Infectious endophthalmitis in Boston keratoprosthesis: incidence and prevention.
OBJECTIVE
To determine the cumulative worldwide incidence of infectious endophthalmitis and associated vision loss after Boston keratoprosthesis (B-KPro) Type I/II implantation and to propose both safe and inexpensive prophylactic antibiotic regimens.


METHODS
Two retrospective methods were used to determine the incidence, visual outcomes and aetiologies of infectious endophthalmitis associated with the B-KPro divided per decade: (i) systematic review of the literature from 1990 through January 2013 and (ii) a surveillance survey sent to all surgeons who implanted B-KPros through 2010 with 1-year minimum follow-up. In addition, a single-Boston surgeon 20-year experience was examined.


RESULTS
From 1990 through 2010, there were 4729 B-KPros implanted worldwide by 209 U.S. surgeons and 159 international surgeons. The endophthalmitis cumulative mean incidence declined from 12% during its first decade of use to about 3% during its second decade in the Unites States and about 5% internationally during the second decade. There remains a large incidence range both in the United States (1-12.5%) and internationally (up to 17%). Poor compliance with daily topical antibiotics is an important risk factor. While Gram-positive organisms remained dominant, fungal infections emerged during the second decade.


CONCLUSIONS
Daily prophylactic topical antibiotics have dramatically reduced the endophthalmitis incidence. Although Gram-positive organisms are the most common aetiology, antimicrobials must be inclusive of Gram-negative organisms. Selection of prophylactic regimens should be tailored to local antibiotic susceptibility patterns, be cost-effective, and should not promote the emergence of antimicrobial resistance. An example of a broad-spectrum, low-cost prophylactic option for non-autoimmune patients includes trimethoprim/polymyxinB once daily.
Ophthalmology, Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute, Harvard Medical School, Boston, Massachusetts, USA; Molecular Biology & Microbiology and Ophthalmology, Tufts-Sackler Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA; Division of Infectious Diseases, Department of Medicine, Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts, USA; Division of Infectious Diseases, Department of Medicine, Tufts University School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts, USA.
Irmgard
I
Behlau
Kathryn V
KV
Martin
Jacqueline N
JN
Martin
Elena N
EN
Naumova
James J
JJ
Cadorette
J Tammy
JT
Sforza
Roberto
R
Pineda
Claes H
CH
Dohlman
D019072:Antibiotic Prophylaxis; D021522:Bioartificial Organs; D003315:Cornea; D009877:Endophthalmitis / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D015818:Eye Infections, Bacterial / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D015821:Eye Infections, Fungal / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D014943:Global Health; D006801:Humans; D015994:Incidence; D019919:Prosthesis Implantation; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D014792:Visual Acuity / Q000502:physiology
Boston keratoprosthesis; endophthalmitis; ocular infections; ocular prophylaxis