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Clinical Sciences |

Anterior Chamber and Vitreous Concordance in Endophthalmitis Implications for Prophylaxis FREE

David R. P. Almeida, MD, PhD, MBA; Darlene Miller, DHSc, MPH; Eduardo C. Alfonso, MD
[+] Author Affiliations

Author Affiliations: Department of Ophthalmology, Queen's University, Hotel Dieu Hospital, Kingston, Ontario, Canada (Dr Almeida); and Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida (Drs Miller and Alfonso).


Arch Ophthalmol. 2010;128(9):1136-1139. doi:10.1001/archophthalmol.2010.202.
Text Size: A A A
Published online

Objective  To examine the relationship between anterior chamber (AC) sterilization and vitreous positivity rate in cases of endophthalmitis.

Design  Retrospective case-control study. A review of all consecutive cases of endophthalmitis (N = 758) between January 1, 1999, and December 31, 2008, identified 229 matched AC and vitreous samples. Matched samples were evaluated for sensitivity and specificity, positive and negative predictive values, and positive and negative likelihood ratios. The main outcome measures were sensitivity and specificity of AC and vitreous samples in cases of endophthalmitis. Antibiotic resistance profiles from culture-positive endophthalmitis cases are given.

Results  Gram-positive organisms accounted for 124 of 154 (80.5%) culture-positive endophthalmitis isolates (146 of 229 [63.8%]). The sensitivity (0.36%) and specificity (0.71%) of AC culture results were poor predictors of positive vitreous culture. Positive and negative predictive values were less than 60%. Positive likelihood ratio (1.24) and negative likelihood (0.91) of AC culture results did not aid in predicting vitreous findings. Gram-positive isolates demonstrated in vitro resistance to moxifloxacin (47.1%), ciprofloxacin (43.4%), gatifloxacin (36.8%), levofloxacin (29.0%), gentamicin (19.2%), and ceftazidime (16.7%).

Conclusions  The AC lacks concordance with vitreous findings in cases of endophthalmitis. Use of broad-spectrum antibiotics to sterilize the ocular surface and provide therapeutic levels in the AC may not prevent endophthalmitis. In this study, the finding of a sterile AC did not rule out vitreous infection. These results may have implications for the routine use of broad-spectrum antibiotics as a means of vitreous protection and endophthalmitis prophylaxis.

Endophthalmitis is a serious and potentially vision-threatening intraocular infection. Exogenous (eg, postoperative, traumatic, and postintravitreous injection) and endogenous (eg, liver abscess, pneumonia, and endocarditis) forms of endophthalmitis manifest as progressive vitritis or panuveitis and require urgent evaluation and management. The Endophthalmitis Vitrectomy Study1 remains the benchmark for the treatment of endophthalmitis and specifies the roles of immediate pars plana vitrectomy (light perception–only visual acuity at initial examination) vs vitreous tap and antibiotic injection and revealed that intravenous antibiotics were not of benefit in the treatment of postsurgical endophthalmitis. Routine use of topical broad-spectrum antibiotics to reduce ocular surface microflora and to provide therapeutic drug levels in the anterior chamber (AC) for vitreous prophylaxis before cataract and other anterior segment surgical procedures is a common but increasingly debated issue.24

Cataract surgery is the most frequently performed intraocular surgery. The incidence rate of acute endophthalmitis following cataract surgery ranges from 0.08% to 0.68%.410 In cataract surgery, the use of fluoroquinolones as perioperative topical broad-spectrum antibiotic eyedrops is considered of benefit in preventing endophthalmitis because of favorable AC penetration and increased efficacy against gram-positive bacteria.1115 The protective and therapeutic effect may be a combination of resident skin flora sterilization and elimination of microbes that might enter the AC during surgery. The relationship between a sterile anterior segment or high intracameral antibiotic levels and the prevention of microbial invasion of the vitreous remains unclear.2,3

In a 2007 study,10 intracameral cefuroxime was shown to reduce the risk of endophthalmitis following cataract surgery in one large multicenter study. The use of levofloxacin (0.5%) eyedrops preoperatively was not found to reduce the risk of endophthalmitis.10 However, debate about the efficacy and safety of intracameral antibiotics for the prevention of post–cataract surgery endophthalmitis remains controversial.1619 Povidone iodine remains the only other agent that has been shown to provide a protective effect against the development of endophthalmitis.20

The purpose of this study was to examine the relationship between AC sterilization and vitreous positivity rate in cases of endophthalmitis. Between January 1, 1999, and December 31, 2008, endophthalmitis cases with both AC and vitreous microbiologic culture results were examined to determine the concordance between AC and vitreous results and the emergence of in vitro resistance to a select group of antibiotics. Given the controversy about topical vs intracameral antibiotics in endophthalmitis prophylaxis, alongside the increasing rates of cataract surgery and intravitreous injections, such a comparison might help in the debate on the value of AC sterilization and its effect on vitreous culture results, as well as endophthalmitis prophylaxis by extrapolation.

We retrospectively reviewed all consecutive cases of endophthalmitis (endogenous and exogenous) (N = 758) submitted for microbiologic culture at the Bascom Palmer Eye Institute, Miami, Florida, between January 1, 1999, and December 31, 2008. From this group, we identified 229 matched AC and vitreous samples, which were evaluated for sensitivity and specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios. Analysis of AC and vitreous by means of a 2 × 2 diagnostic accuracy table was performed to determine the relationship between AC sterilization and vitreous positivity rate. The AC results were defined by the diagnostic test in question, and the vitreous results served as the gold standard.

Antibiotic susceptibility profiles of culture-positive endophthalmitis isolates (n = 146) were reviewed. Trends were assessed for in vitro resistance to vancomycin, gentamicin, ciprofloxacin, levofloxacin, gatifloxacin, and moxifloxacin. The study fully adhered to the Declaration of Helsinki and all federal and state laws.

A significant difference existed between the culture-positive rates for AC (74 of 229 [32.3%]) and vitreous (112 of 229 [48.9%]) (χ2 = 13.07, P < .001). The overall culture-positive rate was 146 of 229 matched study cases (63.8%). In 40 cases, both AC and vitreous identified the same isolate, and these were defined as true-positive results. In 64 cases, AC identified no isolates, but vitreous was positive; in 8 cases, AC and vitreous identified different microorganisms. Together, these 72 cases represent the false-negative group (Table 1). False-positive results included 34 cases in which AC was positive for microorganisms but vitreous revealed no isolates. Finally, 83 cases were negative for both AC and vitreous and correspond to the true-negative group.

Table Graphic Jump LocationTable 1. Summary of 229 Endophthalmitis Cases Between 1999 and 2008

The AC culture results poorly detected vitreous isolates, with a sensitivity of 36% (Table 1). Similarly, AC culture was inadequate at predicting negative vitreous culture results, with a specificity of 71%. The PPV and NPV were 54% and lacked usefulness in interpreting AC and vitreous microbiologic results. The positive and negative likelihood ratios for AC were 1.24 and 0.91, respectively, indicating that AC results did not aid in predicting vitreous findings in any meaningful way. General concordance between AC and vitreous cultures was 53.7% (123 of 229).

A total of 154 microorganisms were identified from 146 culture-positive endophthalmitis cases (Table 2). Gram-positive organisms accounted for 80.5% (124 of 154) of isolates, and the most prevalent included Staphylococcus epidermidis (29.2%), Streptococcus species (18.2%), and coagulase-negative Staphylococcus species (11.7%). Gram-negative microorganisms represented 11.0% of isolates (17 of 154); 82.4% (14 of 17) of these were Pseudomonas aeruginosa. Yeast and fungi composed 8.4% (13 of 154) of isolates, with Candida species being the most common ([30.8%] 4 of 13).

Table Graphic Jump LocationTable 2. Antibiotic Resistance Profiles of Gram-positive and Gram-negative Bacterial Isolates Among 141 Culture-Positive Endophthalmitis Cases Between 1999 and 2008a

Gram-positive organisms demonstrated significant antibiotic resistance to the second-generation fluoroquinolone ciprofloxacin (43.4%), third-generation levofloxacin (29.0%), and fourth-generation moxifloxacin (47.1%) and gatifloxacin (36.8%), as well as gentamicin (19.2%) and ceftazidime (16.7%) (Table 2). All gram-positive microorganisms were sensitive to vancomycin. Gram-negative isolates showed antibiotic resistance to gentamicin (23.1%) but were 100% sensitive to ciprofloxacin and levofloxacin.

In this retrospective study, there was a lack of concordance between culture positivity and spectrum of isolates among matched AC and vitreous cultures. The AC lacked high sensitivity; therefore, a negative test result could not be used to rule out vitreous infection. Similarly, AC results lacked high specificity, and a positive test result could not be used to rule in vitreous infection. Together, AC and vitreous displayed poor concordance, and AC results were in no way helpful at indicating or predicting vitreous positivity or negativity rates. Our calculated PPV and NPV, both of which fell below 60%, demonstrated that AC culture results for this population were not useful in predicting microbial invasion or contamination of the vitreous chamber.

Predictive values were used to ascertain the probability of vitreous outcomes given a positive or negative AC result. The PPV and NPV are dependent on the disease prevalence and the target population. The prevalence of culture-proven endophthalmitis among this population was 48.9%. Therefore, similar to the sensitivity and specificity results, the low PPV and NPV in this study showed AC culture status to be a poor predictor of vitreous results. Unlike predictive values, likelihood ratios are independent of disease prevalence.21 The positive likelihood ratio herein revealed a minimal increase in the likelihood of AC and vitreous congruency. Furthermore, the negative likelihood ratio confirmed an insignificant decrease in the likelihood of vitreous outcomes given AC results. These results are surprising because a common inference is that AC status is, at least partly, congruent with vitreous status and include therapeutic AC antibiotic levels that afford vitreous protection from microbial invasion. Instead, our results demonstrated that AC status has a negative correlation with vitreous results.

Results of matched AC and vitreous samples (N = 21) from the European Society of Cataract & Refractive Surgeons multicenter study22 on prophylaxis of postoperative endophthalmitis confirmed the insensitivity of AC culture results in predicting vitreous culture outcomes. General agreement between AC and vitreous cultures in this population was 76.2%, with sensitivity and specificity of 60% and 91%, respectively. Both PPV (85.7%) and NPV (71.4%) were less than 90%. As in our study, likelihood ratios confirmed the inadequacy of AC culture status to provide relevant information about vitreous culture positivity. The Endophthalmitis Vitrectomy Study23 confirmed a significant difference in culture-positive rates between AC and vitreous samples. Among 323 laboratory-confirmed cases, culture-positive rates were 48.9% (158 of 323) for AC and 87.3% (282 of 323) for vitreous samples (P < .001). These results draw into question the current approach of targeting AC for endophthalmitis prophylaxis.

Fluoroquinolone resistance among 229 matched cases in this study was greater than 20% for all classes. These results confirm previous data from our and other centers about growing in vitro resistance to older and newer fluoroquinolones.2428 Coupled with the increasing reports of clinical failure with this class of antibiotics, the continued use of these antibiotics for prophylaxis and treatment of endophthalmitis may need to be revisited.2931 Current debate about the use of intracameral cefuroxime for the prevention of endophthalmitis needs additional study. Among 11 isolates available for in vitro evaluation among patients with presumed endophthalmitis in the European Society of Cataract & Refractive Surgeons study,22 documented resistance was 45.5% (5 of 11) for cefuroxime and 27.3% (3 of 11) for levofloxacin.

Correspondence: Darlene Miller, DHSc, MPH, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, 900 NW 17th St, Miami, FL 33136 (dmiller@med.miami.edu).

Submitted for Publication: November 14, 2009; final revision received January 23, 2010; accepted March 6, 2010.

Author Contributions: Dr Miller had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Financial Disclosure: None reported.

Funding/Support: This study was supported by Research to Prevent Blindness.

Role of the Sponsor: The sponsor had no role in any part of the design or conduct of the study; in the collection, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript.

Endophthalmitis Vitrectomy Study Group, Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995;113 (12) 1479- 1496
PubMed Link to Article
Buzard  KLiapis  S Prevention of endophthalmitis. J Cataract Refract Surg 2004;30 (9) 1953- 1959
PubMed Link to Article
O’Brien  TP Evidence-based review of moxifloxacin. Int Ophthalmol Clin 2006;46 (4) 61- 72
PubMed Link to Article
Lemley  CAHan  DP Endophthalmitis: a review of current evaluation and management [published correction appears in Retina. 2007;27(7)]. Retina 2007;27 (6) 662- 680
PubMed Link to Article
Javitt  JCStreet  DATielsch  JM  et al. Cataract Patient Outcomes Research Team, National outcomes of cataract extraction: retinal detachment and endophthalmitis after outpatient cataract surgery. Ophthalmology 1994;101 (1) 100- 105, discussion 106
PubMed Link to Article
Norregaard  JCThoning  HBernth-Petersen  PAndersen  TFJavitt  JCAnderson  GF Risk of endophthalmitis after cataract extraction: results from the International Cataract Surgery Outcomes study. Br J Ophthalmol 1997;81 (2) 102- 106
PubMed Link to Article
Somani  SGrinbaum  ASlomovic  AR Postoperative endophthalmitis: incidence, predisposing surgery, clinical course and outcome. Can J Ophthalmol 1997;32 (5) 303- 310
PubMed
Aaberg  TM  JrFlynn  HW  JrSchiffman  JNewton  J Nosocomial acute-onset postoperative endophthalmitis survey: a 10-year review of incidence and outcomes. Ophthalmology 1998;105 (6) 1004- 1010
PubMed Link to Article
Morlet  NGatus  BCoroneo  M Patterns of peri-operative prophylaxis for cataract surgery: a survey of Australian ophthalmologists. Aust N Z J Ophthalmol 1998;26 (1) 5- 12
PubMed Link to Article
Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons, Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007;33 (6) 978- 988
PubMed Link to Article
Busbee  BG Endophthalmitis: a reappraisal of incidence and treatment. Curr Opin Ophthalmol 2006;17 (3) 286- 291
PubMed Link to Article
Kampougeris  GAntoniadou  AKavouklis  EChryssouli  ZGiamarellou  H Penetration of moxifloxacin into the human aqueous humour after oral administration. Br J Ophthalmol 2005;89 (5) 628- 631
PubMed Link to Article
Katz  HRMasket  SLane  SS  et al.  Absorption of topical moxifloxacin ophthalmic solution into human aqueous humor. Cornea 2005;24 (8) 955- 958
PubMed Link to Article
Kim  DHStark  WJO’Brien  TPDick  JD Aqueous penetration and biological activity of moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3% solution in cataract surgery patients. Ophthalmology 2005;112 (11) 1992- 1996
PubMed Link to Article
Scoper  SV Review of third- and fourth-generation fluoroquinolones in ophthalmology: in-vitro and in-vivo efficacy. Adv Ther 2008;25 (10) 979- 994
PubMed Link to Article
Barry  PSeal  DVGettinby  GLees  FPeterson  MRevie  CWESCRS Endophthalmitis Study Group, ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study. J Cataract Refract Surg 2006;32 (3) 407- 410
PubMed Link to Article
Brown  SMAnand  VKTabaee  ASchwartz  TH Role of perioperative antibiotics in endoscopic skull base surgery. Laryngoscope 2007;117 (9) 1528- 1532
PubMed Link to Article
Flynn  HW  JrScott  IUBrod  RDHan  DP Current management of endophthalmitis. Int Ophthalmol Clin 2004;44 (4) 115- 137
PubMed Link to Article
Ou  JITa  CN Endophthalmitis prophylaxis. Ophthalmol Clin North Am 2006;19 (4) 449- 456
PubMed
Ciulla  TAStarr  MBMasket  S Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology 2002;109 (1) 13- 24
PubMed Link to Article
Pewsner  DBattaglia  MMinder  CMarx  ABucher  HCEgger  M Ruling a diagnosis in or out with “SpPIn” and “SnNOut”: a note of caution. BMJ 2004;329 (7459) 209- 213
PubMed Link to Article
Seal  DReischl  UBehr  A  et al. ESCRS Endophthalmitis Study Group, Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract & Refractive Surgeons multicenter study and susceptibility testing. J Cataract Refract Surg 2008;34 (9) 1439- 1450
PubMed Link to Article
Barza  MPavan  PRDoft  BH  et al.  Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. Arch Ophthalmol 1997;115 (9) 1142- 1150
PubMed Link to Article
Recchia  FMBusbee  BGPearlman  RBCarvalho-Recchia  CAHo  AC Changing trends in the microbiologic aspects of postcataract endophthalmitis. Arch Ophthalmol 2005;123 (3) 341- 346
PubMed Link to Article
Benz  MSScott  IUFlynn  HW  JrUnonius  NMiller  D Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol 2004;137 (1) 38- 42
PubMed Link to Article
Harper  TMiller  DFlynn  HW  Jr In vitro efficacy and pharmacodynamic indices for antibiotics against coagulase-negative staphylococcus endophthalmitis isolates. Ophthalmology 2007;114 (5) 871- 875
PubMed Link to Article
Miller  DFlynn  PMScott  IUAlfonso  ECFlynn  HW  Jr In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol 2006;124 (4) 479- 483
PubMed Link to Article
Ta  CN Topical antibiotic prophylaxis in intraocular injections. Arch Ophthalmol 2007;125 (7) 972- 974
PubMed Link to Article
Deramo  VALai  JCFastenberg  DMUdell  IJ Acute endophthalmitis in eyes treated prophylactically with gatifloxacin and moxifloxacin. Am J Ophthalmol 2006;142 (5) 721- 725
PubMed Link to Article
Jensen  MKFiscella  RGMoshirfar  MMooney  B Third- and fourth-generation fluoroquinolones: retrospective comparison of endophthalmitis after cataract surgery performed over 10 years. J Cataract Refract Surg 2008;34 (9) 1460- 1467
PubMed Link to Article
McCulley  JP Fluoroquinolones and postoperative endophthalmitis. J Cataract Refract Surg 2009;35 (2) 206
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Summary of 229 Endophthalmitis Cases Between 1999 and 2008
Table Graphic Jump LocationTable 2. Antibiotic Resistance Profiles of Gram-positive and Gram-negative Bacterial Isolates Among 141 Culture-Positive Endophthalmitis Cases Between 1999 and 2008a

References

Endophthalmitis Vitrectomy Study Group, Results of the Endophthalmitis Vitrectomy Study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995;113 (12) 1479- 1496
PubMed Link to Article
Buzard  KLiapis  S Prevention of endophthalmitis. J Cataract Refract Surg 2004;30 (9) 1953- 1959
PubMed Link to Article
O’Brien  TP Evidence-based review of moxifloxacin. Int Ophthalmol Clin 2006;46 (4) 61- 72
PubMed Link to Article
Lemley  CAHan  DP Endophthalmitis: a review of current evaluation and management [published correction appears in Retina. 2007;27(7)]. Retina 2007;27 (6) 662- 680
PubMed Link to Article
Javitt  JCStreet  DATielsch  JM  et al. Cataract Patient Outcomes Research Team, National outcomes of cataract extraction: retinal detachment and endophthalmitis after outpatient cataract surgery. Ophthalmology 1994;101 (1) 100- 105, discussion 106
PubMed Link to Article
Norregaard  JCThoning  HBernth-Petersen  PAndersen  TFJavitt  JCAnderson  GF Risk of endophthalmitis after cataract extraction: results from the International Cataract Surgery Outcomes study. Br J Ophthalmol 1997;81 (2) 102- 106
PubMed Link to Article
Somani  SGrinbaum  ASlomovic  AR Postoperative endophthalmitis: incidence, predisposing surgery, clinical course and outcome. Can J Ophthalmol 1997;32 (5) 303- 310
PubMed
Aaberg  TM  JrFlynn  HW  JrSchiffman  JNewton  J Nosocomial acute-onset postoperative endophthalmitis survey: a 10-year review of incidence and outcomes. Ophthalmology 1998;105 (6) 1004- 1010
PubMed Link to Article
Morlet  NGatus  BCoroneo  M Patterns of peri-operative prophylaxis for cataract surgery: a survey of Australian ophthalmologists. Aust N Z J Ophthalmol 1998;26 (1) 5- 12
PubMed Link to Article
Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons, Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007;33 (6) 978- 988
PubMed Link to Article
Busbee  BG Endophthalmitis: a reappraisal of incidence and treatment. Curr Opin Ophthalmol 2006;17 (3) 286- 291
PubMed Link to Article
Kampougeris  GAntoniadou  AKavouklis  EChryssouli  ZGiamarellou  H Penetration of moxifloxacin into the human aqueous humour after oral administration. Br J Ophthalmol 2005;89 (5) 628- 631
PubMed Link to Article
Katz  HRMasket  SLane  SS  et al.  Absorption of topical moxifloxacin ophthalmic solution into human aqueous humor. Cornea 2005;24 (8) 955- 958
PubMed Link to Article
Kim  DHStark  WJO’Brien  TPDick  JD Aqueous penetration and biological activity of moxifloxacin 0.5% ophthalmic solution and gatifloxacin 0.3% solution in cataract surgery patients. Ophthalmology 2005;112 (11) 1992- 1996
PubMed Link to Article
Scoper  SV Review of third- and fourth-generation fluoroquinolones in ophthalmology: in-vitro and in-vivo efficacy. Adv Ther 2008;25 (10) 979- 994
PubMed Link to Article
Barry  PSeal  DVGettinby  GLees  FPeterson  MRevie  CWESCRS Endophthalmitis Study Group, ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study. J Cataract Refract Surg 2006;32 (3) 407- 410
PubMed Link to Article
Brown  SMAnand  VKTabaee  ASchwartz  TH Role of perioperative antibiotics in endoscopic skull base surgery. Laryngoscope 2007;117 (9) 1528- 1532
PubMed Link to Article
Flynn  HW  JrScott  IUBrod  RDHan  DP Current management of endophthalmitis. Int Ophthalmol Clin 2004;44 (4) 115- 137
PubMed Link to Article
Ou  JITa  CN Endophthalmitis prophylaxis. Ophthalmol Clin North Am 2006;19 (4) 449- 456
PubMed
Ciulla  TAStarr  MBMasket  S Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology 2002;109 (1) 13- 24
PubMed Link to Article
Pewsner  DBattaglia  MMinder  CMarx  ABucher  HCEgger  M Ruling a diagnosis in or out with “SpPIn” and “SnNOut”: a note of caution. BMJ 2004;329 (7459) 209- 213
PubMed Link to Article
Seal  DReischl  UBehr  A  et al. ESCRS Endophthalmitis Study Group, Laboratory diagnosis of endophthalmitis: comparison of microbiology and molecular methods in the European Society of Cataract & Refractive Surgeons multicenter study and susceptibility testing. J Cataract Refract Surg 2008;34 (9) 1439- 1450
PubMed Link to Article
Barza  MPavan  PRDoft  BH  et al.  Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study. Arch Ophthalmol 1997;115 (9) 1142- 1150
PubMed Link to Article
Recchia  FMBusbee  BGPearlman  RBCarvalho-Recchia  CAHo  AC Changing trends in the microbiologic aspects of postcataract endophthalmitis. Arch Ophthalmol 2005;123 (3) 341- 346
PubMed Link to Article
Benz  MSScott  IUFlynn  HW  JrUnonius  NMiller  D Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol 2004;137 (1) 38- 42
PubMed Link to Article
Harper  TMiller  DFlynn  HW  Jr In vitro efficacy and pharmacodynamic indices for antibiotics against coagulase-negative staphylococcus endophthalmitis isolates. Ophthalmology 2007;114 (5) 871- 875
PubMed Link to Article
Miller  DFlynn  PMScott  IUAlfonso  ECFlynn  HW  Jr In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol 2006;124 (4) 479- 483
PubMed Link to Article
Ta  CN Topical antibiotic prophylaxis in intraocular injections. Arch Ophthalmol 2007;125 (7) 972- 974
PubMed Link to Article
Deramo  VALai  JCFastenberg  DMUdell  IJ Acute endophthalmitis in eyes treated prophylactically with gatifloxacin and moxifloxacin. Am J Ophthalmol 2006;142 (5) 721- 725
PubMed Link to Article
Jensen  MKFiscella  RGMoshirfar  MMooney  B Third- and fourth-generation fluoroquinolones: retrospective comparison of endophthalmitis after cataract surgery performed over 10 years. J Cataract Refract Surg 2008;34 (9) 1460- 1467
PubMed Link to Article
McCulley  JP Fluoroquinolones and postoperative endophthalmitis. J Cataract Refract Surg 2009;35 (2) 206
PubMed Link to Article

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