Can a sneeze after phacoemulsification cause endophthalmitis? A case report

Dear Editor,

We reported the first case of acute exogenous postoperative endophthalmitis caused by a normal human microbiota in the nasopharynx,

.The patient had a successful cataract surgery, but he felt uncomfortable in the surgery eye 4d post-surgery. Besides, he had a heavy sneeze about 6h before the blurred vision. Vitreous sample of the affected eye turned out to be

, a normal inhabitant in the nasopharynx. It might invade into conjunctival sac through inferior nasal meatus to canaliculi lacrimalis with the sudden ocular pressure change.During two months follow-up, the patient had poor visual outcome due to macula edema and subsequent retina thinning despite emergent medical and surgical therapy. To avoid such postoperative complication, patients after cataract surgery should avoid holding the nose when they are sneezing.

Endophthalmitis is a severe sight-threatening ocular infection caused by a variety of microbes. It can be classified as exogenous or endogenous based on the cause of infection.Endogenous endophthalmitis occurs when infectious organisms responsible for infection spread to the eye haematogenously;and exogenous endophthalmitis occurs when infecting microbes enter the eye directly

. Toxic anterior segment syndrome (TASS) is an acute sterile endophthalmitis similar to the infectious exogenous endophthalmitis, but it usually happens 24h within the cataract surgery without bacterial infection. After cataract surgery, infectious endophthalmitis is generally classified as exogenous endophthalmitis, which often leads to poor visual acuity (VA). The reported incidence rates range from 0.03% to 0.7%

. Post-cataract endophthalmitis might be caused by contamination of surgical instruments or improper care after the operation, such as rubbing the eyes or exposing the eyes to bathing water. This is the first case report of acute post-cataract endophthalmitis caused by

possibly due to a heavy sneeze. We obtained the written informed consent from the patient, and this case was in accordance with the tenets of the Declaration of Helsinki.

A 69-year-old man presented with reduced vision and slight pain in his left eye 4d after cataract surgery. And he had a heavy sneeze 6h before the blurred vision. Medical history showed that he had grade III lens opacity in the left eye. The standard phacoemulsification cataract surgery was done by an experienced surgeon in March 2019 and there was no infection during the operation. The surgery was done through a 12 o’clock clear corneal incision of 2.2 mm and 3 o’clock auxiliary incision of 1.0 mm under topical anaesthesia. His VA of the left eye was Snellen 40/50 one day post-surgery. And he was administered with tobradex eyedrops

. The patient had successful right cataract surgery 6mo ago with the same post-operative medication. He had no predisposing factors to endophthalmitis and no special medication.

COPD急性加重期患者因感染造成氣道粘膜充血水腫,導(dǎo)致氣道分泌物增多,咳嗽和憋喘癥狀加重,痰液黏稠不易排出,易造成呼吸道堵塞,最終誘發(fā)呼吸衰竭和心力衰竭等并發(fā)癥[1]。目前,臨床關(guān)于鹽酸氨溴索治療COPD急性加重期療效的研究較多,而對(duì)于鹽酸氨溴索不同持續(xù)用藥時(shí)間治療COPD急性加重期療效的研究較少,為此,本研究通過(guò)隨機(jī)對(duì)照試驗(yàn)對(duì)我院接診的70例患者進(jìn)行研究,現(xiàn)報(bào)道如下:

三聯(lián)書(shū)店出版的《三聯(lián)生活周刊》2018年第13期載文說(shuō)，臺(tái)灣學(xué)者李敖，在乎的是信仰而不是金錢(qián)。他一貫按自己的這一尺度行事。有段時(shí)間，他在香港衛(wèi)視開(kāi)辦《李敖有話說(shuō)》節(jié)目，收入頗豐。但后來(lái)，人們反映他有些話觸犯底線，勸他不要講這些話。他想了想，便去找董事局主席劉長(zhǎng)樂(lè)說(shuō)，“我跟你們鳳凰緣已盡”，“我不要做節(jié)目了”。觸犯底線，當(dāng)然是不對(duì)的，但他在沒(méi)認(rèn)識(shí)到底線的重要性之前，寧可不做節(jié)目、放棄不菲的經(jīng)濟(jì)收入，也不盲目順應(yīng)——有待調(diào)整他的是非尺度。

To our knowledge, there is no other report of postoperative endophthalmitis caused by

, which is quite virulent in the intraocular tissue. Our patient experienced acute onset and severe retina lesions despite immediate surgery and proactive therapy. The vitreous biopsy revealed many bacterial colonies, which might explain the severity of his disease.

has been reported in only 2 cases endogenous endophthalmitis that resulted in relatively good visual outcomes

. In those cases, the pathogenic bacteria were confirmed only in the blood sample, and no bacteria were identified in the vitreous sample. The good VA might due to a low bacterial concentration in the vitreous body.This case suggests that

may cause virulent postoperative endophthalmitis, leading to severe retinal lesions and poor visual outcomes despite emergent medical and surgical therapies. And endophthalmitis after cataract surgery may possibly be caused by the heavy sneeze by holding both sides of nose.

Postoperative endophthalmitis is a rare but disastrous complication of cataract surgery. Less than 50% of patients achieve a final VA of ≥20/40

. Treatment outcomes after endophthalmitis are highly dependent on the causative agents.In post-cataract endophthalmitis, Gram-positive infections are the most prevalent; among them, coagulase-negative

accounts for the most infections, followed by

and

. Early pars plana vitrectomy and proper systemic administration are usually required as initial treatments to rescue VA.

is the second most common genus of germs identified in post-cataract endophthalmitis and usually results in poor visual outcomes

. In Pijl

’s

study of 250 post-cataract endophthalmitis cases, all β-haemolytic

cases(

=9) manifested within 3d after surgery, and 8 out of the 9 cases (88.9%) resulted in a final VA≤light-perception (LP). The study did not clarify the specific bacterial types, so it is unclear whether

infection was present.

The patient’s VA was good in the first three days after surgery.He had routine topical eye drops of tobradex

and with no symptoms of infection. He denied rubbing the eyes after surgery. He had no infection in the right eye post-cataract surgery. Occasionally, we noticed that he sneezed heavily while holding both sides of his nose in our ophthalmology emergency. Asking carefully, the patient had such heavy sneeze 6h before he experienced a decreased vision. Anatomically,nasal cavity is in connection with the lacrimal duct system through inferior nasal meatus. Also, previous reports showed that fungal infection of the nose might infiltrate into lacrimal sac with a rare percentage

. Such a heavy sneeze may cause the sudden rise of the pressure in the nasal cavity. The nasal cavity secretions might be squeezed into the conjunctival sac through the inferior nasal meatus to the canaliculi lacrimalis.

is a normal inhabitant in nasal cavity but pathogenic bacteria in ocular tissue. Therefore, except the infection through finger-nose-eye contact, we speculated that the patient might have been infected with

when it travelled through the nasal cavity to the conjunctival sac. When the ocular pressure suddenly changed,the bacteria invaded the intraocular tissue through the cataract incision, which resulted in acute-onset endophthalmitis.

The left eye underwent three-port pars plana vitrectomy immediately. Vitreous sample was aspirated firstly and sent for microbiological analysis. Then the intraocular lens was extracted and opacities of vitreous were aspirated, followed by silicone oil injection. Finally, before incision closure,norvancomycin (0.1 mg/0.1 mL), ceftazidime (2.25 mg/0.1 mL),and dexamethasone (400 μg/0.08 mL) were injected intravitreally. Meanwhile, ceftazidime, dexamethasone, and vancomycin were used intravenously. Intravitreal injection of norvancomycin, ceftazidime and dexamethasone were repeated once a day three times successively until anterior chamber exudates resolving. Four days post-surgery, the blood plate of vitreous samples turned out to be cocci growth(+++; Figure 1C). Gram staining (Figure 1B) showed Grampositive and identified as

with the mass spectrometry matrix-assisted laser desorption ionization (MALDI) Biotyper system (Microflex LT). Then therapeutic schedule was shifted to penicillin and gentamicin intravenously.

Gram-positive

is a member of the

group, which belongs to the β-haemolytic

group. It is a commensal and normal inhabitant of the mucosal membranes and frequently found in the mouth,nasopharynx, throat, and sinuses

. As a member of the normal microbiota in humans,

is not often properly identified. Therefore, we performed a matrix-assisted laser desorption ionization-time of flight mass spectrometry(MALDI-TOF MS) analysis

. With the development of bacterial typing in recent years, an increasing number of reports have emphasized that

is an important bacterial pathogen in tissues such as the appendix,perianal region, and intra-abdominal region. The bacterial capsule, β-haemolysin, and hydrogen sulphide (H

S) are toxic and constitute prototypic virulence factors

.

During two months’ follow-up, his best correct visual acuity(BCVA) was raised to Snellen 20/200. In fundus photograph,intra-retinal hemorrhage was decreased but retina arteries were narrowing compared with the first time examination postoperatively. SD-OCT demonstrated that retina edema was recovering, but nerve fiber layer of periphery retina was getting thinner (Figure 2A). OCTA showed that vessel density of retina(Figure 2B) and choriocapillaris (Figure 2C) was increasing,but fovea avascular zone in maculae had no improvement compared with the first time examination post-operative.

膽結(jié)石在臨床是比較常見(jiàn)的疾病，該病的形成原因比較復(fù)雜，導(dǎo)致患者的身體以及心理產(chǎn)生不適感。人性化護(hù)理模式秉承著“以人為本”的理念在臨床中的運(yùn)用越來(lái)越多[1]，采用人性化護(hù)理可以全方位的對(duì)患者的身體以及心理狀態(tài)進(jìn)行改善。本研究將深入探討人性化護(hù)理對(duì)于膽結(jié)石患者術(shù)前焦慮的改善效果，現(xiàn)報(bào)道如下。

His VA was fingers counting (FC)/30 cm in the affected eye at presentation. Slit-lamp examination revealed conjunctival congestion, corneal epithelial and stromal edema, dust keratic precipitates (KP++), and Tyndall (+++) in the anterior chamber, obscuring the view of white sheath of blood vessels in the posterior segment. Ultrasound B-scan revealed plenty of moderately reflective mobile dot echoes with diffuse retina thickening (Figure 1A). A diagnosis of acute postoperative endophthalmitis was made based on clinical presentation and ultrasound findings.

Supported by the National Natural Science Foundation of China (No.81900879).

鑒于國(guó)外對(duì)大型科學(xué)儀器設(shè)備的使用和管理較國(guó)內(nèi)起步早，其對(duì)設(shè)備開(kāi)放共享問(wèn)題的研究、實(shí)踐、遇到的問(wèn)題及解決方法均值得探討和思考。

None;

None;

None;

None;

None.

1 Lemley C, Han DP. Endophthalmitis: a review of current evaluation and management.

2007;27:662-680.

2 Kessel L, Flesner P, Andresen J, Erngaard D, Tendal B, Hjortdal J.Antibiotic prevention of postcataract endophthalmitis: a systematic review and meta-analysis.

2015;93(4):303-317.

3 Pijl BJ, Theelen T, Tilanus MAD, Rentenaar R, Crama N. Acute endophthalmitis after cataract surgery: 250 consecutive cases treated at a tertiary referral center in the Netherlands.

2010;149(3):482-487.e2.

4 Lalwani GA, Flynn HW Jr, Scott IU, Quinn CM, Berrocal AM, Davis JL, Murray TG, Smiddy WE, Miller D. Acute-onset endophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features,causative organisms, and visual acuity outcomes.

2008;115(3):473-476.

5 Yannuzzi NA, Si N, Relhan N, Kuriyan AE, Albini TA, Berrocal AM, Davis JL, Smiddy WE, Townsend J, Miller D, Flynn HW Jr.Endophthalmitis after clear corneal cataract surgery: outcomes over two decades.

2017;174:155-159.

6 Asam D, Spellerberg B. Molecular pathogenicity of streptococcus anginosus.

2014;29(4):145-155.

7 Sogawa K, Watanabe M, Sato K, Segawa S, Ishii C, Miyabe A,Murata S, Saito T, Nomura F. Use of the MALDI BioTyper system with MALDI-TOF mass spectrometry for rapid identification of microorganisms.

2011;400(7):1905-1911.

8 Pao KY, Yakopson V, Flanagan JC, Eagle RC Jr. Allergic fungal sinusitis involving the lacrimal sac: a case report and review.

2014;33(4):311-313.

9 Nerurkar NK, Bradoo RA, Joshi AA, Shah J, Tandon S. Lacrimal sac rhinosporidiosis: a case report.

2004;25(6):423-425.

10 Itoh M, Ikewaki J, Kimoto K, Itoh Y, Shinoda K, Nakatsuka K.Two cases of endogenous endophthalmitis caused by gram-positive bacteria with good visual outcome.

2010;1(2):56-62.

11 Hadid OH, Shah SP, Sherafat H, Graham EM, Stanford MR.Streptococcus anginosus-associated endogenous endophthalmitis mimicking fungal endophthalmitis.

2005;43(8):4275-4276.