Post-Keratoplasty and Corneal Refractive Surgery Endophthalmitis
Endophthalmitis is the most dreaded vision threatening complication following any intraocular surgery. This has largely been discussed in the context of cataract surgery. The occurrence of endophthalmitis following keratoplasty or corneal refractive surge
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Post-Keratoplasty and Corneal Refractive Surgery Endophthalmitis Prafulla K. Maharana, Ruchita Falera, and Namrata Sharma
Endophthalmitis is one of the most dreaded complications of ocular surgery. Keratoplasty and refractive surgeries compromise the inherent p rotective barrier of the eye, thereby making it prone to infections. In this chapter we review the incidence, risk factors, etiology and clinical presentation of endophthalmitis in these special cases. We will also discuss the management protocol of such cases with special emphasis on modalities to prevent such an eventuality.
Post-Keratoplasty Endophthalmitis Infectious endophthalmitis following penetrating keratoplasty (PKP), though rare, is a devastating complication leading to poor graft survival and severe visual loss; the incidence ranges from 0.08 to 0.77% [1–6]. A downward trend has been noted over the last few decades from 0.376% during the 1980s to 0.2% in the 2000s [6]. Endophthalmitis may be either acute (within 6 weeks) or delayed in onset.
Risk Factors A number of factors have been associated with development of endophthalmitis in post-keratoplasty patients. They include the donor cornea from persons dyeing from infection [7]; culture-positive donor tissues [8]; high risk indications, such as injury, infection, ulcerative keratitis and impending or actual corneal perforation; and
P.K. Maharana, M.D. • R. Falera, M.D. • N. Sharma, M.D. (*) Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2018 T. Das (ed.), Endophthalmitis, https://doi.org/10.1007/978-981-10-5260-6_16
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history of previous ocular surgery. Postoperative events like suture removal, wound dehiscence and vitreous incarceration are other factors associated with the development of endophthalmitis.
Etiology Both bacteria and fungi have been the cause of post-keratoplasty endophthalmitis. In a study conducted by Kunimoto et al. [9], Gram-positive cocci were the most common aetiologic pathogen isolated in about 76.9% cases. Of these, Streptococcus species were more common, accounting for about 50% of all cases of endophthalmitis. Others included Staphylococcus species as well as Gram-negative bacteria like Proteus mirabilis and Serratia marcescens. Fungi are an important cause of postkeratoplasty endophthalmitis. Candida species (especially C. albicans) is responsible for almost 90% of post-keratoplasty fungal endophthalmitis and accounts for approximately 15–20% of all post-keratoplasty endophthalmitis [10]. Cladosporium, Cryptococcus and Aspergillus species are other rare causative pathogens [11, 12]. Kunimoto et al. [9] noted a higher culture positivity at 92.9% in post-keratoplasty endophthalmitis; this is significantly higher compared to post-cataract surgery endophthalmitis. Higher bacterial load, greater virulence of the pathogens, donor cornea as source of infection and the use of higher potency corticosteroids
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