title: Outcomes of post-cataract surgery endophthalmitis referred to a tertiary center from local hospitals in the south of China.
abstract: BACKGROUND
  Endophthalmitis after cataract surgery is an uncommon but devastating complication. Prophylactic intracameral injection of cefuroxime 1 mg at the end of surgery decreases the incidence five-fold. The visual outcome can be good (53% of cases having a visual acuity [VA] of better than 20/40) if treatment is initiated rapidly and follows the Endophthalmitis Vitrectomy Study (EVS) guidelines; but even with the best treatment, some patients end up with a poor visual outcome. Previous studies on postoperative endophthalmitis mainly focus on the cases performed in metropolitan tertiary hospitals; however, little information is available on the cases performed in local hospitals in rural areas.
  
  
  METHODS
  We retrospectively reviewed the medical records of patients with acute endophthalmitis following cataract surgery, which were performed in local hospitals and later treated at the Zhongshan Ophthalmic Center between 1 January 1998 and 31 December 2009. Details of each case, including the interval from symptoms to presentation, initial treatment in local hospitals, microorganisms isolated, treatment, and visual outcome, were recorded. Cross-tabulations were conducted in order to identify the prognostic factors of final visual outcome.
  
  
  RESULTS
  Forty-six patients referred from 36 local hospitals and later treated at the Zhongshan Ophthalmic Center were reviewed over the audit period. Most of these cases occurred in April. Gram-positive bacteria were the predominant etiology, with fungal infection accounting for 15%. Even though 54% of patients had symptoms within 3 days post-cataract surgery, they did not present to a tertiary center until a mean of 10 days. The main initial treatment in local hospitals is systemic antibiotics, instead of the intravitreal injection of antibiotics. A high proportion of cases (27/46) received immediate pars plana vitrectomy (PPV) in the tertiary center, and the antibiotic used for intravitreal injection was mainly tobramycin. The final visual outcome was poor, with only three cases having a VA ≥20/40.
  
  
  CONCLUSIONS
  A relatively high rate of fungal endophthalmitis suggests that sterilization patterns in local hospitals should be further revised. A delayed presentation, inappropriate treatment procedures, poor presenting VA, and causative organism virulence may account for the unfavorable visual outcome in this study.
authors.affiliation: State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, #54 Xianlie Road, Guangzhou, People's Republic of China.
authors.forename: Y
authors.initials: Y
authors.lastname: Ding
authors.forename: M
authors.initials: M
authors.lastname: Lin
authors.forename: H
authors.initials: H
authors.lastname: Liu
authors.forename: W
authors.initials: W
authors.lastname: Zhang
authors.forename: L
authors.initials: L
authors.lastname: Wang
authors.forename: Y
authors.initials: Y
authors.lastname: Li
mesh_terms: D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D001232:Aspergillus fumigatus / Q000145:classification / Q000187:drug effects; D002387:Cataract Extraction / Q000009:adverse effects*; D002681:China / Q000453:epidemiology; D009877:Endophthalmitis / Q000175:diagnosis / Q000453:epidemiology / Q000382:microbiology* / Q000628:therapy; D015818:Eye Infections, Bacterial / Q000175:diagnosis / Q000453:epidemiology / Q000382:microbiology* / Q000628:therapy; D015821:Eye Infections, Fungal / Q000175:diagnosis / Q000453:epidemiology / Q000382:microbiology* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006090:Gram-Negative Bacteria / Q000145:classification / Q000187:drug effects; D006094:Gram-Positive Bacteria / Q000145:classification / Q000187:drug effects; D006780:Hospitals, Rural; D006801:Humans; D015994:Incidence; D058449:Intravitreal Injections; D007908:Lens, Crystalline / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology / Q000382:microbiology* / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014031:Tobramycin / Q000627:therapeutic use; D016896:Treatment Outcome; D014792:Visual Acuity; D014821:Vitrectomy; D014822:Vitreous Body / Q000382:microbiology / Q000601:surgery
chemical_list: D000890:Anti-Infective Agents; D014031:Tobramycin