Nosocomial acute-onset postoperative endophthalmitis survey. A 10-year review of incidence and outcomes

Toxic Anterior Segment Syndrome after Uncomplicated Cataract Surgery

Purpose

To evaluate the anterior segment examination findings and the response to medical therapy of patients who had toxic anterior segment syndrome (TASS) after uncomplicated cataract surgery.

Methods

Fourteen eyes of 14 patients were enrolled in the study. Visual acuity, biomicroscopic anterior segment examination, intraocular pressure measurement, and fundus examination were performed to assess TASS occurring during postoperative 12–48 hours after uncomplicated phaco surgery. The visual impairment, corneal edema, tyndallization, fibrin formation, hypopyon, vitritis, and response to steroid therapy were evaluated prospectively.

Results

After topical steroid therapy lasting for 1 week, visual acuity improved in 11 eyes. No significant visual improvement occurred in 3 eyes. Significant corneal edema was found in 4 and mild corneal edema was observed in the other 10 eyes. Fibrin reaction occurred in 5 and tyndallization in various degrees was positive in all eyes. There was a 1-mm hypopyon in 1 patient. There was no sign of vitritis and steroid therapy was effective in all of the patients. In addition to topical treatment with steroid and antibiotic drops; systemic and subconjunctival steroids were used in 3 patients who had fibrin formation and in one patient who had hypopyon.

Conclusions

After uncomplicated cataract surgery, toxic anterior segment may occur in the early postoperative period, which is treated successfully with steroids. More studies are needed to understand the multifactorial risk factors affecting the etiopathogenesis of this syndrome.

Burkholderia Cepacia Endophthalmitis: An Unusual Presentation

Purpose

To report three cases of Burkholderia cepacia endophthalmitis following uneventful phacoemulsification surgery.

Case Report

Three cases presented with blurriness of vision 2 to 3 weeks following phacoemulsification. Vitreous culture confirmed the diagnosis. Pars plana vitrectomy with intravitreal injection of vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) was performed. Despite several modalities of treatment, 2 cases did not respond to intravitreal antibiotics and vitrectomy. The first case ended up with phthisis bulbi and the second case underwent evisceration. One case improved after intravitreal injection of the first dose of antibiotic.

Conclusion

B. cepacia endophthalmitis is rare and difficult to treat. More studies are necessary to understand the course and outcome of the infection.

Prevention and management of postoperative endophthalmitis: A case-based approach

Endophthalmitis following intraocular surgery is a disastrous complication and can lead to poor visual outcomes and loss of globe integrity. It should be differentiated from toxic anterior segment syndrome (TASS) where management differs drastically. This article presents basic knowledge about postoperative endophthalmitis and describes nine different real–world scenarios ranging from TASS to milder forms of endophthalmitis responding to intravitreal antibiotics alone and more complicated forms associated with corneal involvement, fungal endophthalmitis and cases requiring intraocular lens removal, radical vitrectomy with hyaloid peeling, base dissection, and silicone oil. A case-based approach is followed where practical considerations have been adopted with each case such that it facilitates the readers’ ability to apply theoretical knowledge to real-life clinical situations.

Predictors of Visual Outcomes and Microbial Profile in Endophthalmitis

BACKGROUND AND OBJECTIVE

To evaluate predictors of visual outcomes and microbial profile in endophthalmitis.

PATIENTS AND METHODS

This was a prospective, interventional case series at a tertiary eye care center. Of the 207 patients included, 83 had post-cataract surgery endophthalmitis (PCE), 84 had post-traumatic endophthalmitis (PTE), and 16 had endogenous endophthalmitis. Vitreous samples were evaluated for microbial profile, and all patients received similar empirical antibiotic therapy. Main outcome measures were good visual acuity, defined as better than 20/400, and microbial profile with drug resistance.

RESULTS

Final visual acuity better than 20/400 was seen in 88% patients previously treated with intravitreal antibiotics (P < .001), 89% with presenting vision of less than 3.3 LogMAR units (P < .001), 61% without retinal detachment (RD) (P < .001), 58% without retained intraocular foreign body (RIOFB) (P = .007), 88% without extensive media haze (P = .007), 71% of culture-negative patients (P = .007), and 65% with gram-positive bacteria (P = .03). On multivariate analysis, presenting visual acuity of less than 3.3 LogMAR units was found to have the highest adjusted odds ratio, 26.28 (95% CI, 9.13-75.6), for better visual outcome. Culture positivity was nearly 37%. Gram-positive bacteria were the most common in both PCE (90%) and PTE (55%) groups, whereas hyphae form fungus was the most common organism grown in endogenous endophthalmitis (50%) (P < .001). In patients without extensive media haze, hyphae form fungus was the most common grown organism (42%) (P = .03). PTE was predominant (60%) in the patients with antibiotic resistance.

CONCLUSIONS

Presenting visual acuity better than hand motions close to face is the single most common indicator of good visual prognoses. Fungal infections are associated with RD, RIOFB, trauma, and absence of extensive media haze. Microbial resistance may be an important concern in PTE patients. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:991-998.].

ONE-YEAR OUTCOMES OF A NOVEL TECHNIQUE FOR RESCUING AND SCLERAL FIXATING A POSTERIOR DISLOCATED INTRAOCULAR LENS-BAG COMPLEX WITHOUT CONJUNCTIVAL OPENING (HOFFMAN POCKETS)

PURPOSE

To present the 1-year follow-up of a novel surgical technique that allows for suture fixation of a posteriorly dislocated lens-bag complex without the need for conjunctival incision.

METHODS

A retrospective chart review of 19 patients who underwent posterior chamber intraocular lens rescue using the novel surgical technique was performed. Data were collected 1 year after surgery for all patients.

RESULTS

Average preoperative vision was 20/500, whereas 3 months and 12 months postoperatively, the vision was 20/65 and 20/54, respectively. Three of 15 eyes had decentration of the sutured intraocular lens, 2 of which required additional surgical repair.

CONCLUSION

Outcome data at 1 year support this novel technique as a viable option for the surgical repair of a dislocated lens-capsular bag complex.

Fabrication of nonfouling, bactericidal, and bacteria corpse release multifunctional surface through surface-initiated RAFT polymerization

Infections after surgery or endophthalmitis are potentially blinding complications caused by bacterial adhesion and subsequent biofilm formation on the intraocular lens. Neither single-function anti-adhesion surface nor contacting killing surface can exhibit ideal antibacterial function. In this work, a novel (2-(dimethylamino)-ethyl methacrylate-co-2-methacryloyloxyethyl phosphorylcholine) (p (DMAEMA-co-MPC)) brush was synthesized by "grafting from" method through reversible-addition fragmentation chain transfer polymerization. 1-Bromoheptane was used to quaternize the p (DMAEMA-co-MPC) brush coating and to endow the surface with bactericidal function. The success of the surface functionalization was confirmed by atomic force microscopy, water contact angle, and spectroscopic ellipsometry. The quaternary ammonium salt units were employed as efficient disinfection that can eliminate bacteria through contact killing, whereas the 2-methacryloyloxyethyl phosphorylcholine units were introduced to suppress unwanted nonspecific adsorption. The functionalized poly(dimethyl siloxane) surfaces showed efficiency in reducing bovine serum albumin adsorption and in inhibiting bacteria adhesion and biofilm formation. The copolymer brushes also demonstrated excellent bactericidal function against gram-positive (Staphylococcus aureus) bacteria measured by bacteria live/dead staining and shake-flask culture methods. The surface biocompatibility was evaluated by morphology and activity measurement with human lens epithelial cells in vitro. The achievement of the p (DMAEMA+-co-MPC) copolymer brush coating with nonfouling, bactericidal, and bacteria corpse release properties can be used to modify intraocular lenses.

Endophthalmitis after small-gauge vitrectomy: a retrospective case series from Sweden

PURPOSE

To investigate the anatomical and functional outcomes of acute-onset endophthalmitis after small-gauge vitrectomy.

METHODS

Retrospective case series of patients who underwent 23- or 25-gauge vitrectomy at four centres in Sweden between 2008 and 2012. Postvitrectomy endophthalmitis was identified through the search of the journal records of each institution, and the diagnosis was based on clinical criteria regardless of culture results.

RESULTS

Twenty-four patients (24 eyes) were included. The incidence of endophthalmitis following small-gauge vitrectomy was 0.14%. Indications for small-gauge vitrectomy enclosed epiretinal membrane (n = 13), retinal detachment (n = 5) and others (n = 6). Surgical technique included 23- and 25-gauge vitrectomy (23:1). Four eyes had sutured sclerotomies, and two had postoperative hypotony <7 mmHg. Days to endophthalmitis presentation varied between 1 and 21 (mean 6 ± 6). Treatment methods included the following: tap and antibiotic injection (n = 7), tap, antibiotic injection with subsequent vitrectomy (n = 2) and prompt vitrectomy with antibiotics (n = 15). Sixteen eyes (66.7%) were culture positive, whereas the other eight cases were culture negative. Anatomical results included evisceration (n = 1), phthisis (n = 1), and globe intact (n = 22). Presenting best corrected visual acuity (BCVA) were hand motion (n = 14), light perception (n = 7), counting fingers (n = 2), and no data (n = 1). Functionally 19 eyes (79%) had Snellen VA ≥0.1; 11 eyes (46%) had VA ≥0.5 Mean logMar BCVA preoperatively and at the last follow-up were 2.07 ± 0.6 and 0.79 ± 0.99, respectively.

CONCLUSIONS

In spite of good anatomical and functional results, this study showed higher rate of endophthalmitis than the latest reports suggesting that small-gauge vitrectomy has reached the safety level of standard 20-gauge vitrectomy when infectious endophthalmitis is concerned.

Comparison of clinico-microbiological profile and treatment outcome of in-house and referred post cataract surgery endophthalmitis in a tertiary care center in South India

Background

The purpose of the study is to compare the clinico-microbiological profile and treatment outcome of in-house vs referred cases of post cataract surgery endophthalmitis in a tertiary eye care facility in South India.

Methods

The clinical records of 50 culture-positive cases each of in-house (group A) and referred (group B) post cataract surgery endophthalmitis were analyzed. The management protocol was similar in both groups.

Results

The time to report to the institute was longer in group B (group B 13.63 [±11.67; 95% CI, 9.95–17.31] days; group A 6.83 [±7.61; 95% CI, 4.57–9.09] days; P = 0.002). The average inflammatory scores in presentation were comparable (group A 17.85 ± 5.83; group B 18.18 ± 7.35; P = 0.243). The final visual outcome was clinically superior in group A (≥20/200-group A 60.42% and group B 44%, P = 0.11; ≤20/400-group A 37.5% and group B 52%, P = 0.62), but statistically not significant. There were more gram-positive organisms in group A (62% vs 38%; P = 0.027) and more gram-negative organisms in group B (52% vs 24%; P = 0.007). Gram-positive bacteria were mostly sensitive to vancomycin (95.24% to 96.67%), but gram-negative bacteria were partly sensitive to ceftazidime (58.33% to 64%).

Conclusions

One could suspect gram-negative infection more often in the referred cases of endophthalmitis. While vancomycin could continue to be the antibiotic of choice in gram-positive bacteria, specific antibiotic following due sensitivity for gram-negative bacteria should replace the empiric use of ceftazidime.

Chronic post-operative iris prosthesis endophthalmitis in a patient with traumatic aniridia: a case report

Background

Post-operative endophthalmitis is a serious complication of intraocular surgery which may present acutely or chronically. Chronic post-operative endophthalmitis is characterized by decreased visual acuity, mild pain, and low-grade uveitis several weeks or months after intraocular surgery which may be responsive to corticosteroids, but recur upon tapering. Low virulence organisms such as Propionibacterium acnes are the most common culprit organisms, and treatment most often consists of both intravitreal antibiotic injections and surgery.

Aniridia is a condition defined by total or partial loss of the iris and leads to decreased visual quality marked by glare and photophobia. Treatment of complex or severe cases of traumatic aniridia in which surgical repair is difficult may consist of implantation of iris prostheses, devices designed to reduce symptoms of aniridia.

Though chronic, post-operative endophthalmitis has been associated with most intraocular surgeries including intraocular lens implantation after cataract removal, it has never been described in a patient with an iris prosthesis.

Case Presentation

In this case report, we describe the case of a 49 year old, male construction worker with traumatic aniridia who experienced chronic, recurrent low-grade intraocular inflammation and irritation for months after implantation of the Ophtec 311 prosthetic iris. Symptoms and signs of inflammation improved temporarily with sub-Tenon’s capsule triamcinolone injections. Ultimately after more than 2 post-operative years, the iris prosthesis was explanted, and intravitreal cultures showed P. acnes growth after 5 days. Intravitreal antibiotics treated the infection successfully.

Conclusions

To our knowledge, this is the first reported case of chronic, post-operative endophthalmitis in a patient with an iris prosthesis. Chronic, post-operative endophthalmitis may be a difficult to identify in the context of traumatic aniridia and iris prosthesis implantation due to other potential etiologies of chronic intraocular inflammation such as implant-induced chafing. Clinicians should suspect chronic, post-operative endophthalmitis in any case of recurrent, low-grade intraocular inflammation.

MICROBIAL SPECTRUM AND OUTCOMES OF ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION VERSUS PARS PLANA VITRECTOMY

PURPOSE

To compare infectious organisms and visual outcomes of endophthalmitis after intravitreal injection (IVI) with endophthalmitis after pars plana vitrectomy (PPV).

METHODS

Retrospective, comparative, consecutive case series of patients diagnosed with presumed infectious endophthalmitis after IVI of an anti-vascular endothelial growth factor medication or PPV between January 1, 2009, and October 1, 2012, from one center. Main outcome measures were infectious organism and final visual acuity.

RESULTS

Forty-four cases of presumed infectious endophthalmitis (17 culture positive) occurred after IVI and 19 cases (9 culture positive) occurred after PPV. Of note, 56.3% of culture-positive IVI cases were due to bacteria associated with oral flora, primarily Streptococcus species, compared with none in the PPV group (P = 0.01). There was a trend approaching significance for IVI patients to have lost ≥3 lines of visual acuity compared with PPV patients at final follow-up (P = 0.07). Within the IVI group, patients were more likely to have lost ≥6 lines of visual acuity at final follow-up when endophthalmitis was due to an organism associated with oral flora (P = 0.007).

CONCLUSION

Endophthalmitis after IVI has a higher likelihood of being due to oral flora compared with endophthalmitis after PPV. Among IVI patients, worse visual outcomes occurred when endophthalmitis was due to oral flora.

Refractive outcomes in nanophthalmic eyes after phacoemulsification and implantation of a high-refractive-power foldable intraocular lens

PURPOSE

To evaluate the refractive and postoperative outcomes of a high-power foldable intraocular lens (IOL) in nanophthalmic eyes.

SETTING

Six ophthalmic surgical centers in Canada.

DESIGN

Retrospective case series.

METHODS

Consecutive charts of nanophthalmic patients having cataract extraction and insertion of the CT Xtreme D IOL were reviewed. Demographic and clinical data were collected, including age, sex, axial length (AL), minimum keratometry (K) value and maximum K value, corneal white-to-white (WTW), anterior chamber depth, lens thickness (LT), and complications. The following preoperative and operative data were collected: uncorrected distant visual acuity (UDVA), corrected distant visual acuity (CDVA), sphere, cylinder, and spherical equivalence (SE). The primary outcome measure was change in SE. The secondary outcome measures were changes in UDVA and CDVA.

RESULTS

A total of 21 eyes from 13 patients with a mean follow-up time of 9.6 ± 8.5 months were studied. Mean preoperative data were: age (51.4 ± 15.2 years), AL (16.63 ± 0.68 mm), minimum K value (46.20 ± 2.26 D), maximum K value (47.55 ± 2.34 D), anterior chamber depth (2.60 ± 0.49 mm), WTW (11.08 ± 1.38 mm), LT (4.70 ± 0.97 mm), and IOL power implanted (+49.9 ± 3.3 diopters [D]). SE improved from +16.11 ± 3.26 D preoperatively to +2.00 ± 2.37 D postoperatively (P < .0001). UDVA improved from 1.47 ± 0.30 logMAR preoperatively to 0.74 ± 0.43 logMAR postoperatively (P = .016). CDVA did not change significantly. Five eyes (23.8%) had serious postoperative complications. Of these eyes, 2 had malignant glaucoma, 2 had vitreous hemorrhages, and 1 eye had a vitreous hemorrhage with retinal detachment resulting in visual acuity of no light perception.

CONCLUSION

Implanting foldable high-power IOLs in a series of nanophthalmic eyes yielded significant improvement in UDVA and SE. Cataract surgery in these eyes carries increased risk.

FINANCIAL DISCLOSURE

Iqbal Ike K. Ahmed is a consultant to Carl Zeiss Meditec AG. No other author has a financial or proprietary interest in any material or method mentioned.

Survey of Intraocular Antibiotics Prophylaxis Practice after Open Globe Injury in China

Purpose

To elucidate the Chinese practice of intraocular antibiotics administration for prophylaxis after open globe injury.

Methods

A cross-sectional questionnaire survey was performed online by scanning a Quickmark (QR) code with smartphones at the 20^th Chinese National Conference of Ocular Trauma in November 2014.

Results

A total of 153 (30.6%) of all participators at the conference responded. Of the respondents, 20.9% were routinely administered with prophylactic intraocular injection of antibiotics at the conclusion of the primary eye repair, and 56.9% were used only in cases with high risk of endophthalmitis development. The intraocular route of delivery was mainly included with intracameral injection (47.9%) and intravitreal injection (42.0%). Cephalosporins (53.8%) and vancomycin (42.0%) were the main choices of antibiotic agents, followed by fluoroquinolones (24.3%), and aminoglycosides (13.4%). Only 21.9% preferred a combination of two or more two drugs routinely. In addition, significantly more respondents from the referral eye hospital (92.7%) replied using intraocular antibiotics injection for prophylaxis compared to those respondents from the primary hospital (69.4%) (p = 0.001, Fisher’s exact test).

Conclusions

Intraocular antibiotics injection for post-traumatic endophthalmitis prophylaxis is widely used in China. However, the choice of antibiotic agents and the intraocular route of delivery vary. A well-designed clinical trial is needed to establish a standardized protocol of intraocular antibiotics administration for post-traumatic endophthalmitis prophylaxis.

Current Perspectives of Prophylaxis and Management of Acute Infective Endophthalmitis

Endophthalmitis is an intraocular inflammatory condition which may or may not be caused by infective agents. Noninfectious (sterile) endophthalmitis may be attributable to various causes including postoperative retained soft lens matter or toxicity following introduction of other agents into the eye. Infectious endophthalmitis is further subdivided into endogenous and exogenous. In endogenous endophthalmitis there is hematogenous spread of organisms from a distant source of infection whereas in exogenous endophthalmitis direct microbial inoculation may occur usually following ocular surgery or penetrating eye injury with or without intraocular foreign bodies. Acute infective endophthalmitis is usually exogenous induced by inoculation of pathogens following ocular surgery, open-globe injury and intravitreal injections. More infrequently the infective source is internal and septicemia spreads to the eye resulting in endogenous endophthalmitis. Several risk factors have been implicated including immunosuppression, ocular surface abnormalities, poor surgical wound construction, complicated cataract surgery with vitreous loss and certain types of intraocular lens. Comprehensive guidelines and recommendations on prophylaxis and monitoring of surgical cases have been proposed to minimize the risk of acute endophthalmitis. Early diagnosis and prompt management of infective endophthalmitis employing appropriately selected intravitreal antibiotics are essential to optimize visual outcome.

Bleb-related infection revisited: a literature review

Bleb-related infection (BRI) is one of the serious complications of glaucoma filtering surgery. This literature review is aimed at the evaluation of recent studies related to BRI. The review presented and discussed risk factors, and clinical and laboratory diagnosis emphasizing advances in diagnostic techniques to detect and distinguish the disease as well as to initiate immediate intensive antibacterial treatment. Clinical features of recognized prognostic factors of visual outcome were also presented. The studies showed that the prognosis of blebitis is usually good, unless infection has progressed to endophthalmitis that would signify a poorer prognosis. Despite prompt and intensive treatment of patients with bleb-related endophthalmitis, the outcomes remain unsatisfactory especially with virulent organisms and low initial visual acuity. It has been recommended that early detection and treatment of risk factors and thorough patient education are indispensable in ensuring best prognosis in post-trabeculectomy patients.

Conjunctival and intraocular swabs for the microbiological assessment of donor corneas

PURPOSE

In this study, we investigated the associations between conjunctival (co) and intraocular (io) swabs and their implications for the contamination rates of organ-cultured corneas.

METHODS

A total of 4177 swabs from 1054 corneas of 527 donors were acquired from the conjunctiva, after disinfection with 5% polyvinylpyrrolidone-iodine solution, and also from the anterior chamber after corneoscleral trepanation (io). Samples were incubated at 22.5 ± 2.5°C and 32.5 ± 2.5°C in thioglycollate broth for 14 days. Donor corneas were cultured in a closed system at 31°C. Microbial differentiation was performed for positive cultures.

RESULTS

A higher temperature (32.5°C) and the intraocular swab retrieving localization led to significantly higher swab positive rates (32.5°C versus 22.5°C, odds 1.65, p < 0.0001; io versus co, odds 1,53, p < 0.0001). Death-to-collection time and laterality (left or right eye) had no significant influence on swab positivity. The cause of death significantly influenced the positive rates (p < 0.0001). Detection at 32.5°C occurred significantly earlier than at 22.5°C (p < 0.0001). The overall comparison of detected species showed no significant differences in the variety between intraocular and conjunctival swabs. During the study period, six contaminations of organ-cultured corneas occurred: four times Pseudomonas aeruginosa and once each Candida albicans and Staphylococcus hominis were found. Swap results and cornea contaminations were not significantly correlated.

CONCLUSIONS

Co and io swabs show high microbial colonization rates, even after standard disinfection. Io swabs generally reproduce the co microbial range, most likely due to a mobilization and diversion of microorganisms during the trepanation procedure. Swab results do not yield a valuable tool to predict contaminations of organ-cultured corneas.

Morphological features in eyes with endophthalmitis after cataract surgery - histopathology and optical coherence tomography assessment

PURPOSE

To assess the ocular damage that occurs in eyes with postoperative endophthalmitis after cataract surgery (PE) based on optical coherence tomography (OCT) retinal scans of PE eyes and histological specimens of eyes removed due to PE.

METHODS

Case-control study and case series. Fifty-one patients who had previously developed PE were clinically examined with OCT scans of the retina of both eyes. Histological specimens of 10 removed PE eyes were studied.

RESULTS

The OCT scans showed that PE eyes had a statistically significantly higher frequency of hyperdense elements on the internal limiting membrane (ILM) of the retina (14 eyes versus 3 eyes, p = 0.015) and a higher degree of retinal atrophy temporal to the fovea (13 eyes versus 1 eye, p = 0.013) compared to fellow eyes. The histopathological analyses showed the formation of epiretinal membranes, derangement of all retinal layers with a reduced number of nuclei in the nuclear layers, loss of photoreceptor outer segments and massive retinal gliosis.

CONCLUSIONS

Optical coherence tomography scans of the retina and histopathology analyses provide insights in the pathological process occurring in PE.

Endophthalmitis following intravitreal injection of anti-VEGF agents: long-term outcomes and the identification of unusual micro-organisms

Background

While the development of targeted molecular therapy to inhibit vascular endothelial growth factor (VEGF) has revolutionized the treatment and visual prognosis of highly prevalent retinal diseases such as diabetic retinopathy and age-related macular degeneration, each intravitreal injection of these agents carries a small risk of endophthalmitis which can be visually devastating. In the absence of specific guidelines, current management of post-injection endophthalmitis is typically extrapolated from data regarding endophthalmitis occurring after cataract surgery despite potential differences in pathogenic organisms and clinical course. Here, we assess the contribution of intravitreal injections of anti-VEGF agents to all cases of endophthalmitis at our tertiary care referral center and characterize the clinical outcomes and microbial pathogens associated with post-injection endophthalmitis in order to inform management of this serious iatrogenic condition.

Results

During the 7-year study period analyzed, 199 cases of endophthalmitis were identified using billing records. Of these, the most common etiology was post-surgical, accounting for 62 cases (31.2 %), with bleb-associated, endogenous, and corneal ulcer-related infections representing the next most frequent causes, comprising 15.6 % (31/199), 13.1 % (26/199), and 13.6 % (27/199) of all cases, respectively. Intravitreal injections of anti-VEGF agents represented 8.5 % of endophthalmitis (17/199 cases). Intraocular cultures yielded positive results in 75 % of post-injection cases, with the majority associated with coagulase-negative Staphylococcus. Consistent with prior literature, a case of Strep viridans displayed more rapid onset and progression. We also report the first association of Enterobacter cloacae and Lactococcus garvieae with post-injection endophthalmitis. While all but one patient were treated with initial vitreous tap and intravitreal injection of antibiotics, both patients with these rare organisms exhibited persistent vitritis requiring subsequent vitrectomy. Long-term outcomes of post-injection endophthalmitis indicated visual recovery to baseline levels, even with resumption of anti-VEGF agents following resolution of the acute infection.

Conclusions

Acute endophthalmitis following intravitreal injections of anti-VEGF agents is an uncommon but potentially devastating complication which may be managed effectively with vitreous tap and injection of intravitreal antibiotics. However, persistent vitritis requiring subsequent vitrectomy should raise suspicion for unusual pathogens.

Staphylococcus aureus and its Bearing on Ophthalmic Disease

PURPOSE

To review antibiotic resistance associated with S. aureus endophthalmitis and the virulence of S. aureus.

METHODS

Review of the current and prospective approaches for treating S. aureus endophthalmitis.

RESULTS

Bacterial endophthalmitis remains to be a major threat for vision. S. aureus endophthalmitis specifically, carries a poor visual prognosis making early diagnosis and treatment crucial. Methicillin resistant Staphylococcus aureus (MRSA) endophthalmitis represents a significant number of S. aureus endophthalmitis cases. MRSA with reduced susceptibility to glycopeptide antibiotics such as vancomycin (vancomycin intermediate S. aureus, VISA) have also emerged in the ocular infections, and there has been a rise in S. aureus resistance to new and old generation fluoroquinolones that are commonly used for prophylaxis after intravitreal injections and intraocular surgeries.

CONCLUSIONS

With the rise in the number of penetrating procedures in the ophthalmology practice and the parallel rise in antibiotic resistance, prophylaxis and awareness of the antimicrobial resistance profiles remain crucial and the identification of novel antimicrobials is essential.

A Prospective Study on the Clinical and Microbiological Spectrum of Endophthalmitis in a Specific Region in Denmark

PURPOSE

To study the clinical and microbiological spectrum of endophthalmitis with emphasis on clinical features, visual outcomes and risks of surgical complications.

METHODS

A prospective observational study was conducted between 2012 and 2013 in a specific region in Denmark. Patients were clinically examined before, during and after surgical intervention for endophthalmitis.

RESULTS

Fifty eyes with endophthalmitis were included. Endophthalmitis after cataract surgery (post-cataract), anti-VEGF (vascular endothelial growth factor) intravitreal injections (post-injection) and cases of endogenous endophthalmitis were responsible for 40, 28 and 18% of all cases, respectively. There was no difference in the microbiological spectrum in post-cataract patients and post-injection patients, but patients with post-cataract endophthalmitis presented statistically significantly more frequently with hypopyon and fibrin in the anterior chamber. Between 20 and 25% of post-cataract and post-injection endophthalmitis patients developed a surgical complication after primary surgical intervention for endophthalmitis, and this was statistically significantly associated with a poor visual outcome. There was no statistically significant difference in the risk of surgical complications in phakic and pseudophakic eyes with post-injection endophthalmitis. Of the 8 patients with endogenous endophthalmitis, 67% developed a surgical complication, and these patients had a high mortality. The visual outcome in the most common types of endophthalmitis was good, with 60% of post-cataract patients achieving a visual outcome ≥ 0.5, and 64% of post-injection patients only had a mild vision loss (1-14 ETDRS letters) or even gained vision.

CONCLUSIONS

The endophthalmitis cases had a broad clinical spectrum. Surprisingly, endogenous endophthalmitis accounted for almost one fifth of all cases. Patients with post-cataract endophthalmitis had a clinically different presentation than patients with post-injection endophthalmitis. In general, the bacteria were low-virulent and the visual outcomes good, but a substantial part of the patients developed a surgical complication which was associated with a poor visual outcome.

ENDOPHTHALMITIS CAUSED BY PSEUDOMONAS AERUGINOSA: Clinical Features, Antibiotic Susceptibilities, and Treatment Outcomes

PURPOSE

To report the clinical features, antibiotic susceptibilities, and visual outcomes associated with endophthalmitis caused by Pseudomonas aeruginosa.

METHODS

A consecutive case series. Microbiology database records were retrospectively reviewed for all patients with endophthalmitis caused by P. aeruginosa from January 1, 2002, to December 31, 2012, at a large university referral center. The corresponding clinical records were then reviewed to evaluate the endophthalmitis clinical features and treatment outcomes.

RESULTS

In the 12 patients identified, clinical settings included postcataract surgery (n = 4), postpenetrating keratoplasty (n = 3), endogenous source (n = 2), post-pars plana vitrectomy (n = 1), trabeculectomy bleb-associated setting (n = 1), and glaucoma drainage implant-associated setting (n = 1). All patients presented with hypopyon. Presenting visual acuity was hand motions or worse in all cases. All isolates were susceptible to ceftazidime and levofloxacin. When comparing isolates in this study with isolates from a previous study (1987 to 2001), the minimal inhibitory concentration required to inhibit 90% of isolates (MIC 90, in micrograms per milliliter) remained the same for ceftazidime (8), ciprofloxacin (0.5), imipenem (4), tobramycin (0.5), and amikacin (4). Initial treatment strategies were vitreous tap and injection (n = 9) and pars plana vitrectomy with intravitreal antibiotics (n = 3). Final visual acuity was light perception or worse in 11 of the 12 patients (92%). Five patients underwent enucleation (42%).

CONCLUSION

All isolates were susceptible to ceftazidime and levofloxacin, and all MIC 90s for isolates in the current period compared with isolates from 1987 to 2001 remained identical. Despite early and appropriate treatment, outcomes were generally poor with a high rate of enucleation.

Benefits and risks of immediately sequential bilateral cataract surgery: a literature review

Immediately sequential bilateral cataract surgery (ISBCS) is a highly contended issue in ophthalmology, mainly due to the risk of bilateral endophthalmitis and financial penalties that many ophthalmologists face when performing simultaneous cataract surgeries. The purpose of this review is to understand the current status of the knowledge of ISBCS, mainly its benefits and risks and how they compare with the standard of care, delayed sequential bilateral cataract surgery. Evidence, although limited, increasingly supports ISBCS for providing faster rehabilitation, improved visual outcomes, and cost and time savings. Evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure. However, stronger and greater evidence is needed before ISBCSs can be considered the standard of care. Where ISBCS can potentially create the most beneficial impact is in public eye health programmes in developing countries, but this has not yet been explored.

Vitreoretinal complications of the Boston Keratoprosthesis

The Boston Keratoprosthesis has allowed for visual restoration in patients with corneal blindness; however, vitreoretinal complications remain a significant cause of ocular morbidity. Retroprosthetic membranes, infectious endophthalmitis, sterile vitritis, vitreous hemorrhage, vitreous opacities, retinal detachment, cystoid macular edema, choroidal detachments, retinal vascular occlusion, and epiretinal membrane have all been described, may require the intervention of a vitreoretinal specialist, and are reviewed herein. A strong familiarity with associated posterior segment complications is important to maximizing patient outcomes.

Clinical features of infectious endophthalmitis in South Korea: a five-year multicenter study

BACKGROUND

To investigate clinical features of infectious endophthalmitis over five years in a South Korean population.

METHODS

Medical records of consecutive patients diagnosed with infectious endophthalmitis at eight institutions located in Gyeongsangnam-do and Pusan city between January 1, 2004 and July 31, 2010 were reviewed.

RESULTS

A total of 197 patients were diagnosed and treated. An average of 30.0 infectious endophthalmitis per year was developed. The annual incidence rate of postoperative endophthalmitis during 2006~2009 was 0.037%. The ratios of male to female and right to left were 50.2%: 49.8 % and 54.8%: 43.2%, respectively. Eighth decade and spring were the peak age (36.6%) and season (32.0%) to develop the infectious endophthalmitis. The most common past history in systemic disease was hypertension (40.4%), followed by diabetes (23.4%). Cataract operation (60.4%) was the most common cause, among which most of them was uneventful phacoemulsification (95.9%). Corneal laceration (51.6%) and liver abscess (42.9%) were the most common causes of traumatic and endogenous endophthalmitis, respectively. The percentages of patients with initial and final visual acuity less than counting fingers were 62.6% and 35.2%, respectively. Treatment with vitrectomy with or without intravitreal antibiotics injection was administered to 72.6% of patients, while 17.3% received intravitreal antibiotics only.

CONCLUSIONS

Our study revealed that the development of infectious endophthalmitis was related with seasonal variation and increased during our study period. Pars plana vitrectomy was preferred for the treatment of infectious endophthalmitis in South Korea.

Bacterial and fungal endophthalmitis in upper Egypt: related species and risk factors

OBJECTIVE

To study risk factors, contributing factors of bacterial and fungal endophthalmitis in Upper Egypt, test the isolated species sensitive to some therapeutic agents, and to investigate the air-borne bacteria and fungi in opthalmology operating rooms.

METHODS

Thirty one cases of endophthalmitis were clinically diagnosed and microbiologically studied. Indoor air-borne bacteria and fungi inside four air-conditioned operating rooms in the Ophthalmology Department at Assiut University Hospitals were also investigated. The isolated microbes from endophthalmitis cases were tested for their ability to produce some extracellular enzymes including protease, lipase, urease, phosphatase and catalase. Also the ability of 5 fungal isolates from endophthalmitis origin to produce mycotoxins and their sensitivity to some therapeutic agents were studied.

RESULTS

Results showed that bacteria and fungi were responsihle for infection in 10 and 6 cases of endophthalmitis, respectively and only 2 cases produced a mixture of bacteria and fungi. Trauma was the most prevalent risk factor of endophthalmitis where 58.1% of the 31 cases were due to trauma. In ophthalmology operating rooms, different bacterial and fungal species were isolated. 8 bacterial and 5 fungal isolates showed their ability to produce enzymes while only 3 fungal isolates were able to produce mycotoxins. Terbinafine showed the highest effect against most isolates in vitro.

CONCLUSIONS

The ability of bacterial and fungal isolates to produce extracellular enzymes and mycotoxins may be aid in the invasion and destruction of eye tissues. Microbial contamination of operating rooms with air-borne bacteria and fungi in the present work may be a source of postoperative endophthalmitis.

Endophthalmitis: state of the art

Endophthalmitis is an uncommon diagnosis but can have devastating visual outcomes. Endophthalmitis may be endogenous or exogenous. Exogenous endophthalmitis is caused by introduction of pathogens through mechanisms such as ocular surgery, open-globe trauma, and intravitreal injections. Endogenous endophthalmitis occurs as a result of hematogenous spread of bacteria or fungi into the eye. These categories of endophthalmitis have different risk factors and causative pathogens, and thus require different diagnostic, prevention, and treatment strategies. Novel diagnostic techniques such as real-time polymerase chain reaction (RT-PCR) have been reported to provide improved diagnostic results over traditional culture techniques and may have a more expanded role in the future. While the role of povidone-iodine in prophylaxis of postoperative endophthalmitis is established, there remains controversy with regard to the effectiveness of other measures, including prophylactic antibiotics. The Endophthalmitis Vitrectomy Study (EVS) has provided us with valuable treatment guidelines. However, these guidelines cannot be directly applied to all categories of endophthalmitis, highlighting the need for continued research into attaining improved treatment outcomes.

Surface modification of intraocular lenses with hyaluronic acid and lysozyme for the prevention of endophthalmitis and posterior capsule opacification

Posterior capsule opacification is one of the complications of cataract surgery caused by the adhesion and reproduction of residual human lens epithelial cells (HLECs) on the posterior capsule.

In vitro antimicrobial analysis of aqueous humor after topical application of moxifloxacin hydrochloride 0.5%

PURPOSE

To evaluate the in vitro antimicrobial activity of aqueous humor in patients who had preoperative topical application of moxifloxacin hydrochloride 0.5%.

SETTING

Department of Ophthalmology, Santa Casa de Misericórdia de São Paulo, Brazil.

DESIGN

Comparative case series.

METHODS

Twenty-nine eyes from 29 cataract surgery patients were included in this study. In the study group (n = 15 eyes), 3 topical applications of moxifloxacin hydrochloride 0.5% were administered preoperatively; in the control group (n = 14 eyes), no topical applications were administered. Aqueous humor samples were collected and stored in sterile microtubes at -80°C until analysis. Antimicrobial analysis was performed using standard strains with standard sterile filter paper disks. Inhibition halos were measured in millimeters, and both bactericidal and bacteriostatic effects were analyzed.

RESULTS

Inhibition halos were observed on most of the study group plates except those with Streptococcus pneumoniae: Escherichia coli (13.93 mm ± 0.64 [SD]), Klebsiella pneumoniae (10.63 ± 0.61 mm), Staphylococcus aureus (7.47 ± 0.68 mm), and S epidermidis (4.20 ± 3.33 mm) The differences between the mean inhibition halo diameters were statistically significant (P < .0001) in all samples. No bactericidal effect was observed against any of the microorganisms studied.

CONCLUSIONS

After topical application of moxifloxacin 0.5%, aqueous humor showed bacteriostatic effect against E coli, K pneumoniae, S aureus, and S epidermidis. No bactericidal effect was observed against any of the microorganisms evaluated. No antimicrobial effect against S pneumoniae was observed.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Post-operative endophthalmitis caused by Acremonium falciforme with orbital and extra-orbital involvement following combined cataract and glaucoma surgery: a case report

Introduction

In this report, we describe an unusual case of post-operative Acremonium falciforme endophthalmitis with orbital and extra-orbital involvement following combined cataract and glaucoma surgery.

Case presentation

A 68-year-old Caucasian man with glaucoma presented with endophthalmitis characterized by pain, redness and impaired vision in the left eye fifteen days after combined cataract and filtering surgery. He subsequently underwent a pars plana vitrectomy, with vitreous sampling, silicone oil placement and intra-vitreal injection of antibiotics, but only after a second vitrectomy we identified Acremonium falciforme as the causative agent for the endophthalmitis. An antifungal systemic and topical therapy was started, but meanwhile the infection extended to orbital and peri-orbital tissues. Following these procedures, even if the eye went slowly in phthisis, we were able to limit the further extension and circumscribe the orbital and extra-orbital involvement.

Conclusion

To our knowledge, this report is the first describe Acremonium falciforme endophthalmitis with orbital and extra-orbital involvement, following anterior segment combined surgery. Ophthalmologists and physicians should be aware of the extension risk of a fungal panophthalmitis, but also to potentially serious side effects related to systemic therapy.

Endophthalmitis following pars plana vitrectomy: a literature review of incidence, causative organisms, and treatment outcomes

Endophthalmitis following pars plana vitrectomy is a very uncommon cause of endophthalmitis. Cases reported over the last decade show a decrease in incidence over time. To optimize visual outcome, early diagnosis and treatment are essential. In this review we report a summary of the incidence of endophthalmitis following vitrectomy, various risk factors for their occurrence, the microbiological profile and the visual outcomes post treatment.

Endophthalmitis after penetrating keratoplasty

PURPOSE

To determine the incidence of endophthalmitis after penetrating keratoplasty (PK) and patient and donor risk factors.

DESIGN

Retrospective cohort study using national transplant registry data.

PARTICIPANTS

All corneal transplant recipients (n = 11 320) registered on the United Kingdom Transplant Registry undergoing their first PK between April 1999 and December 2006.

METHODS

Patients who developed endophthalmitis were identified on the transplant registry. In addition, cases where the fellow cornea from the same donor had been transplanted were included. Clinical information regarding donor and recipient characteristics, surgical details, and postoperative outcomes were collected and analyzed. In cases where endophthalmitis was reported, the diagnosis was verified by a follow-up supplementary questionnaire to the surgeon. Logistic regression was used to investigate differences in the factors associated with the development of endophthalmitis.

MAIN OUTCOME MEASURES

Incidence of endophthalmitis and graft survival.

RESULTS

The overall incidence of endophthalmitis occurring after primary PK in the UK was 0.67%. The incidence of endophthalmitis occurring within 6 weeks of surgery was 0.16%. Graft survival after endophthalmitis was 27% (95% confidence interval, 16-38) at 5 years, with a mean best-corrected visual acuity of 1.13 (logarithm of the minimum angle of resolution) for surviving grafts. Factors associated with endophthalmitis were donor cause of death (infection), high-risk cases, and indication for corneal transplantation.

CONCLUSION

Endophthalmitis remains a serious issue, with those affected having reduced graft survival and poor visual outcomes. Management of the identified recipient and donor risk factors are important to reduce endophthalmitis risk. In particular, the increased incidence of endophthalmitis when the donor dies of infection requires further explanation and review of current donor eye retrieval and eye bank practices. The delayed presentation of endophthalmitis cases also raises questions regarding possible sequestration of microbes within the corneal tissue and the effect of antimicrobials in storage media.

Endophthalmitis and severe blebitis following trabeculectomy. Epidemiology and risk factors; a single-centre retrospective study

PURPOSE

To study the epidemiology and risk factors of early- and late-onset postoperative endophthalmitis (PE) and severe blebitis following trabeculectomy.

METHODS

Retrospective, single-centre, observational study with a case-control design in part. Patients sustaining PE and severe blebitis following trabeculectomy or a combined trabeculectomy with a cataract extraction procedure performed from 1990 through 2008 and diagnosed from 1990 through 2012 were recorded at St Erik Eye Hospital. Incidence data were calculated with help from the hospital records. Notes data of cases and of six randomly selected but procedure matched control patients for each case were compared.

RESULTS

The joint rate of infection was 0.46% or 34 incidents in 7402 procedures. The frequency of early (occurring <6 weeks after surgery) onset PE was 0.19%, late PE was 0.19% and severe blebitis was 0.08%. Dominating aetiologies were staphylococci and streptococci. Overall, the infection severely impaired the visual function. Combined cataract and fistulating operations were less prone to develop late infections, p = 0.04, but no other decisive factors were identified in the case-control study. Data collection for all trabeculectomy surgeries from 1998 and onward identified an increased rate for late infection with the use of mitomycin C (MMC), 8 in 1171 surgeries or 0.7%, versus no such use, 0 case of late PE in 2136 surgeries, p < 0.001.

CONCLUSIONS

Postoperative endophthalmitis is a devastating complication after trabeculectomy. The use of MMC increases the risk for delayed infection. Early PE after trabeculectomy is clearly more common than PE after cataract surgery. Developing efficacious prophylactic antibiotic regimens to reduce early PE after penetrating filtering procedures should be a major priority in ophthalmic surgery.

Pediatric infectious endophthalmitis: a review

Infectious endophthalmitis is a rare but severe complication of septecemia, intraocular surgeries, or penetrating eye trauma. The etiology, prognosis, and management of pediatric endophthalmitis resulting from exogenous and endogenous infections are reviewed. Open-globe trauma and glaucoma surgery are the most frequent causes of endophthalmitis in children, whereas endogenous infection is the least common cause. Streptococcus and Staphylococcus species are common bacterial agents in both posttraumatic and postoperative pediatric endophthalmitis, whereas Candida albicans is a commonly reported organism in endogenous endophthalmitis. Additionally, Streptococcus pneumoniae and Haemophilus influenzae appear more likely as pathogens in children than in adults. The clinical manifestations and outcome usually correlate with the virulence of the infecting organism. The visual prognosis of endophthalmitis is generally poor.

Microbiological spectrum and antibiotic sensitivity in endophthalmitis: a 25-year review

PURPOSE

To identify the spectrum and susceptibility pattern of pathogens responsible for culture-positive endophthalmitis referred to a single institution and investigate possible trends in both pathogens and antibiotic sensitivities over the past 25 years.

DESIGN

A retrospective, laboratory-based study of consecutive microbiological isolates.

PARTICIPANTS

A total of 988 consecutive culture-positive endophthalmitis isolates from 911 eyes.

METHODS

All culture-positive endophthalmitis isolates collected from 1987 to 2011 were identified. Susceptibility rates to a variety of antibiotics were calculated. Chi-square test for trend was used to detect changes in spectrum or susceptibility over time.

MAIN OUTCOME MEASURES

Microbial spectrum and susceptibility pattern over time.

RESULTS

A total of 988 isolates were identified from 911 eyes. The average patient age was 67 ± 18 years, and 55% of the patients were female. The most prevalent pathogens were coagulase-negative staphylococcus (39.4%), followed by Streptococcus viridans species (12.1%) and Staphylococcus aureus (11.1%). Gram-negative organisms and fungi accounted for 10.3% and 4.6% of all isolates, respectively. With the exception of 2 isolates, Enterococcus faecium and Nocardia exalbida, all the other 725 (99.7%) gram-positive bacteria tested were susceptible to vancomycin. Of the 94 gram-negative organisms tested against ceftazidime, 2 were of intermediate sensitivity and 6 were resistant. For 8 antibiotics, increasing microbial resistance over time was observed: cefazolin (P = 0.02), cefotetan (P = 0.006), cephalothin (P<0.0001), clindamycin (P = 0.04), erythromycin (P<0.0001), methicillin/oxacillin (P<0.0001), ampicillin (P = 0.01), and ceftriaxone (P = 0.006). For 3 antibiotics, increasing microbial susceptibility was observed: gentamicin (P<0.0001), tobramycin (P = 0.005), and imipenem (P<0.0001).

CONCLUSIONS

Coagulase-negative staphylococcus remains the most frequently identified cause of endophthalmitis. Vancomycin and ceftazidime seem to be excellent empiric antibiotics for treating endophthalmitis. Although a statistically significant trend toward increasing microbial resistance against a variety of antibiotics, including cephalosporins and methicillin, was observed, a significant trend toward decreasing microbial resistance against aminoglycosides and imipenem also was detected.