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气道粘膜充血水肿,导致气道分泌物增多,咳嗽和憋喘症状加重,痰液黏稠不易排出,易造成呼吸道堵塞,最终诱发呼吸衰竭和心力衰竭等并发症[1]。目前,临床关于盐酸氨溴索治疗COPD急性加重期疗效的研究较多,而对于盐酸氨溴索不同持续用药时间治疗COPD急性加重期疗效的研究较少,为此,本研究通过随机对照试验对我院接诊的70例患者进行研究,现报道如下:

三联书店出版的《三联生活周刊》2018年第13期载文说，台湾学者李敖，在乎的是信仰而不是金钱。他一贯按自己的这一尺度行事。有段时间，他在香港卫视开办《李敖有话说》节目，收入颇丰。但后来，人们反映他有些话触犯底线，劝他不要讲这些话。他想了想，便去找董事局主席刘长乐说，“我跟你们凤凰缘已尽”，“我不要做节目了”。触犯底线，当然是不对的，但他在没认识到底线的重要性之前，宁可不做节目、放弃不菲的经济收入，也不盲目顺应——有待调整他的是非尺度。

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.

胆结石在临床是比较常见的疾病，该病的形成原因比较复杂，导致患者的身体以及心理产生不适感。人性化护理模式秉承着“以人为本”的理念在临床中的运用越来越多[1]，采用人性化护理可以全方位的对患者的身体以及心理状态进行改善。本研究将深入探讨人性化护理对于胆结石患者术前焦虑的改善效果，现报道如下。

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).

鉴于国外对大型科学仪器设备的使用和管理较国内起步早，其对设备开放共享问题的研究、实践、遇到的问题及解决方法均值得探讨和思考。

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