How to Prevent & Manage an
Outbreak of Endophthalmitis?
Dr.R.D.Ravindran
Aravind Eye Hospital,
Madurai
Outbreak (Cluster) vs
Sporadic
Endophthalmitits
Sporadic Endophthalmitis

Sporadic means scattered about.
 Cases
occur irregularly, haphazardly from
time to time & generally infrequently.

The cases are so few & separated from time to
time that they show little or no connection
with each other, nor a recognizable common
source of infection.
Sporadic Endophthalmitis
 Incidence
 0.05%
 Could
to 0.1% for P.O. endophthalmitis
be Infective
 Acute
 Sub
acute
 Chronic
 TASS
/ Sterile Endophthalmitis
Predisposing factors
Pre operative
 Diabetes mellitus
 External eye infections
Blepharitis, conjuctivites, dacrocystitis



Dry eye
Operative factors
Intraoperative complications
Clinical features
Depends on virulence of organism, host
resistance, size of inoculum & delay in
consultation.
 Post op steroid eye drops can mask the
clinical features.

Organisms
Staph. Epidermidis
 Other coagulase – ve staphylococci
 Staphylococcus aureus
 Streptococci
 Nocardia
Gram-ve organisms like Pseudomonas,
Proteus, Klebsiella, E.coli, & Enterococci are
rare

Outbreak / Cluster
Endophthalmitis

Group of cases occurring in a short time
interval due to a common cause

Cluster endophthalmitis defined as two
or more cases of endophthalmitis
occurring on a particular day in a single
operating room
Etiologies
 Infectious
 Non-infectious
 Important
(TASS)
to differentiate as the
treatment & prognosis are different
Clinical Features

Usually acute onset

Timing of onset: 48 to 72 hrs

Pain: severe in 3/4

Visual acuity : Profound loss

Profound clinical signs

Vitreous culture: +ve
Pseudomonas Aeruginosa
Endophthalmitis
Serge Zaluski, MD et al JCRS - Vol 25, April 1999

Setting: Ophthalmology Center, Perpignan,
France.

Report 4 cases of Pseudomonas aeruginosa
endophthalmitis .

Contamination of the internal pathways of a
phacoemulsifier.
12 Cases of Post Surgical Endophthalmitis Due
to Gram -ve Bacteria
Inf control & hospital epidemiology 2006, vol. 27

Contaminated trypan blue dye from a
compounding pharmacy.

Unopened trypan blue vials yielded
Pseudomonas aeruginosa

Contamination of compounded medications
should be considered when investigating
outbreaks of postoperative endophthalmitis.
(J.Cataract Refract Surg 1996:22)



13 Patient underwent ECCE with IOL at
Ankara hospital, Turkey, same day, same OT
Acute endophthalmitis 10-60 hrs post surgery
Vit culture:
Pseudomonas aeruginosa- 4 cases
 C-negative staphylococci- 3 cases
 Culture negative- 3 cases


P aeruginosa isolated from irrigation solution
prepared by hospital pharmacist
Aetiology

Contaminated intraocular irrigating
solutions(Trans R Soc Trop Med Hyg.
1995 pubmed. )
Clinical Profile & Visual outcome in
Cluster Endophthalmitis foll. Cataract
Surgery in Central India.
Sumeet Malhotra et al. IJO Vol 56; 2008

Report three clusters of POE between Feb
05 – Feb 06 involving 24 patients

58% smear +ve / 42% culture +ve

Organism; Pseudomonas aeruginosa

Visual recovery in 33% of cases
Cluster Endophthalmitis in 2008
 11
instances across India in 2008
 165 cases
 Organisms isolated from RL fluid
& from viscoelastics
 Govt directive to autoclave all
solutions / Viscoelastics
Pseudomonas Aeruginosa




Pseudomonas aeruginosa most common
contaminate of ophthalmic solutions.
Related to its capacity to reproduce in
presence of little or no nutritional substrates
other than water.
Grows in wide temperature range
Can survive 4% boric acid
Aetiology –
Outbreak / Cluster POE
Defects in sterilization
 Contaminated irrigating solutions / VEs
 Contaminated water supply
 Poor operation room hygiene
 Improper ventilation system
 Poorly maintained canulated
instruments

TASS Outbreak - Causes

Abnormal irrigation solutions (abnormal pH
or ionic composition)

Denatured viscoelastic

Residual detergent in reusable equipment

Chemical residues left after sterilization

Preservatives in ophthalmic solutions

Endotoxins not destroyed by the sterilization
Outbreak of Endophthalmitis
Defined as “in excess of expected
occurrence”
 Outbreaks of endophthalmitis typically
present over a short time period and
could often be attributed to a single
infective cause.
 A sporadic disease may be the starting
point of an outbreak when conditions
are favorable.

When to Suspect
How many cases of POE should be
allowed to occur before suspecting
something may be seriously wrong?
 After how many cases should one
consider investigating?
 When should one close theatres?

Recommended Protocol
( Royal College of Oph., England)
With annual incidence of 0.14% / 1 in 700 cases
One case:
 Immediately informally review the case,
ideally with a colleague, to identify possible
causative factors & ensure that theatre
procedures and preventative measures are
robust.
 Alert other consultant colleagues in the unit
 Discuss the case at the next audit meeting.
Recommended Protocol
( Royal College of Oph., England)
Two cases in 270 or three cases in 630 or
four in 1000: „Amber alert.‟
 Ask the microbiology department to fully
subtype any organisms grown from the
second and subsequent cases (and also the
first if the cultures have not yet been
discarded).
 Should urgently review all likely relevant
factors following the action plan.
Recommended Protocol
( Royal College of Oph., England)
Two cases in 50 or three in 300 or
four in 500. „Red alert.‟
 In addition give serious consideration
to a temporary closure of theatre(s),
for reasons of patient safety, until
investigation is complete and any
changes made.
Predicting An Outbreak
POE Out break
Environment around theatre
External environment assessment
 ongoing building works next to the
theatre suite.
 Reports have suggested a link between
building works and fungal infections,
especially Aspergillus.

Out Break of Endophthalmitis

Cleaning/sterilization practices

Maintenance of Sterlizing equipments
Hollow bore instruments; Phaco probes & I/A
cannulae

Cannulated instruments contaminated with a
variety of debris, even after syringe flushing

Automated I/A cannulae should be changed
after 3 years because of build-up of debris
Water for cleaning


Avoid using saline
or RL solution to
prevent build up of
debris
RO water free of
salt is preferred
Monitoring surgical supplies

Checking irrigating
solutions




Black/white
Illuminated cabinet
Periodic QC of the
supplies used
Use the same source
Build relationship with
dependable vendors
Leadership
 Standardized
protocols /
procedures
 Maintaining discipline
 Overall cleanliness
 Attitude
. . . in service for sight
The use of control charts in
monitoring postcataract surgery
endophthalmitis:
-P J T Chiam, A Feyi Waboso.
-Eye, May 2009; 23: 1028-1031.
RESULTS:

Sample size:
 21

Acute POE cases:
01/07/97 – 30/06/98
01/07/98 – 30/06/99
01/07/99 – 30/06/00
01/07/00 – 30/06/01
(21 F & 14 M)
01/07/01 – 30/06/02
01/07/02 – 30/06/03
Ave. annual
incidence over 10
years: 0.16%
01/07/03 – 30/06/04
01/07/04 – 30/06/05
01/07/05 – 30/06/06
01/07/06 – 30/06/07
 35

032 patients.
Year
POE
incidence
0.17
0.16
0.21
0.15
0.19
0.40
0.09
0.05
0.10
0.08
Control chart & Early Detection
of Endophthalmitis:


Any point that falls outside the upper & lower
control limits is deemed unusual.
Guidelines recommended for suggesting an
unusual variation in a control chart:
(1) 2 out of 3 consecutive points between the
control limit and one SD below this level.
(2) A run: This occurs when seven or more
consecutive points fall on either side of the centre
line.
(3) A trend: When six consecutive points move
steadily upwards or downwards.
Control Charts to predict POE
outbreak

Control chart provide information of the
altering trends of POE cases & allows
unusual variations to be detected early.

Control chart could provide a reliable
method to detect an early outbreak of POE
before it was suspected and acted on.

Its control limits are dynamic & factor in
recent performance to detect any unusual
variation.