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    Are intracameral antibiotics the answer for endophthalmitis?

    Miami, FL—Postoperative endophthalmitis remains a potentially devastating complication of cataract surgery. However, a good visual outcome is possible if the infection is recognized early and treated appropriately, said Harry W. Flynn Jr, MD.

    He provided an overview of the classification, manifestations, etiology, prophylaxis, and management of post-cataract surgery endophthalmitis.Figure 1: 60-year-old male with acute-onset postoperative endophthalmitis 5 days following complicated cataract surgery with ACIOL. Note the conjunctival hyperemia, corneal edema, hypopyon and fibrin in the anterior chamber. Pars plana vitrectomy and intraocular antibiotics were performed. Images courtesy of Harry W. Flynn Jr, MD

    Dr. Flynn said that endophthalmitis after cataract surgery is divided into acute-onset and delayed-onset cases based on whether the event occurs within 6 weeks of the procedure or later. Acute-onset endophthalmitis presents with ocular redness, pain, hypopyon, and fibrin in the anterior chamber, and is most often due to Gram-positive bacteria, with coagulase-negative staphylococci being the most common pathogen.

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    Patient- and surgery-related features that increase the risk of acute-onset endophthalmitis include significant blepharitis or lid abnormalities, relative immune compromise (e.g., diabetes, older age), incision leak, intraoperative vitreous loss, application of lidocaine gel prior to povidone-iodine preparation of the ocular surface, and contaminated solutions introduced into the anterior chamber.

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    Delayed-onset endophthalmitis usually follows an indolent course in which inflammation gradually progresses, leading to vitritis and infiltrates in the vitreous cavity. Hypopyon is less common with delayed-onset endophthalmitis compared with acute-onset endophthalmitis, but infection in the capsular bag manifested by the appearance of white plaques is seen more often with delayed-onset endophthalmitis.

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    “Despite treatment, there can be infection recurrence in these cases that may necessitate removal of the intraocular lens (IOL) and capsular bag,” said Dr. Flynn, professor of ophthalmology and The J. Donald M. Gass Distinguished Chair in Ophthalmology, Bascom Palmer Eye Institute, University of Miami.

    Propionibacterium acnes are the most common cause of delayed-onset endophthalmitis, and fungi, particularly Candida spp., are also important in the etiology of these infections.

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