Late-Onset Endophthalmitis Associated with Glaucoma Surgery

Sun Young Kim; Young Jung Rho; Su Young Kim

doi:10.3341/jkos.2014.55.11.1651

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Kim, Rho, and Kim: Late-Onset Endophthalmitis Associated with Glaucoma Surgery

Original Article

J Korean Ophthalmol Soc 2014;55(11):1651-1658.

Published online: 2 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.11.1651

Late-Onset Endophthalmitis Associated with Glaucoma Surgery

Sun Young Kim, MD¹, Young Jung Rho, MD², Su Young Kim, MD, PhD¹

¹Department of Ophthalmology and Visual Science, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea

²Department of Ophthalmology, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea

Address reprint requests to Su Young Kim, MD, PhD, Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, #271 Cheonbo-ro, Uijeongbu 480-717, Korea, Tel: 82-31-820-3110, Fax: 82-31-847-3418, E-mail: cassiopeia-su@hanmail.net

Received 23 September 2013 Revised 10 March 2014 Accepted 27 October 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To report cases of late-onset endophthalmitis associated with glaucoma surgery.

Methods

We retrospectively reviewed the medical records of 4905 consecutive patients who underwent glaucoma surgery (trabeculectomy or valve implant surgery) from January 1, 1988 to March 31, 2013.

Results

There were a total of 14 late-onset endophthalmitis (0.29%) cases associated with glaucoma surgery occurring at 1 year to 21 years postoperatively. Six cases (6/993, 0.60%) occurred after valve implantation and the other 8 cases (8/3912, 0.20%) occurred after trabeculectomy (p = 0.046). All but one patient were injected with fortified vancomycin and ceftazidim. Four patients also received a vitrectomy with the injection. The implanted valve was removed in 2 cases. In four cases, organisms were found in the culture (staphylococcus.aureus, streptococcus viridians, propionibacterium acnes and candida parapsilosis). After 1 year, only 4 patients achieved a visual acuity above 4/200 compared with other patients who had a final visual acuity of hand motion or worse. Three patients (33%) who developed endophthalmitis underwent other intraocular procedures.

Conclusions

Late-onset endophthalmitis associated with glaucoma surgery can often occur with fulminant sight-threatening complications. Due to devastating sequelae, the surgeon should carefully check the surgery site in the patients who underwent glaucoma surgery at every follow-up visit. Delayed endophthalmitis after glaucoma surgery still carries a poor visual prognosis and its onset is difficult to predict. Therefore, patients who undergo glaucoma surgery should be educated and carefully evaluated during regular follow-ups.

Keywords: Endophthalmitis, Glaucoma, Glaucoma surgery

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Figure 1.

Representative image of slit lamp photograph shows conjunctival injection and hypopyon (case 8).

Figure 2.

Representative image of B-scan ultrasonograph shows posterior vitreous opacification and multiple abnormal vitreous spikes (case 8).

Figure 3.

Representative images of slit lamp photograph shows markedly injected conjunctiva and thin, cystic bleb (case 4).

Table 1.

Incidences of endopthalmitis associated with glaucoma surgery

Type of surgery	Total cases (n)	Infected cases (n)
Trabeculectomy	3,912	8 (0.20%)
Valve implant surgery	993	6 (0.60%)
Total	4,905	14 (0.29%)
p-value	−	0.046^∗

^∗ p-value by Fisher's exact test: means statistically significant difference (p<0.05).

Table 2.

Baseline demographic and clinical features for the 4,905 patients with glaucoma filtering surgery

Characteristics	Values
Age (years)
Mean ± SD	55.15 ± 17.24
Sex (n, %)
Female	2,188 (44.61)
Male	2,717 (55.39)
Systemic diseases (n, %)
Diabetes mellitus	815 (16.62)
Glaucoma type (n, %)
Primary open-angle glaucoma	2,147 (43.77)
Primary angle closure glaucoma	669 (13.64)
Normal tension glaucoma	18 (0.37)
Secondary glaucoma	1,447 (29.50)
Neovascular glaucoma	564 (11.50)
Primary congenital glaucoma	60 (1.22)
Glaucoma surgery type (n, %)
Trabeculectomy	3,912 (80.00)
Tube implantation	993 (20.00)
Presence of other ocular surgery (n, %)	2,798 (57.00)
Antimetabolite (MMC) used (n, %)	1,917 (49.00)

Values are presented as mean ± SD unless otherwise indicated. MMC = mitomycin-C.

Table 3.

Summary of patients

Case no.	Sex/Age (years)	Associated systemic disease	Glaucoma diagnosis	^∗Symptom duration	Presenting visual acuity	^†Interval	Type of surgery	Mitomycin-C use	Status of glaucoma surgery site	Treatment	Culture organism	Other operation (time)	^‡Final visual acuity
1	M/68	HBP	2nd glaucoma	1 day	8/200	16 years	Trabeculectomy	Yes	Nearly melted conjunctiva, leak (+)	Intravitreal vancomycin + ceftazidim injection	No growth	−	20/200
2	M/49	none	CACG	2 days	LP(+)	21 years	Trabeculectomy	Yes	Pus tinged bleb	Intravitreal, intracameral and subconjunctival vancomycin + ceftazidim injection	No growth	−	HM
3	M/33	none	POAG	the day	CF	9 years	Trabeculectomy	Yes	Bleb thinning, leak (+)	Intravitreal and subconjunctival vancomycin + ceftazidim injection	No growth	−	4/200
4	M/49	none	POAG	1 day	HM	2 years and 6 months	Trabeculectomy	Yes	Pus tinged bleb	Intravitreal vancomycin + ceftazidim injection, ppV	Staphyococcus. aureus	−	LP(-)
5	M/50	none	POAG	1 day	HM	19 years	Trabeculectomy	No	Pus tinged bleb	Intravitreal vancomycin + ceftazidim injection, ppV	No growth	Phacoemulsification + PCL in sertion (14 years after trabeculectomy)	LP(-)
6	M/56	none	2nd glaucoma	2 days	12/200	13 months	Ahmed valve implantation + scleral graft	No	Thin conjunctiva on valve	Intravitreal vancomycin + ceftazidim injection	No growth	PKP (twice, 3 months prior to ahmed valve implantation)	LP(-)
7	M/59	none	2nd glaucoma	the day	LP(+)	8 years and 6 months	Ahmed valve implantation	No	Conjunctival inflammation with exposed valve	Intravitreal vancomycin + ceftazidim injection	No growth	l’ closure, ppV (1 year prior to ahmed valve implantation), PKP (3 years after ahmed valve implanatation)	LP(+)
8	M/80	DM	POAG	1 year	LP(-)	1 year	Ahmed valve implantation	NR	Bullae on conjunctiva	Ahmed valve removal, evisceration	No growth	−	LP(-)
9	M/68	none	Advanced glaucoma (NVG + AACG)	1 day	HM	5 years	Molteno tube implantation	No	Well positioned valve	Intravitreal vancomycin + ceftazidim injection	No growth	ppV (6 months after Molteno tube implantation)	HM
10	M/56	none	Uveitic glaucoma	2 days	HM	8 months	Trabeculectomy	Yes	Pus tinged bleb	Intravitreal vancomycin + ceftazidim injection, ppV	Streptococcus viridans	Phacoemulsification + PCL in sertion (8 years prior to trabeculectomy)	LP(-)
11	M/34	none	Secondary glaucoma	2 days	HM	1 year	Ahmed valve implantation + ppv	NR	Well positioned valve	Intravitreal vancomycin + ceftazidim injection, ppV	Propionibacterium acnes	Ciliary body retension cyst removal (1 year 4 months prior to valve surgery)	LP(-)
12	M/64	none	POAG	10 days	0.16	12 years	Ahmed valve implantation	NR	Ahmed valve tip exposure	Intravitreal vancomycin + ceftazidim injection, ahmed valve removal	No growth	Trabeculectomy (7 years prior to ahmed valve implantation) phacoemulsification + PCL in sertion (8 years prior to ahmed valve implantation	50/200
13	F/69	DM	POAG	30 days	LP(-)	7 years	Trabeculectomy + pressure regulator insertion	No	Exposed tube with whitish pus	Tube removal & AC irrigation & intracameral vancomycin + ceftazidim injection	Candida parapsilosis	Trabeculectomy (6 years prior to 2nd trabeculectomy)	LP(-)
14	F/36	none	POAG	2 days	CF	13 years	Trabeculectomy	Yes	Bleb thinning, leak(+)	Topical fortified antibiotics	No growth	Trabeculectomy (2 years prior to 2nd trabeculectomy)	40/200

HBP = high blood pressure; CACG = chronic angle closure glaucoma; POAG = primary open angle glaucoma; PCL = posterior chamber lens; AACG = acute angle closure glaucoma; NVG = neovascular glaucoma; DM = diabetes mellitus; LP (+) = light perception; CF = counting fingers; HM = handmotion; LP (-) = no light perception; ppV = pars plana vitrectomy; NR = notrecorded; PKP = penetrating keratoplasty.

^∗ Duration of symptom before diagnosis of endophthalmitis;

^† Interval between glaucoma surgery and diagnosis of endophthalmitis;

^‡ Final visual acuity 6 months after diagnosis.

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