratitis requiring emergent early vitrectomy, which is associated with better visual outcomes, because of enabling sufficient visualization.
WHAT WAS KNOWN
- In cases of endophthalmitis caused by Streptococcus species, despite aggressive treatment the visual outcomes are generally poor.
WHAT THIS PAPER ADDS
- Early vitrectomy as the initial treatment of endophthalmitis can decrease the need for additional intervention to control infection and improve the visual prognosis.
- The Eckardt keratoprosthesis is useful in the treatment of endophthalmitis and suppurative keratitis requiring emergent early vitrectomy because it enables sufficient visualization.
1. Relhan N, Forster RK, Flynn HW Jr. Endophthalmitis: then and now. Am J Ophthalmol 2018;187:20–27
2. Vaziri K, Schwartz SG, Kishor K, Flynn HW Jr. Endophthalmitis: state of the art. Clin Ophthalmol 2015;9:95–108
3. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995;113:1479–1496
4. Teweldemedhin M, Gebreyesus H, Atsbaha A, Asgedom SW, Saravanan M. Bacterial profile of ocular infections: a systemic review. BMC Ophthalmol 2017;17:212
5. Miller JJ, Scott IU, Flynn HW Jr, Smiddy WE, Corey RP, Miller D. Endophthalmitis caused by Streptococcus pneumoniae. Am J Ophthalmol 2004;138:231–236
6. Grzybowski A, Turczynowska M, Kuhn F. The treatment of postoperative endophthalmitis: should we still follow the Endophthalmitis Vitrectomy Study more than two decades after its publication? Acta Ophthalmol 2018;96:e651–e654
7. Kitsche M, Herber R, Pillunat LE, Terai N. Clinical and visual outcome of endophthalmitis patients: a single-center experience. Graefes Arch Clin Exp Ophthalmol 2020;258:183–189
8. Jeong SH, Cho HJ, Kim HS, Han JI, Lee DW, Kim CG, Kim JW. Acute endophthalmitis after cataract surgery: 164 consecutive cases treated at a referral center in South Korea. Eye (Lond) 2017;31:1456–1462
9. Damm LJ, Boden KT, Januschowski K. Importance of vitrectomy in endophthalmitis: how immediate vitrectomy can restore visual acuity. Ophthalmologe 2019;116:569–571
10. Choi EY, Han JY, Lee H, Lee SC, Koh HJ, Kim SS, Kim M. Impact of antibiotic resistance of pathogens and early vitrectomy on the prognosis of infectious endophthalmitis: a 10-year retrospective study. Graefes Arch Clin Exp Ophthalmol 2019;257:805–813
11. Yospaiboon Y, Meethongkam K, Sinawat S, Laovirojjanakul W, Ratanapakorn T, Sanguansak T, Bhoomibunchoo C. Predictive factors in the treatment of streptococcal endophthalmitis. Clin Ophthalmol 2018;12:859–864
12. Dave A, Acharaya M, Agarwal M, Dave PA, Singh M, Mathur U. Outcomes of combined keratoplasty and pars plana vitrectomy for endophthalmitis with compromised corneal clarity. Clin Exp Ophthalmol 2019;47:49–56
13. Lee DS, Heo JW, Choi HJ, Kim MK, Wee WR, Oh JY. Combined corneal allotransplantation and vitreoretinal surgery using an Eckardt temporary keratoprosthesis: analysis for factors determining corneal allograft survival. Clin Ophthalmol 2014;8:449–454
14. Helsen S, Ní Dhubhghaill S, Zakaria N, Koppen C. Eckardt keratoprosthesis for tectonic repair of a large corneal perforation. Cornea 2016;35:1147–1149
15. Ikeda T. Pars plana vitrectomy combined with penetrating keratoplasty. Semin Ophthalmol 2001;16:119–125