Endophthalmitis: Changes in Presentation, Management and the Role of Early Vitrectomy

Successful management of drug-resistant rhizobium radiobacter endophthalmitis: A case report

PurposeTo report a unique case of post-cataract surgery endophthalmitis caused by Ceftazidime-resistant Rhizobium radiobacter, successfully managed with timely vitrectomy and intravitreal LevofloxacinCase reportA healthy 73-year-old man underwent phacoemulsification and posterior chamber intraocular lens implantation in his left eye. Postoperative ocular examination (OE) one day after the surgery revealed no specific findings. However, on postoperative day 6, he presented with a painful and red left eye. Diagnosed with postoperative endophthalmitis on day 8 at another hospital, he received IVI of Ceftazidime and Vancomycin before being urgently referred to our hospital on the same day. Early vitrectomy and anterior chamber irrigation were performed timely when he arrived on day 8, with cultures identifying Ceftazidime-resistant Rhizobium radiobacter, sensitive to Levofloxacin. Repeated IVI of Levofloxacin (500 mcg/0.1 ml) ensued on post-cataract operative days 13 and 18. Six months post-cataract surgery, the corrected distance visual acuity of the left eye stabilized at 20/33, and OE remained stable.ConclusionEarly vitrectomy and vitreous culture prove effective in managing postoperative endophthalmitis in drug-resistant Rhizobium radiobacter. IVI of Levofloxacin, though rare, proved to be effective in treating Ceftazidime-resistant and Levofloxacin-sensitive pathogens in our case.

Clinical Features Associated With Return to Pre-endophthalmitis Visual Acuity Following Presumed Infectious Endophthalmitis

BACKGROUND AND OBJECTIVE

This study aimed to investigate clinical characteristics associated with return to pre-endophthalmitis visual acuity (VA) following treatment for presumed infectious endophthalmitis.

PATIENTS AND METHODS

This was a retrospective study of 74 eyes with endophthalmitis and VA recorded ≤ 12 weeks before presentation and 6 months after presentation between 2009 and 2018.

RESULTS

Thirty-six of 74 eyes (49%) returned to preendophthalmitis VA. Eyes with a positive intraocular fluid culture had 71.5% lower odds of returning to pre-endophthalmitis VA. Nine of 10 eyes (90%) treated with initial pars plana vitrectomy failed to return to pre-endophthalmitis VA. Endophthalmitis following cataract surgery was a characteristic of eyes that returned to pre-endophthalmitis VA. Symptom duration, time to presentation, and treatment with systemic corticosteroids were not significant predictors of visual recovery.

CONCLUSION

Just under 50% of eyes with presumed infectious endophthalmitis returned to preendophthalmitis VA. A positive intraocular culture is associated with failure to return to pre-endophthalmitis VA. [Ophthalmic Surg Lasers Imaging Retina 2025;56:145-149.].

Intravitreal Antibiotics versus Early Vitrectomy Plus Intravitreal Antibiotics for Postinjection Endophthalmitis: An IRIS® (Intelligent Research in Sight Registry) Analysis

PURPOSE

To determine if intravitreal injection of antibiotics alone versus early pars plana vitrectomy (PPV) plus injection of intravitreal antibiotics predicted better or worse visual outcomes for patients with endophthalmitis after anti-VEGF injections.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients developing endophthalmitis after receiving an intravitreal anti-VEGF injection from the American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry between 2016 and 2020.

METHODS

Inclusion criteria were endophthalmitis diagnosis within 1 to 28 days after anti-VEGF injection and a recorded visual acuity (VA) at baseline, on the day of diagnosis, and posttreatment. Patients in the Injection Only group underwent intravitreal injection of antibiotics alone and in the Early Vitrectomy group received PPV with intravitreal antibiotics or intravitreal injection followed by PPV within 2 days of diagnosis. Patients were excluded if they had cataract surgery during the study, intravitreal steroids before endophthalmitis, or intermediate/posterior uveitis or cystoid macular edema. The study created a 1:1 matched cohort using Mahalanobis distance matching, accounting for the differences in VA at baseline and diagnosis.

MAIN OUTCOME MEASURES

Posttreatment logarithm of the minimum angle of resolution (logMAR) VA.

RESULTS

A total of 1044 patients diagnosed with postinjection endophthalmitis met the inclusion and exclusion criteria. In the unmatched cohort, there were 935 patients in the Injection Only and 109 in the Early Vitrectomy group. In 1:1 matched cohort, 218 patients (109 in each group) were included; the median logMAR VAs were 0.32 (20/40-20/50) at baseline, 0.88 (∼20/150) at diagnosis, and 0.57 (20/70-20/80) posttreatment. There were no statistically significant differences in the visual outcomes between the 2 matched treatment groups (b = 0.05; P = 0.23); including the subgroup of patients with VA worse than 1.0 logMAR (b = 0.05; P = 0.452).

CONCLUSIONS

There was no significant difference in final VA outcomes between patients receiving Injection Only and those treated with Early Vitrectomy for postinjection endophthalmitis. The findings support the use of either treatment strategy.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Incidence of postoperative retinal detachment and bacterial endophthalmitis in the Swedish national paediatric cataract register and associated risk factors

PURPOSE

To investigate the incidence and risk factors of retinal detachment (RD) and bacterial endophthalmitis in a cohort of children who underwent cataract surgery before the age of eight.

METHODS

Data was retrieved from the Swedish national paediatric cataract register. All eyes with congenital or infantile cataract that underwent surgery between January 1, 2007, and December 31, 2023 with at least one follow-up were included. Cases associated with trauma, uveitis or RD at surgery were excluded. Parameters that could be important for complications were analysed.

RESULTS

RD was found in seven of 1073 eyes reflecting an incidence of 0.65%. There were no statistically significant differences in age at surgery, presences of intellectual disability or general disease, cataract type, surgical technique, axial length, corneal diameter, previous glaucoma surgery or occurrence of persistent fetal vasculature (PFV), although the frequency of glaucoma surgery and PFV was higher in RD cases; 42.9% versus 13.2% and 57.1% versus 26.0%. Aphakia was significantly more common in RD patients; 71.4% versus 19.3% (p = 0.042), as well secondary glaucoma; 57.1% versus 19.5% (p = 0.032). No cases of endophthalmitis were observed.

CONCLUSION

The incidence of RD was low compared to previous studies and no endophthalmitis was found. This might be a result of centralized paediatric cataract care with few but experienced surgeons. Aphakia and secondary glaucoma were associated with higher RD risk and those cases should be followed carefully. PFV and glaucoma surgery were found at a higher frequency in RD cases prompting comprehensive postoperative care also for these children.

Combined pars plana vitrectomy and silicone oil injection for the treatment of acute postoperative infectious endophthalmitis

PURPOSE

To evaluate the efficacy of early pars plana vitrectomy (PPV) and silicone oil (SO) tamponade for treating acute post-phacoemulsification infectious endophthalmitis.

METHODS

This retrospective study included 44 eyes of 44 patients who developed early endophthalmitis after uneventful phacoemulsification. PPV with SO tamponade was performed within 24 h of presentation.

RESULTS

A significant improvement in logMAR visual acuity (VA) was reported in our patients; (2.595 ± 0.249 at baseline compared to 1.052 ± 0.462 at final visit), with P value 0.0001. SO was removed in all cases after 4-9 months (6 ± 1.3) and all patients continued follow-up for at least 6 months after SO removal (15.4 ± 6.5). Postoperative complications included; three eyes (6.8%) developing severe proliferative vitreoretinopathy (PVR), four eyes (9.1%) developing inferior retinal detachment (RD) under SO, Two eyes (4.5%) developing pupillary block glaucoma and two eyes (4.5%) suffered from recurrent RD after SO removal.

CONCLUSION

Early PPV with SO tamponade for the treatment of acute endophthalmitis after phacoemulsification has good visual outcomes and lower complication rates if performed early within 24 h of patient presentation.

Clinical analysis of 101 cases of infectious endophthalmitis

This study aimed to analyze the pathogenesis, clinical features, and treatment of infectious endophthalmitis and provide reference data for its prevention and treatment. The study retrospectively analyzed 101 cases of infectious endophthalmitis patients who received treatment at the Second People's Hospital of Jinan from January 2020 to December 2022, including pathogenic factors, microbiology, treatment, and prognosis of the patients. We found that traumatic endophthalmitis accounted for 48.51% of all cases, with iron foreign bodies being the leading cause of injury, while postoperative endophthalmitis after intraocular surgery accounted for 32.67% of all cases, with cataract surgery being the leading cause. The improvement in posttreatment visual acuity varied significantly among different causes of pathogenesis, with intraocular surgery showing the most improvement. In particular, postcataract surgery endophthalmitis showed better improvement than noncataract surgery-related endophthalmitis. Staphylococcus epidermidis was the main pathogenic bacteria causing infectious endophthalmitis, followed by fungi. Vitrectomy and intravitreal injection were the main treatment methods, with pars plana vitrectomy (PPV) + intravitreal injection (IVT) having a longer treatment time than PPV, IVT, or other approaches. In conclusion, this study provided important reference data for the prevention and treatment of infectious endophthalmitis. Traumatic and postoperative endophthalmitis were the most common causes, with iron foreign bodies and cataract surgery being the main contributors, respectively. The improvement in posttreatment visual acuity varied significantly among different causes of pathogenesis, with postcataract surgery endophthalmitis showing better improvement. Staphylococcus epidermidis was the main pathogenic bacteria causing infectious endophthalmitis, and vitrectomy and intravitreal injection were the main treatment methods.

Endophthalmitis in Eyes Treated with the Port Delivery System with Ranibizumab: Summary of Cases during Clinical Trial Development

PURPOSE

The Port Delivery System with ranibizumab (PDS) is approved in the United States for neovascular age-related macular degeneration. The United States Prescribing Information has a Boxed Warning for endophthalmitis and reports the incidence rate in patients developing endophthalmitis after receiving the PDS compared with monthly intravitreal ranibizumab. Endophthalmitis cases noted in the Boxed Warning, treatment outcomes, potential contributing factors, and potential mitigations are summarized.

DESIGN

Retrospective review of endophthalmitis cases in PDS-treated patients in the phase II Ladder (NCT02510794) and phase III Archway (NCT03677934) and Portal (NCT03683251) trials.

PARTICIPANTS

Endophthalmitis cases in the pooled all-PDS safety population (N = 555) including PDS patients in Ladder, Archway, or Portal.

METHODS

Ladder patients received PDS (10, 40, or 100 mg/ml) with pro re nata refill-exchanges. Archway patients received PDS 100 mg/ml with fixed refill-exchanges every 24 weeks (PDS Q24W). Portal patients received PDS Q24W from day 1.

MAIN OUTCOME MEASURES

Clinical features, management, and visual outcomes were summarized. Cases were summarized by date of PDS implant and/or refill, other prior invasive procedures/refills, and preceding/concurrent conjunctival complications.

RESULTS

Twelve endophthalmitis events were reported in 11 patients (11/555 [2.0%]) through March 12, 2021. All were cultured (3 were culture positive) and treated with intravitreal antibiotics. Two cases (2/555 [0.4%]) occurred in the immediate postoperative period (days 5 and 6). Nine cases occurred later (day range: 57-853), including 4 before the first refill-exchange (day range: 57-161). Five patients received between 1 and 11 refill-exchanges before the event (onset: 6-168 days after last refill-exchange). Seven cases (7/11 [63.6%]) had preceding/concurrent conjunctival complications. At last follow-up, 7 patients recovered vision to study baseline levels or ≥20/40; 4 patients experienced vision loss of ≥15 ETDRS letters.

CONCLUSIONS

Endophthalmitis is a serious complication that can endanger vision after any ocular procedure, including PDS implantation. Most, but not all, of this limited series of endophthalmitis cases were late onset, associated with conjunctival breach, and recovered vision with treatment. Meticulous attention to PDS surgical techniques with vigilant monitoring of conjunctiva during follow-up may minimize risk of endophthalmitis. Prompt treatment is critical for optimizing patient outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The diagnosis and treatment progress of infectious endophthalmitis

Endophthalmitis is a blinding disease that may lead to permanent vision loss. The diagnosis of endophthalmitis relies on clinical findings. It is crucial to identify causative microorganisms in time for subsequent treatment and saving vision. For a long time, cultures of vitreous and/or aqueous humours have been the gold standard for the diagnosis of endophthalmitis. The development of modern molecular diagnostic techniques has brought new opportunities for identifying pathogens rapidly and improving sensitivity. Intravitreal antibiotic injection has the become standard treatment option for infectious endophthalmitis in clinical practice, however, the role and timing of pars plana vitrectomy remains controversial. Moreover, the development of new drugs for intravitreal injection and posterior segment drug delivery systems is expected to achieve the transition from invasive to non-invasive management. Thus, endophthalmitis is an ophthalmic emergency and timely diagnosis and treatment are crucial for preserving vision.

Timing of vitrectomy for treatment of endophthalmitis after intravitreal anti-VEGF injection: a systematic literature review of case reports and series

Objective

To perform a systematic literature review analyzing visual outcomes of immediate, early, and delayed vitrectomy in the treatment of acute endophthalmitis after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections.

Methods

We conducted a literature search using the Ovid Medline, Embase.com, and Web of Science databases, and relevant articles were selected from original English papers published from 2005 to 2021. Inclusion criteria were studies reporting cases of acute post-anti-VEGF endophthalmitis, defined as occurring within 6 weeks of injection treatment. Exclusion criteria were pediatric cases and cases explicitly reported to be caused by injections of contaminated drugs. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tool for case reports and case series. The study dataset for descriptive and statistical analysis comprised patient-level data extracted from included studies. The timing of vitrectomy compared were defined as (1) immediate vitrectomy as occurring within 24 h of endophthalmitis diagnosis; (2) early vitrectomy as occurring between 24 and 48 h of endophthalmitis diagnosis; (3) late vitrectomy as occurring after 48 h of endophthalmitis diagnosis. Primary outcome was final visual acuity following treatment with vitrectomy.

Results

Twenty-five articles were published that met our inclusion and exclusion criteria for a total of 86 cases. Thirty-seven were immediate vitrectomy, 25 were early, and 24 were late vitrectomy treatment groups, respectively. We observed differences in final visual outcomes and in improvement from diagnosis to final visual acuity, with patients receiving immediate and late vitrectomy to have better final visual outcomes than those patients receiving early vitrectomy (p < 0.005).

Conclusion

Our results show that there may be an association between time to vitrectomy and visual outcomes. Immediate and late vitrectomy treatment groups had better visual outcomes than the early group. Our results were limited by the reliance on case reports and series and the paucity of data available specifying the timing of vitrectomy. Additional research is necessary to elucidate the effects of treatment timing in patients with endophthalmitis following anti-VEGF injection.

Do Treatment Patterns for Endophthalmitis after Cataract Surgery Follow the Endophthalmitis Vitrectomy Study Recommendations?: An Academy IRIS® Registry Analysis

OBJECTIVE

To evaluate whether treatment patterns for endophthalmitis after cataract surgery in American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry patients are in line with evidence-based guidelines established by the 1995 Endophthalmitis Vitrectomy Study (EVS), which showed that patients who present with light perception (LP) vision have better visual outcomes with immediate vitrectomy (VIT) compared with vitreous tap with antibiotic injection (TAP).

DESIGN

Retrospective cohort study.

SUBJECTS

Intelligent Research in Sight Registry patients undergoing cataract surgery between 2014 and 2022 (identified by Current Procedural Terminology codes), presenting with endophthalmitis (identified by International Classification of Diseases 10 codes) within 42 days postcataract surgery, and having a record of being treated with VIT or TAP on the same or 1 day after endophthalmitis diagnosis were identified.

METHODS

Potential covariates of age, sex, race, ethnicity, geographic region, insurance status, and visual acuity on the day of endophthalmitis diagnosis were evaluated using multivariable logistic regression.

MAIN OUTCOME MEASURES

Treatment with VIT or TAP.

RESULTS

Of the 2425 patients who met the inclusion criteria, 14% (345) underwent VIT and 86% (2080) underwent TAP. Notably, 80% of patients (1946) presented with endophthalmitis within 14 days from cataract surgery (median = 6 days). Notably, 66% (173/263) of the patients presenting with LP vision underwent TAP instead of VIT. In a multivariable logistic regression model, receiving VIT instead of TAP was positively associated with poor vision at endophthalmitis presentation (LP - odds ratio [OR] = 5.4; confidence interval [CI], 2.9-10.6; counting fingers, hand motions - OR = 1.9; CI, 1.1-3.6) versus (20/20-20/40) vision; Asian versus White race (OR = 2.6; CI, 1.3-5.2); Hispanic versus non-Hispanic ethnicity (OR = 1.9; CI, 1.1-3.2); living in the West (OR = 1.6; CI, 1.1-2.2) and Midwest (OR = 1.5; CI, 1.1-2.0) (vs. South), but not with age, sex, and insurance coverage (P > 0.05).

CONCLUSIONS

In the IRIS Registry, treatment patterns for postcataract surgery endophthalmitis did not match evidence-based recommendations of the EVS, a randomized controlled clinical trial. More work is needed to evaluate whether the current treatment patterns are optimal for patients with postcataract surgery endophthalmitis.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Post-surgical endophthalmitis with secondary meningitis. About a case

A 61-year-old man presented hyperacute endophthalmitis due to Proteus mirabilis after a pars plana vitrectomy. In the first examination (24 h after surgery), visual acuity (VA) was of hand movement, biomicroscopy showed edematous cornea, Tyndall ++++ and fibrin membrane, with vitritis and impossibility of visualizing retina details. Treatment with intravitreal injections was performed. Despite the treatment, the patient's symptoms worsened, and he began with poor general condition, fever, and leukocytosis, requiring hospitalization and intravenous treatment because of a diagnosis of secondary meningitis due to post-surgical endophthalmitis. The patient required enucleation of the affected eye without prosthesis placement. Even though post-surgical bacterial endophthalmitis is usually an infection confined to the eye, this clinical case demonstrates the possibility of the infection spreading to the rest of the body, potentially endangering the patient's life.

Regional Variation of Infectious Agents Causing Endogenous Endophthalmitis in the United States: A National Database Analysis

OBJECTIVE

To describe regional variation in microbes causing infectious endogenous endophthalmitis (EE) in the United States.

DESIGN

This is a retrospective, national database analysis utilizing the 2002-2014 National Inpatient Sample database.

SUBJECTS

Using the International Classification of Disease 9 codes, we identified cases with EE. Cases were stratified regionally into Northeast, South, West, or Midwest.

METHODS

Unadjusted chi-square analysis followed by adjusted multivariate logistic regression was performed to evaluate variation in demographic factors, comorbidities using the Elixhauser Comorbidity Index (ECI), microbial variation, mortality, and use of vitrectomy or enucleation by region.

MAIN OUTCOME MEASURES

Proportion of microbes, mortality, and vitrectomy by region in addition to factors with significant odds ratios for mortality and for in-hospital vitrectomy.

RESULTS

A total of 10 912 patients with infectious EE were identified, with 2063 cases in the Northeast (18.9%), 2145 cases in the Midwest (19.7%), 4134 cases in the South (37.9%), and 2570 cases in the West (23.6%). Chi-square analysis indicated significant regional variation in patient demographics, microbes causing the infection, ECI, mortality, and surgical intervention. The 4 most common microbes for all regions were methicillin-sensitive Staphylococcus aureus (MSSA), Streptococcus, Candida, and methicillin-resistant Staphylococcus aureus. Methicillin-sensitive S. aureus was the most common cause of EE in all regions, although the proportion of MSSA infection did not significantly vary by region (P = 0.03). Further, there was significant regional variation in the proportion of other microbes causing the infection (P < 0.001). Higher rates of vitrectomies were seen in the South and Midwest regions than that in the Northeast and West (P = 0.04).

CONCLUSIONS

Regional variation exists in the infectious microbes causing EE. Further studies are needed to elucidate the etiology of these variations.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ocular Hornet Injury: A Case Report on Corneal Microperforation and Endophthalmitis

The lesser-banded hornet (Vespa affinis indosinensis) is a prevalent species in tropical and subtropical regions of Asia, including Malaysia. Its stings can result in local reactions, severe anaphylactic shock, and even death. We report a rare case of corneal microperforation and endophthalmitis following an ocular hornet injury. A 76-year-old farmer was attacked by hornets and suffered multiple stings, including one to his right eye. He developed right eye pain, redness, and visual impairment. Ocular examination revealed right corneal haziness with a retained stinger. Attempts to remove the retained stinger were unsuccessful, as the stinger broke and stayed deep in the corneal tissue layer. Corneal microperforation occurred at the site of the retained stinger. Subsequently, he developed endophthalmitis despite extensive topical and systemic antibiotics. He also required a scleral patch procedure for sclerokeratouveitis. This report highlights the importance of quick and vigilant management to prevent severe complications and preserve vision after a hornet sting injury. Retained stingers pose unique challenges that require specialized interventions. There is a need for continuous research and awareness in the management of ocular hornet injuries, aiming to establish standardized treatment guidelines and improve patient outcomes.

Evaluating the efficacy of pars plana vitrectomy in the management of endophthalmitis after following the endophthalmitis vitrectomy study: A systematic review and meta-analysis

Endophthalmitis is a devastating eye complication that requires prompt and effective treatment. A pivotal study in the field of endophthalmitis treatment is the endophthalmitis vitrectomy study (EVS), conducted over a decade ago. The primary objective of this study was to assess the effectiveness of pars plana vitrectomy (PPV) as a treatment option for endophthalmitis following the EVS study. We conducted a comprehensive search across three databases: PubMed, EBSCO host, and ProQuest. Reference lists of published articles were searched. Our study encompassed research conducted between January 2013 and January 2023 to ensure the most up-to-date findings. The best-corrected visual acuity (BCVA) in logMar, causative agents, and predicting factors for visual outcome were evaluated. Nine studies involving 351 eyes were included in the study; however, only eight were included in the meta-analysis. We observed a significant BCVA improvement compared to baseline at 1 month, >1-3 months, >3-6 months, and ≥12-month follow-up, with mean differences of 1.06 (P < 0.001), 1.25 (P < 0.001), 1.41 (P < 0.001), and 1.01 (P < 0.001), respectively. A causative organism was cultured in 61.4% of cases, and the majority of them were Coagulase-negative Streptococcus, Staphylococcus aureus, and Streptococcus sp. Factor associated with better visual acuity includes a younger age, lower intraocular pressure, and culture-negative endophthalmitis. Meanwhile, culture-positive endophthalmitis particularly Streptococcus sp., lower baseline vision, and presence of retinal detachment at initial presentation were identified as a prognostic for poorer visual outcome. PPV demonstrated a significant visual gain in patients with endophthalmitis in the 1st, 3rd, and 6th months. However, caution is warranted in drawing a definitive conclusion.

Endophthalmitis caused by Hathewaya histolytica: A diagnostic dilemma

A 76-year-old male presented with pain, redness, and decreased vision in the left eye for 5 days. The patient had undergone combined cataract extraction and vitrectomy for a macular hole 2 weeks back. The vision had reduced to the perception of light in the left eye. Clinical examination revealed lid edema, conjunctival congestion, hazy cornea, and exudative membrane in the pupillary axis with no view of the fundus. Ultrasound examination of the left eye showed plenty of moderate reflective dot echoes. The patient was diagnosed with postoperative endophthalmitis and underwent vitrectomy with intravitreal injection of antibiotics. Growth of Hathewaya histolytica was obtained from the vitreous sample. The organism was sensitive to imipenem. Three weeks following the presentation, visual acuity had improved to counting fingers at one meter in the left eye. This is the first report of endophthalmitis due to H. histolytica. Ophthalmologists should be aware of such ocular infections due to a rare microorganism.

Exploring the Spectrum of VEGF Inhibitors' Toxicities from Systemic to Intra-Vitreal Usage in Medical Practice

The use of Vascular Endothelial Growth Factor inhibitors (VEGFi) has become prevalent in the field of medicine, given the high incidence of various pathological conditions necessitating VEGF inhibition within the general population. These conditions encompass a range of advanced neoplasms, such as colorectal cancer, non-small cell lung cancer, renal cancer, ovarian cancer, and others, along with ocular diseases. The utilization of VEGFi is not without potential risks and adverse effects, requiring healthcare providers to be well-prepared for identification and management. VEGFi can be broadly categorized into two groups: antibodies or chimeric proteins that specifically target VEGF (bevacizumab, ramucirumab, aflibercept, ranibizumab, and brolucizumab) and non-selective and selective small molecules (sunitinib, sorafenib, cabozantinib, lenvatinib, regorafenib, etc.) designed to impede intracellular signaling of the VEGF receptor (RTKi, receptor tyrosine kinase inhibitors). The presentation and mechanisms of adverse effects resulting from VEGFi depend primarily on this distinction and the route of drug administration (systemic or intra-vitreal). This review provides a thorough examination of the causes, recognition, management, and preventive strategies for VEGFi toxicities with the goal of offering support to oncologists in both clinical practice and the design of clinical trials.

Literature- and Experience-Based Consensus for Acute Post-operative Endophthalmitis and Endogenous Endophthalmitis in Taiwan

Clinical practices on acute post-operative and endogenous endophthalmitis (EnE) are highly variable among clinicians due to a lack of up-to-date, high-quality evidential support. An expert consensus is thus much needed. A panel consisting of ten retinal specialists in Taiwan was organized. They evaluated relevant literature and developed key questions regarding acute post-operative and EnE that are cardinal for practice but yet to have conclusive evidence. The panel then attempted to reach consensus on all the key questions accordingly. There were eight key questions proposed and their respective consensus statements were summarized as follows: Gram staining and culture are still the standard procedures for the diagnosis of endophthalmitis. Vitrectomy is recommended to be performed earlier than the timing proposed by the Endophthalmitis Vitrectomy Study (EVS). Routine intracameral antibiotic injection for post-cataract surgery endophthalmitis prophylaxis is not recommended because of potential compounding error hazards and a lack of support from high-quality studies. Routine fundus examination is recommended for all patients with pyogenic liver abscess. In EnE, vitrectomy is recommended if diffused and dense vitritis is present, or if the disease progresses. These consensus statements may work as handy guidance or reference for clinical practices of acute post-operative and EnE.

Susceptibility of Ocular Surface Bacteria to Various Antibiotic Agents in a Romanian Ophthalmology Clinic

Periodic assessment of bacterial contamination is necessary as it allows proper guidance in cases of eye infections through the use of appropriate antibiotics. Due to the extensive use of antibiotic treatment, many strains of the microbiota that cause infections are resistant to the usual ophthalmic antibiotics. The present study provides an updated assessment of the susceptibility of Gram-positive and Gram-negative bacteria found on the ocular surface to the most commonly used antibiotic agents in patients undergoing cataract surgery. A total of 993 patients were included in the study with ages between 44 and 98 years old. Conjunctival cultures were collected 7 days before cataract surgery. The response of Gram-positive and Gram-negative bacteria to various antibiotic classes, such as glycopeptides, cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, phenicols, tetracyclines, rifamycins, macrolides and penicillins, was assessed. From the tested antibiotics, vancomycin had 97.8% efficacy on Gram-positive bacteria. In the cephalosporin category, we observed a high level of resistance of the cefuroxime for both Gram-positive and negative bacteria. Antibiotics that have more than 90% efficacy on Gram-positive bacteria are meropenem, imipenem, netilmicin, amikacin and rifampicin. On Gram-negative bacteria, we found 100% efficacy of all tested fluoroquinolones, i.e., aminoglycosides (except for tobramycin), doxycycline, azithromycin, clarithromycin and chloramphenicol. The current study illustrates patterns of increased resistance in certain bacteria present on the ocular surface to some of the commonly used antibiotics in ophthalmological clinical practice. One such revealing example is cefuroxime, which has been highly used as an intracameral antibiotic for the prevention of bacterial endophthalmitis after cataract surgery.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

Early Vitrectomy for Endophthalmitis: Are EVS Guidelines Still Valid?

BACKGROUND

Endophthalmitis, a potentially sight-threatening condition, remains a challenge for ophthalmologists worldwide. The endophthalmitis vitrectomy study (EVS) conducted in 1995 compared vitrectomy and intravitreal antibiotic injections to intravitreal antibiotic injections alone for acute post-cataract surgery and secondary intraocular lens endophthalmitis, setting treatment guidelines. However, the landscape of clinical practice has evolved considerably since then, raising questions about the applicability of EVS recommendations today.

SUMMARY

Recent studies have proposed that early and complete vitrectomy (CEVE) could potentially be an effective approach for managing endophthalmitis cases, irrespective of the initial visual acuity. However, it is important to note that the level of rigor in these recent studies may not match that of the EVS study, and as such, this assertion should be considered with caution. Furthermore, the EVS study exclusively focused on post-cataract surgery cases, leaving other endophthalmitis types, like post-intravitreal injection and post-traumatic endophthalmitis, without standardized treatment guidelines. Research exploring the role of early vitrectomy in these contexts yields mixed results, emphasizing the need for further investigation and well-designed prospective trials. Endogenous endophthalmitis, originating from systemic infections, adds complexity to the scenario. While early vitrectomy shows promise in specific cases, conflicting evidence necessitates comprehensive research.

KEY MESSAGES

This review underscores the necessity for tailored treatment strategies, supporting early vitrectomy when clinically indicated, and advocating for prospective trials to clarify its role in diverse endophthalmitis scenarios. As surgical techniques and antimicrobial therapies continue to advance, reevaluating treatment paradigms becomes crucial to enhance patient outcomes and protect ocular health.

An All-in-One Highly Multiplexed Diagnostic Assay for Rapid, Sensitive, and Comprehensive Detection of Intraocular Pathogens

PURPOSE

Intraocular infections are sight-threatening conditions that can lead to vision loss. Rapid identification of the etiologies plays a key role in early initiation of effective therapy to save vision. However, current diagnostic modalities are time consuming and lack sensitivity and inclusiveness. We present here a newly developed comprehensive ocular panel designed to improve diagnostic yields and provide a tool for rapid and sensitive pathogen detection.

DESIGN

Experimental laboratory investigation.

METHODS

A panel containing 46 pathogens and 2 resistance/virulence markers that are commonly detected in intraocular infections was developed. Genomic targets were scrutinized for stretches predicted to be specific for a particular species while being conserved across different strains. A set of primers for sample enrichment, and two 50mer NanoString compatible probes were then designed for each target. Probe-target hybrids were detected and quantified using the NanoString nCounter SPRINT Profiler. Diagnostic feasibility was assessed in a pilot clinical study testing samples from infectious retinitis (n = 15) and endophthalmitis (n = 12) patients, for which the etiologies were confirmed by polymerase chain reaction (PCR) or culture.

RESULTS

Analytical studies demonstrated highly sensitive detection of a broad spectrum of pathogens, including bacteria, viruses, and parasites, with limits of detection being as low as 2.5 femtograms per reaction. We also found excellent target specificity, with minimal cross-reactivity detected. The custom-designed NanoString ocular panel correctly identified the causative agent from all clinical specimens positive for a variety of pathogens.

CONCLUSION

This highly multiplexed panel for pathogen detection offers a sensitive, comprehensive, and uniform assay run directly on ocular fluids that could significantly improve diagnostics of sight-threatening intraocular infections.

Analysis of antibiotic resistance and genetic profile of conjunctival bacteria flora before and after cataract surgery

PURPOSE

To analyze antibiotic resistance and genetic profile of conjunctival bacteria flora before and after cataract surgery with the focus on coagulase-negative staphylococci (CNS) during cataract surgery and discuss the implications of this colonization as a potential risk of acquiring endophthalmitis.

METHODS

After approval of the institutional review board and informed consent from patients had been obtained, conjunctival swabs for culture from 59 patients undergoing cataract surgery were taken of the fellow eye at baseline (C0) and from the eye to be operated before (T0) and after (T1) irrigation with povine-iodine 5%, and at the end of surgery (T2). Genes responsible for virulence (mecA, ica and atlE) and antibiotic profile were determined; strain clonality of persistent colonizing Staphylococcus epidermidis strains was established by the Multi-locus sequence typing (MLST).

RESULTS

The frequency of CNS was significantly reduced in T1 (13.6%) from 81.4% in T0 and 86.4% in C0. The frequency of mecA, ica and atlE genes was 34.4%, 37.5% and 61.4%, respectively; and methicillin phenotypic resistance was 35.4%. S. epidermidis was the most frequent species isolated in every time point. MLST revealed in 7 patients 100% coincidence of the seven alleles of the S. epidermidis isolated previous to povine-iodine 5% disinfection and at the end of the surgery. CNS isolates from T1 or T2 corresponded to the same species, antibiotic and virulence profile as those isolates from C0 or T0.

CONCLUSION

Povidone-iodine 5% prophylaxis before surgery significantly reduced conjunctival contamination; in those that persisted, the source of contamination was mostly the patient's microbiota confirmed by the MLST system.

A Review on Pathogens and Necessary Diagnostic Work for Bleb-Related Infections (BRIs)

At the present time, as newer techniques and minimally invasive procedures gain popularity among anterior segment surgeons for regulating intraocular pressure, trabeculectomy still has a leading role in glaucoma surgery. Trabeculectomy retains a highly successful and safe profile; however, one of the major complications includes bleb-related infections (BRIs). To date, the most common pathogens remain Gram-positive cocci, but the list of pathogens that have been identified in the literature includes more than 100 microorganisms. Because antibiotic use is more widespread than ever before and our ability to identify pathogens has improved, the pathogen spectrum will broaden in the future and more pathogens causing BRIs will be described as atypical presentations. The scope of this review was to identify all pathogens that have been described to cause bleb-related infections to date, as well as focus on the risk factors, clinical presentation, and various available diagnostic tools used for an appropriate diagnostic workup.