Cataract surgery during active methicillin-resistant Staphylococcus aureus infection
A 69-year-old diabetic, hypertensive, dyslipidemic, morbidly obese (body mass index 40 kg/m2) housewife underwent bifrontal craniotomy in 1996 that was complicated by osteomyelitis. Several courses of combination antibiotics failed to eradicate the infection. Repeated attempts at closing the craniotomy site with flaps failed. The wound () continued to be foul-smelling. The infectious diseases team was reluctant to allow any ocular surgery. Examination revealed counting finger vision with mature cataract bilaterally. Funduscopy was negative for diabetic retinopathy. The patient was consented for surgery with the risks of endophthalmitis explained. Sequential sutureless phacoemulsification was done, with final uncorrected vision of 6/7.5 in each eye and a 5-month interval between surgeries. Surgery was carried out under topical anesthesia with xylocaine gel and without the application of topical povidone iodine that could decrease corneal clarity (due to severe dry eye povidone iodine drops were omitted to avoid corneal epithelial toxicity that would affect visualization in this very dense cataract)., The eyelid and eyebrow region was scrubbed with povidone iodine. Special attention was paid to creating elongated, three-plane, self-sealing limbal tracts (using a crescent blade), avoiding multiple entry and exit from the eye, and keeping the eye at a pressure of 25 mmHg throughout the procedure. No intracameral antibiotics were given at the end of surgery. The eye was patched with tobramycin and dexamethasone ointment for 1 hour. One hour after surgery, drops were applied every hour during waking time for 1 day with gradual taper (first week every 2 hours, second week every 4 hours, and third week every 6 hours). The postoperative regimen consisted of topical moxifloxacin along with a combination of netilmicin sulfate 0.3% with dexamethasone phosphate 0.1% drops for 3 weeks together with 5 days of oral moxifloxacin. Close observation (examination every 2 days) failed to reveal any signs of anterior chamber inflammation in the postoperative period of 2 months. The patient had no cultures (wound, nose, blood, conjunctival cul de sac), and no preoperative antibiotics.