An outbreak of a bacterial infection after immediate sequential bilateral cataract surgery (ISBCS) at a community-based eye clinic was likely due to a systemic breach of sterility, according to a retrospective case series.
The same strain of Staphylococcus epidermidis was detected in all cultures of three consecutive patients who presented with bilateral simultaneous postoperative endophthalmitis (BSPOE) after undergoing ISBCS on the same day at the same clinic in Denmark, reported Jakob Bjerager, MD, of Rigshospitalet in Glostrup, and colleagues.
The outbreak of post-surgical BSPOE had “devastating consequences in 2 of 6 eyes,” the group noted in JAMA Ophthalmology, although “all patients recovered good visual function in at least 1 eye.”
However, “because of its numerous benefits, including rapid visual rehabilitation with avoidance of intersurgical anisometropia, reduced health care costs, few postoperative visits, and short travel distance and time for patients, we believe that ISBCS is safe with strict adherence to guideline-recommended precautions,” they wrote.
Brian L. VanderBeek, MD, MPH, of the University of Pennsylvania in Philadelphia, explained to MedPage Today that for “many, many years, the cataract community has resisted performing same-day bilateral cataract surgery, [primarily due to] concern over severe blinding infection related to a contamination. The main rationale for not doing bilateral surgery being that if something was to happen to one eye, the other is not likely to have the same fate.”
But VanderBeek, who was not involved in the case series, said that same-day bilateral cataract surgery has become more common because of financial and patient pressures.
“This transition has been mostly successful in that reports like this are incredibly rare. However, as seen in this study, when the worst-case scenario does happen, it ends very, very badly for the patient,” he said.
He cautioned that “assuming this is an isolated one-time incident, I do not think this one report of a contamination issue should stop the practice [of ISBCS], but certainly if this recurs, then the practice will need to be rethought.”
Bjerager and colleagues emphasized that BSPOE is a very rare complication of ISBCS. They cited a 2022 systematic review that identified only nine unrelated cases over the past 50 years. Nevertheless, the potentially devastating impact of post-surgical BSPOE on the patient makes in-depth evaluation of such cases important “to maintain patient safety,” they noted.
Following the clinic’s infectious outbreak in December 2022, the authors retrospectively evaluated post-surgical recovery of all patients who developed BSPOE after ISBCS at ophthalmology departments in Denmark, based on clinical and microbiological reports. Vitreous culture sample laterality was not disclosed.
Their case series included three patients who developed BSPOE after receiving ISBCS on the same date and at the same eye clinic:
- A woman, age 71, developed pain and blurred vision in her left eye 4 days after surgery. Vitreous cultures showed Staphylococcus hemolyticus in one eye and S. epidermidis and Brevundimonas species in the other eye.
- A man, age 84, presented 6 days after ISBCS with bilateral painless loss of vision. Vitreous cultures from both eyes showed S. epidermidis.
- A woman, age 79, presented with blurred vision and irritation in the left eye 8 days after ISBCS; culture was also positive for S. epidermidis.
Genome sequencing of vitreous cultures isolated the same cefuroxime-resistant strain of S. epidermidis in four of five eyes that underwent vitrectomy. There was no leakage observed before vitrectomy, Bjerager’s group noted. Observed “low IOP [intraocular pressure] values across eyes may have been associated with capillary shutdown secondary to endophthalmitis rather than suboptimal cataract incision architecture,” they wrote.
Initial suspicion that the infections were due to contaminated ophthalmic viscosurgical devices (OVDs) were dispelled, since repeated cultures of new OVD packages and the absence of infections in patients from other clinics using the same batch of OVDs did not support this, the authors explained.
None of the patients received systemic therapies. Treatments included tobramycin and dexamethasone (Tobradex) drops, topical chloramphenicol ointment, intravitreous injection of antibiotics, and subconjunctival injection of dexamethasone.
For the 71-year-old woman, the left eye was eviscerated 2 months later due to phthisis. Six weeks later, the right eye recovered, with visual acuity improved to 20/25 OD.
In the man, the left eye showed vitreous hemorrhage and choroidal detachment at 1 week after surgery. Both eyes recovered gradually. At 3 weeks post-surgery, visual acuity was 20/20 OD, and reached 20/65 OD after 2 months.
The third patient had leakage of the main cataract incision and deterioration of the right eye, but vitrectomy was not performed. At the end of treatment, visual acuity improved to 20/25 OD in both eyes.
“The outcome of these cases emphasizes the need to adhere to a strict surgical methodology and sterile principles during ISBCS,” Bjerager and team wrote.
Limitations of the case series included lack of details on ISBCS and intraoperative devices or sterility procedures used.
Bjerager and co-authors disclosed no relationships with industry.
VanderBeek disclosed a relationship with EyePoint Pharmaceuticals.
Source Reference: Bjerager J, et al “Outbreak of bilateral endophthalmitis after immediate sequential bilateral cataract surgery” JAMA Ophthalmol 2023; DOI: 10.1001/jamaophthalmol.2023.4637.