Infectious endophthalmitis in Boston keratoprosthesis: incidence and prevention

Acta Ophthalmol. 2014 Nov;92(7):e546-55. doi: 10.1111/aos.12309. Epub 2014 Jan 25.

Abstract

Purpose: 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.

Keywords: Boston keratoprosthesis; endophthalmitis; ocular infections; ocular prophylaxis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antibiotic Prophylaxis*
  • Bioartificial Organs*
  • Cornea*
  • Endophthalmitis / epidemiology*
  • Endophthalmitis / microbiology
  • Endophthalmitis / prevention & control
  • Eye Infections, Bacterial / epidemiology*
  • Eye Infections, Bacterial / microbiology
  • Eye Infections, Bacterial / prevention & control
  • Eye Infections, Fungal / epidemiology*
  • Eye Infections, Fungal / microbiology
  • Eye Infections, Fungal / prevention & control
  • Global Health
  • Humans
  • Incidence
  • Prosthesis Implantation
  • Retrospective Studies
  • Risk Factors
  • United States / epidemiology
  • Visual Acuity / physiology