Status:
Ready to upload
Record number:
2008
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Rare overall to have bacterial endophthalmitis after corneal transplant. Per reference 2 (Oguido, J, Clin Micro 2011), among the cases of culture-proven endophthalmitis after keratoplasty, cases attributed to P. aeruginosa are generally uncommon (5%). Pseudomonas aeruginosa is the causative organism of endophthalmitis following keratoplasty in 2% of reported infections per the EBAA Online Adverse Reaction Reporting System (OARRS) database.
In a retrospective analysis of a case series (2006-2018) Das and colleagues found 28 patients with endophthalmitis after EK or PK with the following attributes: the estimated incidence of endophthalmitis was 0.23% in the entire cohort; it was 0.34% and 0.15%, after EK and PK, respectively (P = 0.049). Donor-related endophthalmitis was recognized in 7/28 (25%) eyes. Culture positivity was 68% (n = 19 of 28). Bacteria was isolated in 84% (n = 16 of 19) instances; Gram-negative bacilli were more common (87.5%; 14 of 16), and Pseudomonas species (50%; 7 of 14) was the most common Gram-negative bacterium. Majority (>75%) of the Gram-negative bacteria were resistant to all fluoroquinolones, aminoglycosides, 3rd generation cephalosporins, and meropenam; 1/3rd were resistant to imipenem; and 90% were sensitive to colistin.
Du and colleagues published in 2014 an analysis based on medicare claims in the US to estimate the frequency of endophthalmitis after ocular surgery and found the following: The infectious endophthalmitis incidence rates ranged from 0.11% to 1.05% in the corneal transplant cohort, 0.06% to 0.20% in the cataract surgery cohort, and 0.16% to 0.68% in the concurrent surgery cohort, depending on the definition and time interval after surgery. Compared with the cataract surgery cohort, the corneal transplant cohort had a higher adjusted hazard ratio (HR) of endophthalmitis within the 6-week postoperative interval (HR, 2.744; 95% confidence interval [CI], 1.544–4.880 in the sensitive definition and HR, 2.792; 95% CI, 1.146–6.802 in the specific definition) and within the 6-month postoperative interval (HR, 4.607; 95% CI, 3.144–6.752 for the sensitive definition and HR, 4.385; 95% CI, 2.245–8.566 for the specific definition).
Time to detection:
3 days in the referenced report (in the Das and colleagues series, the median time of endophthalmitis was 4.5 days postsurgery)
Alerting signals, symptoms, evidence of occurrence:
Patient admitted three days post-keratoplasty with complaints of pain and decreasing vision. Biomicroscopy showed intense conjunctival injection, edematous graft with superior and inferior infiltrates, and 1 mm hypopyon. B-scan ultrasonography was suggestive for vitreous abscess and pseudomembranes. The patient was diagnosed with endophthalmitis after penetrating keratoplasty, and aqueous and vitreous taps grew P. aeruginosa with antibiotic resistance identical to the isolate from the mate cornea.
Demonstration of imputability or root cause:
Culture of the preservation media from the right donated cornea grew Pseudomonas aeruginosa and was discarded. Culture from the left cornea showed no microbial growth. The culture was repeated and results remained negative for the left cornea, so cornea was determined eligible for transplantation. Patient developed endophthalmitis after penetrating keratoplasty caused by a multidrug-resistant Pseudomonas aeruginosa, detected only in the contralateral donor tissue. Sequence analysis of the 16S ribosomal gene from the two isolates and confirmation analyzing the sequence of P. aeruginosa heat shock protein gene (groES) were performed showing the same strain for both organisms.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
Suggest new keywords:
Pseudomonas aeruginosa
endophthalmitis
Infection
bacteria
keratoplasty
multi-drug resistant
Reference attachment:
Suggest references:
Serna-Ojeda JC, et al. Post-keratoplasty Endophthalmitis by Multidrug-resistant Pseudomonas Aeruginosa With Positive Culture of the Contralateral Donor Cornea: A Case Report. Transplant Proc. 2018 Apr;50(3):964-966
Oguido AP, Casella AM, Hofling-Lima AL, Pacheco SA, Bispo PJ, Marques F. Pseudomonas aeruginosa endophthalmitis after penetrating keratoplasty transmitted from the same donor to two recipients confirmed by pulsed-field gel electrophoresis. J Clin Microbiol. 2011 Sep;49(9):3346-7. doi: 10.1128/JCM.02565-10. Epub 2011 Jul 20. PMID: 21775545; PMCID: PMC3165635.
Das S, Ramappa M, Mohamed A, Chaurasia S, Sharma S, Das T. Acute endophthalmitis after penetrating and endothelial keratoplasty at a tertiary eye care center over a 13-year period. Indian J Ophthalmol. 2020 Nov;68(11):2445-2450. doi: 10.4103/ijo.IJO_71_20. PMID: 33120636; PMCID: PMC7774176.
Du DT, Wagoner A, Barone SB, Zinderman CE, Kelman JA, MaCurdy TE, Forshee RA, Worrall CM, Izurieta HS. Incidence of endophthalmitis after corneal transplant or cataract surgery in a medicare population. Ophthalmology. 2014 Jan;121(1):290-298. doi: 10.1016/j.ophtha.2013.07.016. Epub 2013 Aug 29. PMID: 23993357.
Expert comments for publication:
This case report suggests that we must be cautious in deciding to transplant tissues with positive culture in the contralateral donor cornea. Pseudomonas due to donor corneas tends to be multi-drug resistant.