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Delayed- Versus Acute-Onset Endophthalmitis AfterCataract Surgery

ANITA R. SHIRODKAR, AVINASH PATHENGAY, HARRY W. FLYNN JR, THOMAS A. ALBINI,AUDINA M. BERROCAL, JANET L. DAVIS, GEETA A. LALWANI, TIMOTHY G. MURRAY,

WILLIAM E. SMIDDY, AND DARLENE MILLER

ormS

● PURPOSE: To report a large consecutive case series ofatients who developed delayed-onset and acute-onsetndophthalmitis after cataract surgery.

● DESIGN: Retrospective consecutive case series.● METHODS: The current study is a retrospective con-ecutive case series of patients treated between January000 and December 2009 for culture-proven endoph-halmitis after cataract surgery. The study defined 2roups after cataract surgery: acute-onset endophthalmi-is (<6 weeks after surgery) and delayed-onset endoph-halmitis (>6 weeks after surgery).

● RESULTS: A total of 118 patients met study criteria;cases included 26 delayed-onset cases and 92 acute-onsetcases. The following clinical features and outcomesoccurred in delayed- vs acute-onset cases: 1) the present-ing visual acuity was <5/200 in 31% vs 89%; 2)hypopyon was found in 46% vs 80%; 3) the mostfrequent isolate was Propionibacterium acnes (11/26) vscoagulase-negative Staphylococcus (57/92); and 4) pa-tients with the most frequent isolate achieved a visualoutcome of >20/100 in 91% vs 56%. In delayed-onsetases, the intraocular lens was removed or exchanged in9 of 26 cases (73%). Of these 19 cases, 13 achieved aisual outcome of >20/100.

● CONCLUSIONS: Patients with delayed-onset endoph-halmitis generally presented with better initial visualcuities, had a lower frequency of hypopyon, and hadetter visual outcomes compared to acute-onset patients.ropionibacterium acnes and coagulase-negative Staphy-

ococcus species were the most common organisms cul-ured in delayed- and acute-onset categories, respectively,nd were associated with the best visual acuity outcomesn each group. (Am J Ophthalmol 2012;153:391–398.

2012 by Elsevier Inc. All rights reserved.)

E NDOPHTHALMITIS IS A SERIOUS SIGHT-THREATEN-

ing condition that can be classified into 2 broadcategories: acute-onset and delayed-onset. As used

in the Endophthalmitis Vitrectomy Study, acute-onsetpostoperative endophthalmitis was defined as infectionswithin 6 weeks of surgery.1 By contrast, delayed-onset

Accepted for publication Aug 22, 2011.From the Department of Ophthalmology, Bascom Palmer Eye Institute,

University of Miami, Miller School of Medicine, Miami, Florida.Inquiries to Anita R. Shirodkar, Bascom Palmer Eye Institute, 900 NW

17th St, Miami, FL 33136; e-mail: ashirodkar@med.miami.edu

© 2012 BY ELSEVIER INC. A0002-9394/$36.00doi:10.1016/j.ajo.2011.08.029

postoperative endophthalmitis has been defined as greaterthan 6 weeks after the surgery.1 These 2 categories maydiffer in their incidence, clinical features, microbiology,and visual acuity outcomes.

The reported incidence of acute-onset endophthalmitisafter cataract surgery ranges from 0.03% to 0.15%.2–4

Since the mid-1990s, cataract surgical techniques haveevolved to clear corneal, sutureless techniques. In spite ofthis change in technique, the nature of acute-onset endo-phthalmitis in both settings is virtually identical.5 Acute-nset postoperative endophthalmitis is characterized by aapid onset of visual loss and marked intraocular inflam-ation and is frequently caused by coagulase-negative

taphylococcus.1

In 1 single-center study, the reported rate of delayed-onset endophthalmitis following cataract surgery was0.017%.6 In delayed-onset postoperative endophthalmitis,the onset is frequently insidious and the inflammation isoften low grade, and is caused by less virulent bacteria andfungi. Propionibacterium acnes has been reported to be acommon organism isolated in published series.6–8

The purpose of the current study was to compare theclinical features, causative organisms, and visual acuityoutcomes associated with delayed-onset vs acute-onsetendophthalmitis after cataract surgery in a contemporaryseries from a university referral center.

METHODS

THE CLINICAL AND MICROBIOLOGY RECORDS WERE RE-

viewed for all patients treated at Bascom Palmer EyeInstitute between January 1, 2000 and December 31, 2009for clinically diagnosed, culture-positive endophthalmitisfollowing cataract surgery. The study included patientswho were operated elsewhere and referred for care, as wellas patients who underwent cataract surgery at BascomPalmer Eye Institute. Patients were excluded from thestudy if the endophthalmitis was not associated withcataract surgery or if consequent to combined procedures(glaucoma and cataract surgery). Patients with preexistingmacular degeneration, diabetic retinopathy, or glaucomawere not excluded from the study.

Intraocular fluid specimens were plated directly on

chocolate agar, 5% sheep blood agar, CDC anaerobic

LL RIGHTS RESERVED. 391

An

blood agar, Sabouraud agar, and thioglycolate medium.Chocolate and blood agar plates and thioglycolate brothwere incubated for up to 2 weeks at 35 C in 5% CO2.

naerobic plates were incubated in an anaerobic jar inon-CO2 for up to 2 weeks. Sabouraud agar was incubated

at 35 C for 72 hours and then at 25 C for up to 2 weeks.To be considered a positive culture, a specimen must havedemonstrated growth of the same organism on 2 or moresolid culture media or growth on a single medium afteridentification on an initial smear.

Because the current study was a retrospective case series,there was no rigid protocol for managing these patients,although the practice algorithm is fairly consistent for allinvestigators. Intravitreal antibiotics were injected at thetime of initial treatment in all patients. The use ofvitrectomy was at the discretion of the treating physician,although the guidelines of the Endophthalmitis Vitrec-tomy Study (EVS) were generally followed for acute-onsetcases. Recorded data included clinical features, visualacuity at diagnosis, cultured organisms, and visual acuity atfollow-up.

RESULTS

BETWEEN JANUARY 1, 2000 AND DECEMBER 31, 2009, 118

patients met study criteria. Of these 118 patients, 26(22%) had delayed-onset postoperative endophthalmitisand 92 (78%) had acute-onset postoperative endophthal-mitis (Tables 1 and 2). In this study, 71 of the 118 cases(60%) were from male patients and 47 (40%) were fromfemale patients. The mean age at presentation was 74 years(range 52–87, SD 9) in the delayed-onset group and 76

TABLE 2. Visual Acuity Outcom

Total n � 118 �20/40

Delayed-onset (n � 26) 50%

Acute-onset (n � 92) 27%

NLP � no light perception.

TABLE 1. Presenting Clinical FeaturesCatara

Total n � 118 VA � 5/200

Delayed-onset (n � 26) 8 (31%)

Acute-onset (n � 92) 82 (89%)

VA � visual acuity.

years (range 48–90, SD 9) in the acute-onset group.

AMERICAN JOURNAL OF392

● DELAYED-ONSET POSTOPERATIVE ENDOPHTHALMIT-

IS: The mean time between surgery and the diagnosis ofendophthalmitis was 343 days (range 48–1840, SD 379).Intraocular cultures became positive on days 2 to 7 afterobtaining the specimen (mean time to culture positivity:3.5 days). The average follow-up time after initial treat-ment was 804 days (range 61–3069, SD 774). A presentingvisual acuity of �5/200 was noted in 8 of 26 patients(31%). Hypopyon was present in 12 of 26 patients (46%),and keratic precipitates were present in 19 of 26 patients(73%) (Figure 1). A white plaque associated with thecapsular bag was noted in 17 of 26 patients (65%) (Figures2 and 3). In the 26 delayed-onset cases, the followingorganisms were isolated: Propionibacterium acnes in 11(42%), fungal species in 7 (27%), gram-negative species in3 (12%), gram-positive species in 3 (12%), and Mycobac-terium chelonae in 2 (8%).

Initial treatment consisted of 3 different strategies: 1)vitreous tap and injection of intraocular antibiotics; 2)3-port pars plana vitrectomy (PPV) with injection ofintraocular antibiotics; and 3) 3-port pars plana vitrec-tomy with partial posterior capsulectomy and injectionof intraocular antibiotics. No patients underwent initialtreatment with total capsulectomy, intraocular lens(IOL) exchange, or IOL removal. However, 19 of 26delayed-onset patients (73%) subsequently underwentcombinations of these procedures because of recurrenceof inflammation (Figure 4).

Of these 19 patients who underwent exchange orremoval of the IOL, initial treatment included injection ofintraocular antibiotics in 2, PPV with intraocular antibi-otics in 8, and PPV with partial capsulectomy and intra-ocular antibiotics in 9. Seventeen of 19 patients (89%)

y Category of Endophthalmitis

�20/100 �5/200 NLP

65% 27% 12%

41% 35% 4%

tients With Endophthalmitis Followingrgery

opyon Mean Days to Diagnosis

46%) 343 (median: 230, range: 48–1840)

80%) 9 (median: 7, range: 1–39)

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of Pact Su

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74 (

underwent PPV with total capsulectomy and IOL removal

OPHTHALMOLOGY MARCH 2012

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or exchange as a secondary procedure. Only 2 of these 17patients (12%) developed recurrence, which was managedby PPV with IOL removal in 1 patient and penetratingkeratoplasty for keratitis in the other patient. Two patientswho underwent PPV as a secondary procedure developedrecurrence, which was treated with PPV, total capsulec-tomy, and IOL removal. In patients without recurrence,removal or exchange of the IOL was often the lastprocedure used to eliminate the infection.

Seven of 26 patients (27%) did not undergo exchange orremoval of the IOL. Initial treatment in these patientsincluded injection of intraocular antibiotics in 1, PPV withintraocular antibiotics in 2, and PPV with partial capsu-lectomy and intraocular antibiotics in 4. None of thesepatients had further recurrences or interventions after

FIGURE 1. Hypopyon and granulomatous keratic precipitatesassociated with Propionibacterium acnes endophthalmitis.Top) Initial presentation of Patient 2; visual acuity 5/200.Bottom) After pars plana vitrectomy with total capsulectomynd intraocular lens removal; visual acuity was 20/20 withphakic contact lens correction.

initial treatment.

DELAYED VS ACUTE ENDOPHTHALMVOL. 153, NO. 3

Visual outcomes were �20/100 in 17 of 26 (65%) and�5/200 in 7 of 26 (27%) of delayed-onset patients. Thedistribution of visual outcomes according to the variousisolates is displayed in Table 3. Clinical features, present-ing visual acuity, and visual outcomes of delayed-onsetpatients classified by those who underwent IOL exchangeor removal are shown in Table 4 and Figure 4.

● ACUTE-ONSET POSTOPERATIVE ENDOPHTHALMITIS:

The mean time between surgery and the diagnosis ofendophthalmitis was 9 days (range 1–39, SD 8). Theaverage follow-up time after initial treatment was 268 days(range 7–3307, SD 477). A presenting visual acuity of�5/200 was noted in 82 of 92 patients (89%). Hypopyonwas present in 74 of 92 patients (80%). The cultureisolates in the 92 acute-onset cases were the following:Staphylococcus epidermidis in 57 cases (62%), S. aureus in11(12%), Streptococcus species in 8 (8.7%), and otherrganisms including gram-negative species in 16 (17.4%). Aisual outcome of �20/100 was achieved in 41% of patients.n unfavorable visual outcome of �5/200 was present in 32

f 92 (35%) patients. The distribution of visual outcomesccording to the various isolates is shown in Table 3.

DISCUSSION

PATIENTS WITH DELAYED-ONSET POSTOPERATIVE ENDOPH-

thalmitis have several distinguishing clinical features. Thesigns and symptoms vary according to time to presenta-tion and causative microorganism. The inflammation isoften low grade and slowly progressive for delayed-onsetpostoperative endophthalmitis, since it is typicallycaused by less virulent bacteria and fungi. P. acnes washe most common organism isolated in the current seriesnd other delayed-onset postoperative endophthalmitiseries (Table 5).6 – 8 Other less virulent gram-positiverganisms (coagulase-negative Staphylococcus species,orynebacterium species), gram-negative organisms, and

ungi have also been reported in delayed-onset postop-rative endophthalmitis.6,9 –12

The syndrome of delayed-onset postoperative endoph-thalmitis caused by P. acnes, manifesting with a whiteintracapsular plaque, moderate visual loss, and often gran-ulomatous inflammation, was originally described byMeisler and associates.13 In 2 previous published reports, a

hite intracapsular plaque was noted in 28.5%, 89%, and00% of patients with P. acnes.6–8 Such plaques have beeneported in association with other microorganisms asell.6,11,12 In the present series, 65% of delayed-onset

patients were noted to have this clinical sign. Intracapsularwhite plaques were not noted in acute-onset patients inthe current study. All patients demonstrated conjunctivalcongestion and varied amounts of vitreous inflammation.Hypopyon as a presenting feature was noted in 46% of

delayed-onset patients in the current study, compared to

ITIS AFTER CATARACT SURGERY 393

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tocdth

80% of acute-onset patients, which is similar to previousreports in the literature.1,6–8 P. acnes has also beenreported to present uncommonly as acute-onset postoper-ative endophthalmitis.14

The spectrum of microorganisms seen in delayed-onsetpostoperative endophthalmitis differs from those seen inacute-onset postoperative endophthalmitis. Even thoughStaphylococcus species often occur in both categories, Strepto-coccus species and gram-negative organisms are more com-monly noted in acute-onset postoperative endophthalmitis.

Anaerobic culture techniques are critical to microbio-logically confirm P. acnes. In addition, it is important tomonitor anaerobic cultures for a longer period of timebecause of the slow growth of these microorganisms; thetime to culture positivity ranged from 2 to 7 days in thepresent case series. The findings of other aerobic bacteriaand fungi underscore the importance of using both aerobicculture and Sabouraud agar in patients with delayed-onsetpostoperative endophthalmitis.

The ideal management of P. acnes endophthalmitis iscontroversial. In 1 report, resolution of inflammation in

FIGURE 2. White plaque within the capsular bag associatpresentation of Patient 22; visual acuity was 20/40. (Bottom) Awas 20/25.

patients with P. acnes endophthalmitis occurred with

AMERICAN JOURNAL OF394

ystemic antibiotics alone.15 Other cases of resolution afterintraocular antibiotics injected into the capsular bag orsimultaneously into the aqueous and the vitreous have alsobeen described.13,16–19 Recurrence of inflammation inhese patients may warrant PPV with partial capsulectomyr total capsulectomy, with or without removal or ex-hange of the IOL. In the current series, recurrence ofisease was noted in 73% of delayed-onset patients afterhe initial procedure. Similar recurrences of inflammationave also been described in other published reports.6,7,8,17

Of the 19 of 26 delayed-onset patients in the current studywho underwent PPV with total capsulectomy and IOLremoval or exchange for recurrence of inflammation eitheras a secondary or a tertiary procedure, 17 (89.4%) showedresolution of inflammation. In the current series, intraoc-ular vancomycin and ceftazidime was used for empiriccoverage of gram-positive and gram-negative organisms inthe primary procedure. Intraocular amikacin or amphoter-icin B was injected in cases of culture-proven Mycobacte-ria or fungal endophthalmitis, respectively. Although thestudy was not designed to prospectively compare the

ith Propionibacterium acnes endophthalmitis. (Top) Initialpars plana vitrectomy with partial capsulectomy; visual acuity

ed wfter

various treatment modalities in the management of de-

OPHTHALMOLOGY MARCH 2012

ow2

layed-onset postoperative endophthalmitis, the study datasuggests that PPV with total capsulectomy and IOL re-moval or exchange may be the procedure of choice in casesof recurrent infection.

A potential distinction could be argued between the

FIGURE 3. White plaque within the capsular bag associated witf Patient 12; visual acuity was 20/200. (Middle) Recurrence oas hand motions. (Bottom) After pars plana vitrectomy with0/30 with aphakic contact lens correction.

terms “delayed-onset” and “chronic” endophthalmitis. The

DELAYED VS ACUTE ENDOPHTHALMVOL. 153, NO. 3

term “delayed-onset” was used in the current study basedon the onset of the signs and symptoms greater than 6weeks after surgery. It is not possible to determine if theinfecting organism was present from the time of cataractsurgery, which would be more in keeping with the term

remonium strictum endophthalmitis. (Top) Initial presentationction with hypopyon after pars plana vitrectomy; visual acuitycapsulectomy and intraocular lens removal; visual acuity was

h Acf infetotal

“chronic” endophthalmitis. The significance of this case

ITIS AFTER CATARACT SURGERY 395

FIGURE 4. Surgical procedures in delayed-onset endophthalmitis patients who had intraocular lens implant (IOL) removal.Procedures were intraocular antibiotics (IOAB), pars plana vitrectomy (PPV), partial capsulectomy (PC), total capsulectomy (TC),IOL removal (noIOL), penetrating keratoplasty (PKP), and IOL exchange (IOLx). Of the 7 patients with delayed-onsetendophthalmitis who did not undergo IOL removal, initial treatment was PPV/PC/IOAB (4 patients), PPV/IOAB (2 patients), andIOAB (1 patient). None of these 7 patients had recurrences or further interventions. TAP � vitreous tap.

TABLE 3. Visual Acuity Outcomes by Cultured Organism in Delayed-Onset andAcute-Onset Endophthalmitis

Delayed-Onset Endophthalmitis

Total n � 26 �20/40 �20/100 �5/200 NLP

Propionibacterium acnes (n � 11) 55% 91% 9% 0

Fungal speciesa (n � 7) 57% 57% 29% 0

Mycobacterium chelonae (n � 2) 50% 50% 50% 50%

Gram-negative species (n � 3) 0 0 67% 33%

Other gram-positive species (n � 3) 67% 67% 33% 33%

Acute-Onset Endophthalmitis

Total n � 92 �20/40 �20/100 �5/200 NLP

Coagulase-negative Staphylococcus (n � 57) 38% 56% 13% 0

S. aureus (n � 11) 0 0 100% 0

Streptococcus species (n � 8) 0 0 67% 33%

Otherb (n � 16) 11% 22% 67% 11%

NLP � no light perception.aFungal species include Candida parapsilosis (3), Aspergillus fumigatus, Penicillum citrinum,

Paecilomyces variotti, Acremonium strictum.b

Other cultured organisms include gram-negative species.

AMERICAN JOURNAL OF OPHTHALMOLOGY396 MARCH 2012

TABLE 4. Clinical and Microbiologic Features of Delayed-Onset Endophthalmitis Patients Who Had Intraocular Lens ImplantRemoval vs Those Who Did Not Have Implant Removal

Patient Eye

Days to

Diagnosis Organism

Visual Acuity at

Diagnosis Hypopyon

Keratic

Precipitates Visual Outcome

Delayed Onset Endophthalmitis With IOL Removal

1a OD 278 Propionibacterium acnes 20/60 Y Y 20/25

2 OD 256 Propionibacterium acnes 5/200 Y Y 20/20

3a OD 476 Propionibacterium acnes 20/100 N N 20/30

4 OD 735 Propionibacterium acnes 20/150 N Y 20/80

5a OD 127 Propionibacterium acnes 20/30 N Y 20/40

6a OS 808 Propionibacterium acnes 20/80 N Y 20/60

7 OS 714 Propionibacterium acnes 20/40 N Y LPc

8a OD 210 Propionibacterium acnes 20/40 N Y 20/70

9 OS 331 Candida parapsilosis 20/200 N Y 20/400

10 OS 125 Candida parapsilosis CF N Y 5/200

11 OD 133 Candida parapsilosis 20/200 N Y 20/25

12 OD 250 Acremonium strictum 20/200 N Y 20/30

13 OS 125 Aspergillus fumigatus 20/60 Y Y 20/20

14 OD 716 Paecilomyces variotti CF Y N 5/200

15b OD 154 Mycobacterium chelonae 20/30 Y Y 20/25

16 OS 57 Mycobacterium chelonae 20/400 Y Y NLPd

17 OD 276 Agrobacterium radiobacter HM Y Y LP

18a OD 202 Staphylococcus

epidermidis

5/200 Y Y 20/15

19 OS 104 Staphylococcus

epidermidis

2/200 Y N 20/40

Delayed Onset Endophthalmitis Without IOL Removal

20 OS 126 Propionibacterium acnes 20/50 N Y 20/25

21 OD 111 Propionibacterium acnes 20/50 N Y 20/100

22 OS 381 Propionibacterium acnes 20/40 N N 20/25

23 OD 258 Penicillum citrinum 20/60 N Y 20/30

24 OD 73 Ewingella americana 20/400 Y N 20/300

25 OS 1840 Haemophilus influenzae LP Y N NLP

26 OD 48 Streptococcus intermedius LP Y N NLP

CF � count fingers; HM � hand motions; IOL � intraocular lens; LP � light perception; NLP � no light perception.aPatients who underwent IOL exchange.bPatient who underwent IOL exchange, and then subsequent IOL removal for recurrence.cPatient had a suprachoroidal hemorrhage in the first week after pars plana vitrectomy/IOL removal.d

Patient had a retinal detachment 3 months after pars plana vitrectomy/IOL removal.

TABLE 5. Microbiologic Comparison of Delayed-Onset PseudophakicEndophthalmitis Studies

Current Study

(2000–2009)

Al-Mezaine6

(1997–2006)

Clark7

(1974–1996)

Fox8

(1979–1989)

Number of cases 26 17 36 19

Propionibacterium acnes 11 7 36 12

Fungal species 7 3 0 3

Gram-positive species 3 3 0 4

Gram-negative species 3 1 0 0

Mycobacteria 2 0 0 0

Mixed 0 3 0 0

DELAYED VS ACUTE ENDOPHTHALMITIS AFTER CATARACT SURGERYVOL. 153, NO. 3 397

series is the delayed worsening of signs and symptomsleading to treatment beyond 6 weeks from cataract surgery.

The current study is a large contemporary seriescomparing clinical features and outcomes in delayed-onset and acute-onset postoperative endophthalmitis.This large series of delayed-onset patients helps to betterdefine management options and outcomes. The study islimited by its small sample size, retrospective nature,and the variability between multiple physicians in-

volved in the treatment of these patients. The current

Am J Ophthalmol 1991;111(2):163–173.

1

1

1

1

1

1

1

1

1

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AMERICAN JOURNAL OF398

study from a large tertiary care center population dem-onstrated that patients with delayed-onset endophthal-mitis generally presented with better initial acuities andvisual outcomes, and with less frequent hypopyon thanpatients with acute-onset endophthalmitis. Recurrenceof infection is more commonly observed in patients withdelayed-onset postoperative endophthalmitis. Inflam-mation that recurs after initial IOL-sparing treatmentmay warrant removal of the entire capsular bag includ-

ing removal or exchange of the IOL.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OFInterest. Publication of this article was supported by The National Institutes of Health Center Grant P30-EY014801, and an unrestricted grant to theUniversity of Miami from Research to Prevent Blindness, New York, New York. Harry W. Flynn Jr is consultant for Alcon, Allergan, Pfizer, and Santen.Thomas A. Albini is consultant for Alcon Surgical, Bausch & Lomb Surgical, and Allergan. Janet L. Davis is consultant for Centocor and Novartis,and received grant support from Centocor and Novartis. Involved in conception and design (A.S., A.P., H.F.); analysis and interpretation (A.S., A.P.,H.F., T.A., A.B., J.D., G.L., T.M., W.S., D.M.); writing the article (A.S., A.P., H.F., T.A.); critical revision of the article (A.S., A.P., H.F., T.A., A.B.,J.D., G.L., T.M., W.S., D.M.); final approval of the article (A.S., A.P., H.F., T.A., A.B., J.D., G.L., T.M., W.S., D.M.); data collection (A.S., A.P.);provision of materials, patients, or resources (A.S., H.F., T.A., A.B., J.D., G.L., T.M., W.S., D.M.); statistical expertise (A.S.); literature search (A.S.,A.P., H.F.); and administrative, technical, or logistic support (A.S., A.P., H.F.). This retrospective study was approved by the Institutional Review Boardat the University of Miami Miller School of Medicine prior to the beginning of the study.

REFERENCES

1. Johnson MW, Doft BH, Kelsey SF, et al. The Endophthal-mitis Vitrectomy Study: relationship between clinical pre-sentation and microbiologic spectrum. Ophthalmology 1997;104(2):261–272.

2. Wykoff CC, Parrott MB, Flynn HW Jr, Shi W, Miller D,Alfonso EC. Nosocomial acute-onset postoperative endoph-thalmitis at a university teaching hospital (2002–2009).Am J Ophthalmol 2010;150(3):392–398.

3. Freeman EE, Roy-Gagnon MH, Fortin E, Gauthier D,Popescu M, Boisjoly H. Rate of endophthalmitis after cata-ract surgery in Quebec, Canada 1996-2005. Arch Ophthal-mol 2010;128(2):230–234.

4. Ravindran RD, Venkatesh R, Chang DF, Sengupta S, Gyat-sho J, Talwar B. Incidence of post-cataract endophthalmitisat Aravind Eye Hospital, Outcomes of more than 42000consecutive cases using standardized sterilization and prophy-laxis protocols. J Cataract Refract Surg 2009;35(4):629–636.

5. Lalwani GA, Flynn HW Jr, Scott IU, et al. Acute-onsetendophthalmitis after clear corneal cataract surgery (1996-2005). Clinical features, causative organisms, and visualacuity outcomes. Ophthalmology 2008;115(3):473–476.

6. Al-Mezaine HS, Al-Assiri A, Al-Rajhi AA. Incidence,clinical features, causative organisms, and visual outcomes ofdelayed-onset pseudophakic endophthalmitis. Eur J Ophthal-mol 2009;19(5):804–811.

7. Clark WL, Kaiser PK, Flynn HW Jr, Belfort A, Miller D,Meisler DM. Treatment strategies and visual acuity outcomesin chronic postoperative Propionibacterium acnes endophthal-mitis. Ophthalmology 1999;106(9):1665–1670.

8. Fox GM, Joondeph BC, Flynn HW Jr, Pflugfelder SC,Roussel TJ. Delayed-onset pseudophakic endophthalmitis.

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0. Pflugfelder SC, Flynn HW Jr, Zwickey TA, et al. Exogenousfungal endophthalmitis. Ophthalmology 1988;95(1):19–30.

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OPHTHALMOLOGY MARCH 2012

Biosketch

Anita Rajadhyaksha Shirodkar, MD, received undergraduate double degrees in bioengineering and economics at RiceUniversity in Houston, Texas. She then received her medical degree from Baylor College of Medicine in Houston, Texas,which was followed by a residency in ophthalmology at Bascom Palmer Eye Institute in Miami, Florida. She is currentlya second year fellow in vitreoretinal diseases and surgery at Bascom Palmer Eye Institute, where she is also serving as ChiefResident.

DELAYED VS ACUTE ENDOPHTHALMITIS AFTER CATARACT SURGERYVOL. 153, NO. 3 398.e1

Biosketch

Avinash Pathengay, MD, FRCS, completed his residency in ophthalmology at Regional Institute of Ophthalmology inChennai, India. He went on to do a fellowship in vitreoretinal diseases and surgery at Sankara Nethralaya in Chennai,India. He is an associate ophthalmologist at L.V. Prasad Eye Institute in India, and is currently at Bascom Palmer EyeInstitute as an international fellow with Dr Harry Flynn, Jr. His main areas of research interest are endophthalmitis andvitreoretinal diseases.

AMERICAN JOURNAL OF OPHTHALMOLOGY398.e2 MARCH 2012