Topical antibiotic helps prevent endophthalmitis after keratoprosthesis

Issue: August 25, 2012

A higher risk of infectious endophthalmitis was associated with keratoprosthesis compared to more common procedures such as cataract surgery, a study found.

Perspective from Clara Chan, MD, FRCSC

A high recurrence rate of infectious endophthalmitis was also seen after keratoprosthesis.

“Visual outcomes can be poor in these cases,” the study authors said. “Topical vancomycin use, patient education, adherence to bandage contact lens hygiene and careful monitoring for areas of thinning or leakage around the K-Pro are recommended to aid in endophthalmitis prevention.”

The retrospective chart review included 141 eyes of 130 patients who underwent Boston type 1 keratoprosthesis between 2004 and 2008.

Study results showed that 10 eyes (7.1%) were diagnosed and treated for bacterial endophthalmitis. Coagulase-negative staphylococci were identified in seven of 10 eyes.

Endophthalmitis recurred in seven of 10 eyes a mean 4 months after resolution of the first occurrence. The average interval between K-Pro placement and development of endophthalmitis was 9.8 months.

At each occurrence of endophthalmitis, no eye was receiving vancomycin ophthalmic drops; five eyes were receiving only moxifloxacin drops at varied dosage levels.

“The concurrent use of topical vancomycin is recommended because it seems to be important in reducing the incidence and recurrence of endophthalmitis and because fluoroquinolone drops do not seem to be sufficient prophylaxis in these eyes,” the authors said.

Perspective

Clara Chan, MD, FRCSC

Topical vancomycin and fluoroquinolone use has been established to decrease the risk of bacterial endophthalmitis after Boston type 1 keratoprosthesis (K-Pro) implantation. In this study, all patients had discontinued vancomycin drops for at least 1 month at the time of developing endophthlamitis. The importance of patient compliance to this prophylaxis regimen must be emphasized.

Long-term follow-up of K-Pro patients is also crucial. In this study, the average time to endophthalmitis developing after K-Pro was 9.8 months (range: 2 to 25 months). Furthermore, there was a high risk of recurrence with 70% of eyes developing another episode on average 4 months after resolution of the first. A review of 126 eyes from 105 patients after K-Pro implantation at another center revealed three cases of endophthalmitis that occurred at 4, 11 and 35 months after surgery.

Primary K-Pro implantation is not recommended for high risk eyes such as those with a diagnosis of Stevens-Johnson syndrome, ocular cicatricial pemphigoid or chemical burns with chronic inflammation. Given the increased risk for corneal melt and infectious keratitis in these eyes, a K-Pro is truly a ticking time bomb in these patients.

References:

Chan CC, Holland EJ. Infectious endophthalmitis after Boston Type 1 Keratoprosthesis Implantation. Cornea. 2012 (accepted in press).
Chan CC, Holland EJ. Infectious keratitis in Boston Type 1 Keratoprosthesis. Cornea. 2012 (accepted in press).
Chan CC, Nordlund ML, Holland EJ. Risk factors and surgical management of Boston Type 1 keratoprosthesis-related tissue melts, leaks and extrusions. The American Cataract and Refractive Surgery Symposium & Congress 2011, San Diego, CA.
Durand ML, Dohlman CH. Successful prevention of bacterial endophthalmitis in eyes with Boston keratoprosthesis. Cornea. 2009; 28:3896-901.

Clara Chan, MD, FRCSC

Faculty, University of Toronto, Dept. of Ophthalmology and Vision Sciences, St. Michael’s Hospital and Toronto Western Hospital, Toronto

Disclosures: Chan has served as a consultant and received lecture honoraria or travel grants from Alcon, Allergan, and Bausch + Lomb.

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Sources/Disclosures

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Source:

Ophthalmology. 2012;119(4):674-681.