|Year : 2016 | Volume
| Issue : 2 | Page : 66-69
Postcataract surgery endophthalmitis in Port Harcourt, Nigeria
CS Ejimadu, NE Chinawa
Department of Ophthalmology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
|Date of Submission||24-Jun-2016|
|Date of Acceptance||25-Jun-2016|
|Date of Web Publication||30-Aug-2016|
C S Ejimadu
Department of Surgery, University of Port Harcourt, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Background: Endophthalmitis is a rare but dreaded complication of cataract surgery. It is, therefore, imperative for cataract surgeons to know about its prevalence and how to prevent it in their institutions.
Aim: The aim of this study was to determine the prevalence of postcataract surgery endophthalmitis in a private health facility in Port Harcourt.
Methods: A retrospective analysis of the case files and theater records of 92 eyes of all 83 patients who had cataract surgery at the DDS Eye Centre and Surgery, Port Harcourt, Nigeria, between August 2006 and November 2012 was done. This included pre-, intra-, and post-operative care and features of endophthalmitis. Statistical software package SPSS version 17 was used to analyze the data (P < 0.005) with the prevalence of endophthalmitis between extracapsular cataract extraction and small incision cataract surgery.
Results: A total of 2484 (1490 males and 994 females) patients were seen in the private eye hospital in the period under review and 92 eyes of 83 (3.34%) patients (59 males and 24 females) were included in the study. Sixty-seven (73%) eyes had extracapsular cataract extraction with intra-ocular lens (ECCE + IOL) whereas twenty-five (27%) had small incision cataract surgery with intra-ocular lens (SICS + IOL). Among those who had ECCE, one (1.49%) developed endophthalmitis while two (8%) developed endophthalmitis following SICS, and they were all males which was statistically significant for surgery type. The prevalence of endophthalmitis in this study was 3.23%.
Conclusion: The high prevalence of endophthalmitis in this study may be due to inadequate management of comorbid conditions such as corneal ulcer and diabetes. The incisions were temporally placed and sutures were not used which may have compromised the integrity of the wound in SICS, causing a higher prevalence of endophthalmitis with this method.
Keywords: Cataract surgery, endophthalmitis, Port Harcourt
|How to cite this article:|
Ejimadu C S, Chinawa N E. Postcataract surgery endophthalmitis in Port Harcourt, Nigeria. Port Harcourt Med J 2016;10:66-9
|How to cite this URL:|
Ejimadu C S, Chinawa N E. Postcataract surgery endophthalmitis in Port Harcourt, Nigeria. Port Harcourt Med J [serial online] 2016 [cited 2021 Jun 25];10:66-9. Available from: https://www.phmj.org/text.asp?2016/10/2/66/189456
| Introduction|| |
Cataract extraction is the most common intraocular surgery performed worldwide, and it is estimated that in India alone, more than 5.1 million patients have cataract surgery annually.  Postoperative endophthalmitis is a rare but dreaded complication of cataract surgery, with a reported incidence currently in the range of 0.04-0.41%.  It is an uncommon but serious intraocular infection that can occur following intraocular surgeries and often causes severe visual impairment or even the loss of an eye. 
Since postoperative endophthalmitis continues to be a devastating, sight-threatening complication of cataract surgery, there is a great need for determining its burden and an effective prevention strategy. This includes the adoption of pre-, intra-, and post-operative care and surgical technique, with the least risk for developing endophthalmitis.  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 to late 20 th centuries.  The incidence of endophthalmitis after cataract surgery was approximately 5-10% in the late 1800s and early 1900s, , 1.5-2% during the 1930s,  and 0.5-0.7% in the mid and late 1900s. ,
Improvements in microsurgical and aseptic techniques, advancements in surgical materials, and the use of prophylactic broad-spectrum antibiotics, in combination with a better understanding of causes of the infection, may explain this favorable trend.  Powe et al. reported a 0.13% incidence of acute postoperative endophthalmitis following cataract extraction.
Recent reports suggest that the postcataract endophthalmitis rate may be substantially higher, suggesting a greater risk of endophthalmitis coincident with the increase in self-sealing clear corneal incisions. ,, Colleaux and Hamilton  reported a 0.129% and 0.05% incidence of endophthalmitis following cataract extraction with sutureless clear corneal and scleral tunnel incisions, respectively. In a study on postcataract endophthalmitis done in Aravind Hospital, India, it was observed that the incidence of postcataract endophthalmitis was higher in patients who had manual small-incision cataract surgery (SICS) than extracapsular cataract extraction (ECCE) among the different cadres of operating staff. This ranged from 0.12% for SICS compared to 0.04% for ECCE.  The relative rarity of endophthalmitis following intraocular surgery poses a significant difficulty in ascertaining accurate incidence rates or in analyzing the effects of multiple risk factors. Most reports regarding the rates of endophthalmitis are based on the experience of individual institutions or groups of surgeons and are limited by the small sample sizes, thereby making comparisons and statistical validity of data difficult.  This study is, therefore, aimed at determining the prevalence and gender distribution of postcataract surgery endophthalmitis and comparing the same in the two different surgical procedures used in this center so as to add to the limited available data.
| Materials and Methods|| |
A retrospective analysis of the case files and theater records of 92 eyes of all 83 patients who had cataract surgery at the DDS Eye Centre and Surgery, Port Harcourt, Nigeria, between August 2006 and November 2012 was done. Every patient who had cataract surgery was included in the study. All cases of postcataract surgery endophthalmitis from other hospitals but presenting at the DDS and cases with a history of trauma as the underlying cause of endophthalmitis were excluded from this study.
SICS is a modified form of ECCE performed through a 6.5-7.0 mm sclerocorneal tunnel.  The procedure is performed using a can-opener capsulotomy or capsulorhexis depending on the preference of the surgeon. The nucleus is prolapsed from the bag using a Sinskey Hook or a hydrodissection injection. The prolapsed nucleus is then removed using an irrigating vectis attached to a 5.0 ml syringe. After intraocular lens (IOL) implantation, the chamber is pressurized, and the wound is left unsutured in all cases in this study.
Endophthalmitis was diagnosed based on the examining ophthalmologist's clinical judgment during the normal course of postoperative care lasting up to 3 months after surgery. This will include visual loss, eye pain and irritation, headache, photophobia, ocular discharge, intense ocular and periocular inflammation, injected eye, and hazy media. Hypopyon is usually caused by rapidly growing bacteria such as coagulase-negative Staphylococci and some Gram-negative bacteria. Other signs are corneal infiltrate, cataract wound abnormalities, afferent pupillary defect, and loss of red reflex occurring within 2 days of surgery in acute cases. Mild-to-moderate vitritis, white posterior capsular plaque, and keratic precipitates occur in chronic cases.
On the day before the surgery, the patients had tablet acetazolamide 500 mg to reduce pressure, and anxiolytics and dilating drops were also given. On the day of the surgery, they were dressed in hospital gowns. Their heads were covered with a clean protective cap. After routine cleaning of skin with savlon and draping, the eye was further cleaned with 5% povidone-iodine solution. Patients were observed in the hospital in the first postoperative 24 h. At the time of discharge, all patients received detailed verbal instructions from trained staff regarding topical medications and postoperative precautions. The patients in both groups had the same antibiotics/steroid combination. They were evaluated on 1 day, 1 week, 3 weeks, 6 weeks, and 3 months postsurgery.
Statistical Software Package SPSS, version 17 (IBM Corporation Chicago City Illinois, USA) was used to analyze our data. P < 0.05 was considered statistically significant.
| Results|| |
A total of 2484 (1490 males and 994 females) patients were seen in the period under review. Ninety-two eyes were included in the study. More men (more than two-thirds) had cataract surgeries [Table 1].
Sixty-seven eyes had ECCE. The prevalence of endophthalmitis following cataract surgeries in our study was 3.23% [Table 2].
Two patients developed endophthalmitis after SICS [Table 3].
|Table 3: Total number of eyes that developed endophthalmitis among small-incision cataract surgery patients|
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Only one patient developed endophthalmitis after ECCE [Table 4].
|Table 4: Total number of eyes that developed endophthalmitis among extracapsular cataract extraction patients|
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No patient who had vitreous loss during surgery developed endophthalmitis [Table 5].
|Table 5: Number of patients who developed endophthalmitis along with vitreous loss|
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The three patients who developed endophthalmitis were all between 46 and 60 years [Table 6].
| Discussion|| |
Only 83 (3.34%) patients seen during the study period had cataract surgery [Table 1] and among these, the prevalence of endophthalmitis following cataract surgeries in our study was 3.23% [Table 2]. This is high compared to studies conducted elsewhere which reported 0.2% and 0.09%, respectively. , With the projected doubling of the number of people older than 65 years by 2020, ,, this may as well increase the incidence of cataract and attendant complication arising from surgery including endophthalmitis. Endophthalmitis is a dreaded postoperative complication of cataract surgery.
In this study, the patients were subjected to the same conditions before, during, and after the surgery so that poor outcome could probably be due to the difference in the technique. The higher percentage of patients who had endophthalmitis following SICS [Table 2] may be related to weak wound closure with sutureless incisions, since its stability and surgical integrity are believed to be the critical factors.  It is, therefore, necessary to ascertain the impact of surgical technique on postoperative complication by all centers involved in cataract surgeries. The higher prevalence of endophthalmitis after SICS is statistically significant, though the number is few [Table 2] and may be due to the potential for momentary wound incompetence. This creates a nidus for infection. In a study by Maxwell et al., up to 80% of the postsurgical cases of endophthalmitis were associated with wound defects, such as wound gape and/or malposition and leakage.  A retrospective study found wound abnormality to be a statistically significant risk factor in a review of more than 22,000 cataract surgeries.  Wound leak and malposition may have contributed to endophthalmitis in our study. Only men developed endophthalmitis in this study. This did not show any statistical significance, P > 0.05 [Table 3] and [Table 4].
Vitreous loss is a documented risk factor for endophthalmitis; interestingly, out of the six patients who had vitreous loss in our study, five had ECCE with IOL while one had SICS with IOL, but none of them developed endophthalmitis [Table 5]. This is in contrast to the study in India which showed a positive association between vitreous loss and endophthalmitis. 
There is no infection control unit in this small center to periodically collect samples from different sites within the operating theater to isolate causative organisms, review of intraocular irrigating solutions, assess infections and commensals among staff in the operating theater, and ensure maintenance of cold chain as is the case in centers with lower endophthalmitis prevalence. , The infection control unit should be setup to ensure this. This is a major setback and limitation. The absence of a standard sterilization system, which would have ensured a uniform method of preparing and handling all the patients and instruments for surgery, may also be implicated in the high prevalence of endophthalmitis in this center.
Visual outcome was poor following endophthalmitis management in our study. The progression was very rapid in the only case associated with diabetes. Proper counseling should be given to patients due to the poor visual prognosis following the standard treatment of endophthalmitis.
Surveillance and timely action for eliminating the potential sources of infection and ensuring a standard mode of management for endophthalmitis should be emphasized.
One of the two cases of endophthalmitis following SICS had recurrent corneal ulcer, which was difficult to treat after the surgery, and the patient eventually lost the eye. The only case of endophthalmitis following ECCE had poorly managed diabetes, the eye was also lost.
All these conditions are potential risk factors for the development of endophthalmitis following cataract surgery. The high prevalence of endophthalmitis in this study may be due to the poor management of comorbid conditions such as corneal ulcer and diabetes. Weak integrity of the wound in SICS may also be a contributory factor. Hence, the proper management of comorbid conditions is very crucial in the prevention of endophthalmitis.  Good wound closure and high aseptic standards before and after surgery are the other important conditions to adhere to in preventing endophthalmitis. 
There were some limitations to our study. Mild endophthalmitis might have been underestimated, as topical antibiotics used postoperatively may mask the signs and pose a problem in diagnosis. Ocular comorbidities such as retinopathies and optic neuropathies occurring before the primary surgeries were not noted. Hence, compromised vision before and after endophthalmitis treatment can be due to causes other than endophthalmitis.
| Conclusion|| |
An effective infection control unit is highly recommended in all eye hospitals, and all cases suspected to have endophthalmitis should undergo microscopic examination of material collected through the aspiration of vitreous/aqueous and then they should be tested for culture and sensitivity. Intravitreal injection of effective antibiotics should be given as soon as possible. Based on the report of the culture and sensitivity, the subsequent antibiotic treatment should be altered. Surgeons should give only guarded prognosis to the patients, as visual prognosis is usually poor.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]