An Outbreak of Postsurgical Endophthalmitis Due to Contaminated Carbachol Solution


In a period of 4 months our institution experienced an outbreak of 8 cases of post surgical endophthalmitis after uncomplicated cataract surgery by four different surgeons. Six cases were after phacoemulsification and two cases after extracapsular cataract extraction. Prophylactive intracameral antibiotic had been used in all cases. One case was in December 2015, two cases in January 2016 and three cases in March 2016. Five cases were managed by vitrectomy and intravitreal antibiotics while three cases by only intravitreal antibiotics. After the second case a complete audit was done of all the sterilization procedures and additional steps were done to ensure that there was completely effective sterilization. After the third case one of the surgeons mentioned that she suspected it might have been due to an injected intraocular solution. We ordered that all intraocular injections must be filtered by a micropore filter and all empty vial to be kept for at least 2 days to allow microbiological investigation if there should be a case of endophthalmitis. After the use of micropore filters there was a lapse of one month without any cases of endophthalmitis, however, in March there were three cases. All three cases had used a the same brand of carbachol. The severity of the endophthalmitis in the cases after micropore filtration was less than before micropore filtration, however, the inflammation was still very severe. We isolated bacteria from one vial carbachol of which contained Pseudomonas. In conclusio n even though we used a micropore filter, there must have been bacterial toxins which were so toxic that they caused endophthalmitis. After changing the brand of carbachol no more cases of endophthalmitis were seen.


Sjakon Tahija
Jakarta, Indonesia
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