Post-traumatic endophthalmitis in 143 eyes of children and adolescents from India

Clinical Profile, Antibiotic Resistance and Outcomes in Bacterial Endophthalmitis: Coagulase-Negative Staphylococcus Endophthalmitis as Compared to Other Organisms

BACKGROUND

To evaluate the clinical profile, outcomes and antibiotic resistance in bacterial endophthalmitis.

METHODS

This was a post-hoc analysis of a study conducted at a tertiary centre, where 60 consecutive cases of culture-proven bacterial endophthalmitis were included prospectively. Group 1 included coagulase-negative Staphylococcus endophthalmitis (CNSE), while group 2 included the remaining cases. Clinical features, antibiotic resistance and visual outcomes were compared. Visual acuity >3/60 at six months of follow-up was defined as a good visual outcome.

RESULTS

Group 1 had 31 cases, while group 2 had 29. Group 2 included 12 gram-positive and 17 gram-negative isolates. Among the groups, group 2 had more patients with presenting visual acuity below hand motions close to the face (25 vs. 12, p<0.001), poor visual outcomes (26 vs. 3, p<0.001) and retinal detachment (RD) (10 vs. 2, p=0.007). Pseudomonas was most commonly resistant to antibiotics, and ceftazidime (p=0.005) and cefazolin (p=0.009) resistance were higher in group 2 isolates. In group 1, five isolates were resistant to any one of the antibiotics, whereas in group 2, 13 isolates were resistant to any one of the antibiotics (p=0.024).

CONCLUSIONS

In the current study, eyes in the group of endophthalmitis caused by CNSE achieved better visual acuities at the last follow-up compared to eyes with endophthalmitis caused by other bacteria. Antibiotic resistance in isolates other than CNSE is a cause of concern.

Microbiological Landscape and Epidemiology of Endophthalmitis in Children and Adolescents in a Multi-Tier Ophthalmology Network in India: An Electronic Medical Record-Driven Analytics Report

PURPOSE

To study the epidemiology and microbiological landscape in patients (≤21 yrs) diagnosed with endophthalmitis across a multi-tier ophthalmology network in India.

METHODS

This cross-sectional hospital-based study included 1,041 patients (≤21 yrs) diagnosed with endophthalmitis, between April 2012 and May 2022. The data were collected using an electronic medical record system.

RESULTS

Bacteria (24%) was the most common etiology followed by fungus (2%). The majority of the patients were male (66%) with a mean age of 8.37 ± 5.99 years. The most common age group was middle childhood (6-11 years) with 365 (35.06%) patients. The patients were more commonly from the lower socio-economic status (60.81%) and urban geography (49%). The common cause of endophthalmitis was trauma (59.33%) and amongst the 279 culture positive eyes, the predominant bacteria isolated was Streptococcus pneumoniae followed by Bacillus species and fungus included predominantly Aspergillus and Candida species. The most common surgical intervention performed was intraocular antibiotics (74%) followed by pars plana vitrectomy (52%).

CONCLUSION

The most common etiology of endophthalmitis in children is bacterial and traumatic in nature and presented from the lower socio-economic status. A half of the eyes warranted a vitreo-retinal surgical intervention.     .

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.

Clinical Features, Antibiotic Susceptibilities, and Outcomes of Endophthalmitis Caused by Streptococcal Infection: Children vs. Adults

Streptococcus spp. are common causative organisms of endophthalmitis. Analysis of the clinical features, antibiotic susceptibilities, and outcomes of streptococcal endophthalmitis in children and adults may guide future management. Sixty-seven patients (67 eyes) with streptococcal endophthalmitis who were admitted to the Zhongshan Ophthalmic Center between January 2013 and December 2022 were retrospectively reviewed. The mean age was 20.7 ± 21.6 years, and 59.7% were children. Streptococcal infection accounted for 13.9% of culture-proven bacterial endophthalmitis cases; the proportion was higher in children than in adults (32.3% vs. 7.6%, p < 0.01) and increased from 8.1% in 2013-2017 to 20.1% in 2018-2022 (p < 0.01). Eye trauma was the most common etiology in both children and adults (82.5% and 66.7%, respectively). Viridans group streptococci were the most common isolates, followed by S. pneumoniae. The susceptibility rates of the streptococci to vancomycin, cefuroxime, and levofloxacin were 100%, 95.5%, and 93.0%, respectively. The overall mean best-corrected visual acuity increased from 2.74 ± 0.19 logMAR initially to 2.32 ± 0.75 logMAR at the last follow-up (p < 0.05). In conclusion, streptococcal infections have increased in cases of bacterial endophthalmitis in recent years and are more common in children. The commonly used antibiotics, vancomycin, cefuroxime, and fluoroquinolone, showed higher antibiotic susceptibility. After prompt treatment, visual outcomes improved.

Microbiological study on foreign body and vitreous samples of patients with intraocular foreign body

OBJECTIVE

To evaluate the relationship between the microbiological results of the vitreous humor and those of foreign body specimens in patients with intraocular foreign body (IOFB).

METHODS

Seventy-one patients with an IOFB were included in this descriptive prospective case series. All patients underwent immediate IOFB removal. Vitreous sampling was performed during vitrectomy. Foreign bodies were placed directly into culture media for microbiological study.

RESULTS

Thirteen (18.3%) patients developed endophthalmitis. The results of microbiological analysis of IOFB and vitreous humor specimens were negative in nine patients and positive in four. Fifty-eight (81.6%) patients with an IOFB had no evidence of endophthalmitis. Among them, seven patients showed positive microbiological results of foreign bodies with no manifestations of endophthalmitis. In five patients, a Staphylococcus epidermidis strain was observed in the culture of the IOFB specimen. Two patients had only positive smear test results of their vitreous humor specimen.

CONCLUSION

A correlation appears to be present between the microbiological results of the vitreous humor and IOFB specimens in patients with clinical findings of endophthalmitis but not in patients with a pure IOFB without clinical features of endophthalmitis. This may justify early use of intravitreal and intravenous antibiotics before the development of endophthalmitis.

Risk Factors for Development of Endophthalmitis after Open Globe Injury in Children: A Case-Control Study

AIM

To identify risk-factors for developing endophthalmitis following open globe injury (OGI) in children.

METHODS

Retrospective, single-center, case-control study of children aged <18 years who sustained OGI.

RESULTS

Our cohort of 93 eyes consisted of 30 cases (Group A- endophthalmitis) and 63 controls (Group B- no endophthalmitis). Twenty-four eyes (80%) diagnosed with endophthalmitis presented after 24 hours of injury. The presence of central corneal zone-1 injuries (Odd ratio [OR]: 6.64, p= 0.001) and vitreous in wound (OR: 3.53) were associated with the risk of developing endophthalmitis. (p= < 0.05) Additionally the presence of iris prolapse (OR: 4.76) and posterior capsular rupture (PCR) (OR: 5.80) increased the risk of developing endophthalmitis.(p <0.05) . Streptococci was isolated in 15 eyes, Pseudomonas in 3 eyes, and Candida in 1 eye. The visual outcomes at three months were significantly worse in Group A (LogMAR 1.77±1.06) compared to Group B (LogMAR 0.65±0.68)(p<0.05).

CONCLUSION

Central corneal involvement, vitreous/ iris incarceration and PCR were important risk factors for development of PTE in children.

Fireworks ocular injury in Saudi children: profile and management outcomes

To explore the demographic profiling, causes, types, complications, management outcomes, and severity of fireworks-inflicted ocular injuries in children in KSA. This is a retrospective study of 115 cases with eye injuries managed at the Emergency Department, of our institution between 2003 and 2019. Demography, clinical features at presentation, mode of management and the Best-corrected visual acuity (BCVA) were evaluated at the last follow up. The study included 117 eyes of 115 children [median age: 9 years; 96 (83.5%) boys;19 (16.5%) girls]. Fifty-six (48.7%) participants were bystanders. The injuries were caused mainly due to bangers (n = 47; 40.9%), rockets in bottle (n = 28; 24.3%), firecrackers (n = 27; 23.5%), and nonspecific reasons (n = 13; 11.3%). The children had presented with various severity levels: corneal abrasion (n = 52; 44.4%); cataract (n = 47;40.2%); penetrating injury (n = 40; 34.2%); secondary glaucoma (n = 22;18.8%); subluxated lens (n = 19;16.2%); limbal stem cell deficiency (n = 14;12.0%); Iridodialysis (n = 12;10.3%), and vitreous hemorrhage (n = 11;9.4%). Management interventions of the eyes under study included: penetrating injury repair (n = 40; 34.2%), lens removal plus intraocular lens implantation (n = 26; 22.2%), removal of foreign body (n = 9; 7.7%). The BCVA after six months was 20/20 to 20/60 in 49 (41%) cases; 20/70 to 20/200 in 27 (23.1%) cases; < 20/200 to 20/400 in 7 (6%) cases, and < 20/400 in 34 (29.1%) of the cases. Out of 51.3% eyes with < 20/200 before management, only 35% recorded severe visual impairment. Fireworks-related eye injuries were mainly observed in boys primarily due to the use of bangers. Visual disability remained in one-third of the managed cases.

Post-traumatic endophthalmitis caused by streptococcus species in preschool children: clinical features, antibiotic susceptibilities and outcomes

BACKGROUND/OBJECTIVES

Streptococcus is a common cause of post-traumatic endophthalmitis in children. This study aimed to analyse the clinical features, antibiotic susceptibilities and outcomes of traumatic endophthalmitis caused by streptococcus in preschool children.

SUBJECTS/METHODS

Patients aged ≤6 years with traumatic streptococcal endophthalmitis seen at Zhongshan Ophthalmic Center between January 2013 and December 2018 were included in this retrospective study.

RESULTS

In total, 21 patients (21 eyes) were included. The mean age of the patients was 3.3 ± 1.7 years, where 57.1% were males. Scissors (28.6%, n = 6) were the most common cause of injury; 86.7% of patients were injured at home. Zone I (80.9%) was the most common wound site; 90.5% of patients presented with a traumatic cataract. In general, Streptococcus pneumoniae (47.6%) was the most common isolate. Viridans group streptococci accounted for 58.3% of cases in children aged 0-3 years, while S. pneumoniae accounted for 66.7% of cases in children aged 4-6 years. The susceptibility rates of streptococcus to cefuroxime, levofloxacin and ofloxacin were 100%, 95.0% and 90.5%, respectively. Although all the patients underwent vitrectomy combined with silicone oil tamponade, the final visual outcomes were no better than counting fingers.

CONCLUSIONS

Although S. pneumoniae was the most prevalent organism in general, the dominant species varied between different age groups. The commonly used antibiotics, cefuroxime and fluoroquinolone, showed higher antibiotic susceptibility. Despite prompt treatment, the visual outcomes of paediatric post-traumatic endophthalmitis in preschool children were poor.

ENDOPHTHALMITIS IN OPHTHALMOLOGICAL REFERRAL CENTRE IN COLOMBIA: AETIOLOGY AND MICROBIAL RESISTANCE

AIMS

To describe the aetiology and microbial susceptibility profile of endophthalmitis cases treated at an ophthalmological referral centre in Colombia.

MATERIAL AND METHODS

A retrospective descriptive study was carried out with all endophthalmitis cases referred to the Fundación Oftalmológica de Santander FOSCAL (Floridablanca, Colombia) from 1 January 2012 to 31 December 2015.

RESULTS

121 eyes of 121 patients were evaluated. 77.7% of them were male and the mean age was 42.9 years. Five of them (4.1%) corresponded to endogenous endophthalmitis, and 116 (95.9%) to exogenous endophthalmitis. Of the latter, 66.9% were associated with trauma (almost one-half of them associated with intraocular foreign body), and 29.5% with intraocular surgery. The most common isolated microorganisms in the exogenous endophthalmitis group corresponded to methicillin-resistant and methicillin-sensitive strains of Staphylococcus epidermidis and Staphylococcus aureus, which were mostly susceptible to imipenem, vancomycin and moxifloxacin and resistant to ceftazidime.

CONCLUSION

Endophthalmitis is a potentially sight-threatening condition, especially in cases of inadequate treatment. Therefore, antimicrobial therapy should be guided by vitreous humour culture to assure that the causative microorganism is susceptible to the selected agent. The results of our study lead us to propose vancomycin, moxifloxacin or imipenem as first-line antimicrobial options.

Risk factors and outcomes of post-traumatic endophthalmitis: a retrospective single-center study

Background

To describe the epidemiology, characteristics, risk factors, and outcomes of post-traumatic endophthalmitis.

Main body

Medical records of consecutive open globe injury patients admitted and primarily treated between January 2006 and December 2016 were retrospectively reviewed. Patients were defined as having or not having associated endophthalmitis. Data of demographics, injury characteristics, clinical presentations, and visual outcomes were collected. The potential risks and significant factors for visual outcomes of post-traumatic endophthalmitis were determined. There were 591 patients included in this study. Among these, 118 patients were clinically diagnosed as having accompanied endophthalmitis. Higher proportions of intraocular foreign body (IOFB) (55.1% vs. 27.3%) and injury related to high-velocity objects (55.9% vs. 32.6%) were noted in patients with endophthalmitis compared to patients without endophthalmitis. Anterior wound location (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1 to 3.7; P = 0.020), presence of IOFB (OR, 1.9; 95% CI 1.2 to 3.0; P = 0.005), and delayed presentation of > 24 h (OR, 3.9; 95% CI 2.3 to 6.4; P < 0.001) were significant risk factors for associated endophthalmitis. Final visual acuity (VA) of the overall population improved significantly from 2.4 (0.6) logMAR to 1.4 (0.1) logMAR, P < 0.001, however, patients in the endophthalmitis group achieved a worse final VA than the non-endophthalmitis group (66.1% vs. 43.5%, P < 0.001).

Conclusion

High proportions of post-traumatic endophthalmitis patients had subsequent poor visual outcomes. Therefore, safety and protective measurements, especially when performing activities related to high-velocity objects, and the institution of prophylactic antibiotics in high-risk groups should be promptly considered to reduce the incidence.

Hypopyon: Is-it Infective or Noninfective?

Hypopyon usually corresponds to the sedimentation of white blood cells, and it signifies severe intraocular inflammation. This key clinical sign may occur in association with a wide variety of infectious, inflammatory, and neoplastic conditions that may be sight- and, occasionally, life-threatening. A careful history and thorough clinical examination are the cornerstones for orienting the differential diagnosis, identifying the causative agent, and initiating prompt and appropriate treatment. This review outlines the clinical characteristics and management of hypopyon in relation with the underlying causative infectious or noninfectious ocular or systemic diseases.

Epidemiology of keratitis/scleritis-related endophthalmitis in a university hospital in Thailand

To demonstrate the demographics, associated factors, clinical presentations, microbiology, management, visual outcome and complications of keratitis/scleritis-related endophthalmitis (KSE). A retrospective chart of all endophthalmitis patients diagnosed between September 2001 and August 2011 was reviewed. Only endophthalmitis cases with previous corneal or scleral infection were included in the study. The patients were followed until losing vision or eyeball, becoming phthisis, or the end of 2018. Eighty-seven patients with KSE were identified, all unilateral. The mean age was 56.4 ± 21.4 years. There was a slight male predilection (55 patients, 63.2%). The mean follow-up time was 50 ± 149 weeks. The causative pathogens were identified in 35 patients (40.2%), with the highest frequency being bacteria. The most common bacterium was Pseudomonas aeruginosa (n = 13), and the most common fungus was Aspergillus sp. (n = 5). Fifteen patients achieved (17.2%) final visual acuity (VA) of hand motion or better after treatment. Eyeball removal was performed in 61 (70.1%) patients. From multivariate analysis, the only prognostic factor for poor final VA (worse than hand motion, HM) was poor VA (worse than HM) at the initial visit (relative risk 1.97, 95% confidence interval 1.15–3.36, p = 0.013). KSE is uncommon but has a devastating outcome. We found that the patient’s initial VA was the only predictor for their final vision. P. aeruginosa was the most common identifiable organism in this study. However, several fungal infections were recognised. These findings should raise awareness for treatment of KSE in the tropics.

Antimicrobial resistance of ocular microbes and the role of antimicrobial peptides

Isolation of antimicrobial-resistant microbes from ocular infections may be becoming more frequent. Infections caused by these microbes can be difficult to treat and lead to poor outcomes. However, new therapies are being developed which may help improve clinical outcomes. This review examines recent reports on the isolation of antibiotic-resistant microbes from ocular infections. In addition, an overview of the development of some new antibiotic therapies is given. The recent literature regarding antibiotic use and resistance, isolation of antibiotic-resistant microbes from ocular infections and the development of potential new antibiotics that can be used to treat these infections was reviewed. Ocular microbial infections are a global public health issue as they can result in vision loss which compromises quality of life. Approximately 70 per cent of ocular infections are caused by bacteria including Chlamydia trachomatis, Staphylococcus aureus, and Pseudomonas aeruginosa and fungi such as Candida albicans, Aspergillus spp. and Fusarium spp. Resistance to first-line antibiotics such as fluoroquinolones and azoles has increased, with resistance of S. aureus isolates from the USA to fluoroquinolones reaching 32 per cent of isolates and 35 per cent being methicillin-resistant (MRSA). Lower levels of MRSA (seven per cent) were isolated by an Australian study. Antimicrobial peptides, which are broad-spectrum alternatives to antibiotics, have been tested as possible new drugs. Several have shown promise in animal models of keratitis, especially treating P. aeruginosa, S. aureus or C. albicans infections. Reports of increasing resistance of ocular isolates to mainstay antibiotics are a concern, and there is evidence that for ocular surface disease this resistance translates into worse clinical outcomes. New antibiotics are being developed, but not by large pharmaceutical companies and mostly in university research laboratories and smaller biotech companies. Antimicrobial peptides show promise in treating keratitis.

Posttraumatic Bacillus cereus Endophthalmitis: Clinical Characteristics and Antibiotic Susceptibilities

Purpose

To report the clinical characteristics, antibiotic susceptibilities, and visual outcomes of patients with posttraumatic endophthalmitis caused by Bacillus cereus.

Methods

In this retrospective, noncomparative case series, the medical records of eyes with culture-proven Bacillus cereus endophthalmitis treated from January 2016 to December 2019 at a referral center were reviewed. Clinical features, antibiotic susceptibilities, and visual outcomes were assessed.

Results

A total of 19 eyes of 19 patients were identified. Three patients progressed to orbital cellulitis. Vitrectomy was performed in 13 eyes, and 11 required silicone oil tamponade. Finally, seven eyes underwent silicone oil removal surgery during follow-up. Only two patients retained a visual acuity better than FC. Four patients underwent evisceration, and three patients had NLP. The cultured Bacillus cereus was sensitive to levofloxacin, ofloxacin, tobramycin, and neomycin at 100%.

Conclusions

The visual outcomes of posttraumatic Bacillus cereus endophthalmitis were generally poor regardless of the prophylactic and therapeutic measures administered. Vitrectomy combined with silicone oil tamponade could help to save the eyeball. Bacillus cereus has a good susceptibility to ofloxacin, levofloxacin, tobramycin, and neomycin; therefore, fluoroquinolones and aminoglycosides can be used to treat Bacillus cereus infection.

Strain heterogeneity, cooccurrence network, taxonomic composition and functional profile of the healthy ocular surface microbiome

BACKGROUND

There is growing evidence indicating that the microbial communities that dwell on the human ocular surface are crucially important for ocular surface health and disease. Little is known about interspecies interactions, functional profiles, and strain heterogeneity across individuals in healthy ocular surface microbiomes.

METHODS

To comprehensively characterize the strain heterogeneity, cooccurrence network, taxonomic composition and functional profile of the healthy ocular surface microbiome, we performed shotgun metagenomics sequencing on ocular surface mucosal membrane swabs of 17 healthy volunteers.

RESULTS

The healthy ocular surface microbiome was classified into 12 phyla, 70 genera, and 140 species. The number of species in each healthy ocular surface microbiome ranged from 6 to 47, indicating differences in microbial diversity among individuals. The species with high relative abundances and high positivity rates were Streptococcus pyogenes, Staphylococcus epidermidis, Propionibacterium acnes, Corynebacterium accolens, and Enhydrobacter aerosaccus. A correlation network analysis revealed a competitive interaction of Staphylococcus epidermidis with Streptococcus pyogenes in ocular surface microbial ecosystems. Staphylococcus epidermidis and Streptococcus pyogenes revealed phylogenetic diversity among different individuals. At the functional level, the pathways related to transcription were the most abundant. We also found that there were abundant lipid and amino acid metabolism pathways in the healthy ocular surface microbiome.

CONCLUSION

This study explored the strain heterogeneity, cooccurrence network, taxonomic composition, and functional profile of the healthy ocular surface microbiome. These findings have important significance for the future development of probiotic-based eye therapeutic drugs.

Etiology, microbiological isolates, and antibiotic susceptibilities in culture-proven pediatric endophthalmitis: a 9-year review

Purpose

To analyze the etiology, microbiological isolates, and antibiotic susceptibilities of endophthalmitis in pediatric patients.

Methods

Patients aged < 18 years with culture-positive endophthalmitis in Zhongshan Ophthalmic Center between January 2010 and December 2018 were included retrospectively.

Results

A total of 127 patients (127 eyes) were included, and 108 (85%) had posttraumatic endophthalmitis. Streptococcus (21.4%), coagulase-negative Staphylococcus (14.5%), Aspergillus (6.9%), and Bacillus cereus (5.3%) were the common organisms. The proportion of Streptococcus decreased with age (40.0% in 0–3 years, 16.3% in 4–12 years, and 6.3% in 13–17 years), while coagulase-negative Staphylococcus increased from 5.7% to 18.8%. Overall, fluoroquinolones achieved the highest antibiotic susceptibility rate (> 95%), while the susceptibility of isolated bacteria to tobramycin and cefazolin was only 60.2% and 59.4%, respectively. The susceptibility rates of Gram-positive cocci to cephalosporins were nearly 90%. For Gram-negative bacilli, susceptibility to neomycin was 91.3%.

Conclusion

Trauma was the main etiology for pediatric endophthalmitis. Although Streptococcus was the most prevalent organism in general, the dominant pathogen varied with age, which merits clinical attention. Fluoroquinolones showed the highest antibiotic efficacy; however, commonly used antibiotics tobramycin and cefazolin showed relatively low antibiotic susceptibility. Thus, antibiotic resistance in pediatric populations merits clinical attention.

Traumatic endophthalmitis and the outcome after vitrectomy in young children

AIM

To explore the traumatic endophthalmitis in young children and the outcome of pars plana vitrectomy (PPV).

METHODS

Twenty-two eyes of 22 cases of young children consecutive pediatric traumatic endophthalmitis treated and followed up between September 2014 and May 2018 were included. Aqueous humor or vitreous samples were taken for bacterial culture and sensitivity tests. Intravitreal antibiotics (norvancomycin and ceftazidime) injection, combined with 23-gauge PPV, were administered in 22 eyes. Silicone oil (SO; 5000 centistoke) tamponade or perfluoropropane gas (C₃F₈) was used in all patients. Main outcome measures were best-corrected visual acuity (BCVA) and retinal attachment, the ratio of penetrating injury, and the existence of intraocular foreign body.

RESULTS

The mean age of patients was 6.9±2.2 (range, 3-10)y. All injured eyes suffered from penetrating ocular injury with retained intraocular foreign body in one eye. Bacterial culture was positive in only 2 eyes. The mean follow-up time was 21.1±4.7 (range, 12-30)mo. In the primary PPV, intravitreal antibiotics was administrated in all eyes, SO in 18 eyes, and C₃F₈ in 4 eyes. The secondary operation of SO removal and C₃F₈ endotamponade was performed in 16 eyes and a second SO endotamponade due to emulsification of the oil and retinal detachment (RD) was operated in 7 eyes underwent 3 to 11.5mo after primary PPV. A third operation was done in 7 eyes. The final intraocular pressure (IOP) was 8.9±1.8 (range, 6.9-11.4) mm Hg. The final BCVAs were 20/200 or better in 5, counting fingers in 2, and light perception to hand movement in 8 eyes. Whose (66.7%) had retinal injury exhibited worse BCVA (P=0.019, Fisher's exact test). Eyes underwent SO tamponade exhibited worse final BCVA than that with C₃F₈ in the primary PPV (P=0.026, Fisher's exact test).

CONCLUSION

Traumatic endophthalmitis in children is generally more severe and associated with more complicated surgical procedures. Most patients have retinal injury need multiple operations and the final BCVA is poor. Prevention of ocular trauma, especially in children, is still critical.

The cereus matter of Bacillus endophthalmitis

Bacillus cereus (B. cereus) endophthalmitis is a devastating intraocular infection primarily associated with post-traumatic injuries. The majority of these infections result in substantial vision loss, if not loss of the eye itself, within 12-48 h. Multifactorial mechanisms that lead to the innate intraocular inflammatory response during this disease include the combination of robust bacterial replication, migration of the organism throughout the eye, and toxin production by the organism. Therefore, the window of therapeutic intervention in B. cereus endophthalmitis is quite narrow compared to that of other pathogens which cause this disease. Understanding the interaction of bacterial and host factors is critical in understanding the disease and formulating more rational therapeutics for salvaging vision. In this review, we will discuss clinical and research findings related to B. cereus endophthalmitis in terms of the organism's virulence and inflammogenic potential, and strategies for improving of current therapeutic regimens for this blinding disease.

Clinical and Microbiological Features of Pediatric Endopthalmitis After Open Globe Injury in the North of VietNam

BACKGROUND

Pediatric endophthalmitis after open-globe injury had its clinical features, microbiological profile different from those in aldults. In Viet Nam, there was no report on the clinical and microbiological characteristics of pediatric posttraumatic endophthalmitis. Therefore, we conduct this study.

AIM

To describe clinical features, ultrasound results, gram stain and culture results of endophthalmitis in pediatric open globe injuries.

METHODS

Prospective non-controlled study. Case series of 30 eyes presenting with post-traumatic endophthalmitis between 2015 and 2016 were reviewed.

RESULTS

Mean age was 8.03 ± 3.99 years. Metallic and organic etiologies were the most common causes for injuries (n = 11). 27 cases had penetrating corneal trauma. Dense opaque vitreous was seen in 25 eyes. Retinal necrosis < 1 quadrant and chorioretinal abscess > 1 quadrant were the most common fundus lesions. Dense vitreous opacity on ultrasound was most common (n = 28). Gram stain bacteria positivity was 93.3%, gram-positive was isolated in 63.3%. Vitreous samples were more often positive than aqueous (P = 0,002).

CONCLUSION

Posttraumatic endophthalmitis in children is more common in boys aged 6-10 years and most often caused by injury with metallic and organic matters. Culture results were very low. Vitreous samples were more often positive than aqueous. Gram-positive bacteria were the most common causative organism.

Intraocular foreign body injury in children: clinical characteristics and factors associated with endophthalmitis

Background/Aims

To analyse the clinical characteristics of intraocular foreign body (IOFB) injury in children and evaluate factors associated with endophthalmitis development.

Methods

Patients aged <18 years with IOFB attending Zhongshan Ophthalmic Center between January 2003 and July 2016 were included retrospectively. Demographic features, clinical characteristics and factors associated with endophthalmitis development were analysed.

Results

Consecutive subjects (n=484, 484 eyes) were included: mean age 10.12±4.54 years, 86.4% male. Fireworks (28.5%) were the most common cause of injury. Injury of uncertain cause (17.5%), fireworks (36.7%) and metal splatter (31.7%) accounted for most injuries in the 0–3, 4–12 and 13–17 years age groups, respectively. Plant branches (16.7%) and fireworks (31.1%) were the most common causes of injuries in females and males, respectively. Endophthalmitis occurred in 116 patients (24.0%), with metallic IOFB (OR=0.338, p=0.001), intraocular haemorrhage (OR=0.100, p<0.001) and uveal tissue prolapse (OR=0.206, p<0.001) conferring lower risk, while zone II wound (OR=4.336, p<0.001) and traumatic lens rupture (OR=2.567, p=0.028) were associated with higher risk.

Conclusion

Clinical characteristics of children with IOFB injury differ from those of adults. Fireworks are the most common cause of injury, indicating a ban on children igniting fireworks should be advocated. Safety education and protective measures should vary by age and sex. Endophthalmitis is associated with zone II wound, traumatic lens rupture, IOFB material, intraocular haemorrhage and uveal tissue prolapse, which has clinical relevance.

Polybacterial community analysis in human conjunctiva through 16S rRNA gene libraries

The conjunctival sac of healthy human harbours a variety of microorganisms. When the eye is compromised, an occasional inadvertent spread happens to the adjacent tissue, resulting in bacterial ocular infections. Microbiological investigation of the conjunctival swab is one of the broadly used modality to study the aetiological agent of conjunctiva. However, most of the time such methods yield unsatisfactory results. Hence, the present study intends to identify the bacterial community in human conjunctiva of pre-operative subjects through 16S rRNA gene libraries. Out of 45 samples collected from preoperative patients undergoing cataract surgery, 36 libraries were constructed with bacterial nested-PCR-positive samples. The representative clones with unique restriction pattern were generated through Amplified Ribosomal DNA Restriction Analysis (ARDRA) which were sequenced for phylogenetic affiliation. A total of 211 representative clones were obtained which were distributed in phyla Actinobacteria, Firmicutes, α-Proteobacteria, β-Proteobacteria, γ-Proteobacteria, Bacteroidetes, and Deinococcus-Thermus. Findings revealed the presence of polybacterial community, especially in some cases even though no bacterium or a single bacterium alone was identified through cultivable method. Remarkably, we identified 17 species which have never been reported in any ocular infections. The sequencing data reported 6 unidentified bacteria suggesting the possibility of novel organisms in the sample. Since, polybacterial community has been identified consisting of both gram positive and gram negative bacteria, a broad spectrum antibiotic therapy is advisable to the patients who are undergoing cataract surgery. Consolidated effort would significantly improve a clear understanding of the nature of microbial community in the human conjunctiva which will promote administration of appropriate antibiotic regimen and also help in the development of oligonucleotide probes to screen the predominant pathogens for early predisposition.

Recent Updates on Treatment of Ocular Microbial Infections by Stem Cell Therapy: A Review

Ocular microbial infection has emerged as a major public health crisis during the past two decades. A variety of causative agents can cause ocular microbial infections; which are characterized by persistent and destructive inflammation of the ocular tissue; progressive visual disturbance; and may result in loss of visual function in patients if early and effective treatments are not received. The conventional therapeutic approaches to treat vision impairment and blindness resulting from microbial infections involve antimicrobial therapy to eliminate the offending pathogens or in severe cases; by surgical methods and retinal prosthesis replacing of the infected area. In cases where there is concurrent inflammation, once infection is controlled, anti-inflammatory agents are indicated to reduce ocular damage from inflammation which ensues. Despite advances in medical research; progress in the control of ocular microbial infections remains slow. The varying level of ocular tissue recovery in individuals and the incomplete visual functional restoration indicate the chief limitations of current strategies. The development of a more extensive therapy is needed to help in healing to regain vision in patients. Stem cells are multipotent stromal cells that can give rise to a vast variety of cell types following proper differentiation protocol. Stem cell therapy shows promise in reducing inflammation and repairing tissue damage on the eye caused by microbial infections by its ability to modulate immune response and promote tissue regeneration. This article reviews a selected list of common infectious agents affecting the eye; which include fungi; viruses; parasites and bacteria with the aim of discussing the current antimicrobial treatments and the associated therapeutic challenges. We also provide recent updates of the advances in stem cells studies on sepsis therapy as a suggestion of optimum treatment regime for ocular microbial infections.

Enterococcus faecalis Endophthalmitis in Children - A 21 Year Study

PURPOSE

To report Enterococcus faecalis endophthalmitis (EFE) in children and its comparison with adults.

METHODS

Retrospective study of 19 children up to 18 years age, undergoing vitrectomy for EFE at a referral eye center from January 1995 to December 2015. The results were compared to 18 adults with EFE.

RESULTS

The mean age was 7.4 ± 3.06 years. Post-traumatic EFE was seen in 17 (89.4%) children (p < 0.05) versus postoperative EFE seen in 12 (66%) adults. Broomstick 9 (52.9%) and hypodermic needle injury 6 (35.2%) were common associations. "Optimum functional outcome" was achieved in 12 (63.1%) eyes of children and 5 (27.7%) eyes of adults (p = 0.03). Sealed and Zone II wounds, lens, and needle injuries had good outcome whereas intervention after 3 days and retinal detachment had poor outcomes (p < 0.05). The was no correlation with the Ocular Trauma Score.

CONCLUSION

EFE in children is rare; seen with broom stick and needle injuries, if managed early recovers optimum vision.

An evidence-based medicine audit of the ophthalmic emergency services unit of King Abdulaziz University Hospital (KAUH)

PURPOSE

To improve the interventions provided for patients presenting with acute ophthalmic conditions to the ophthalmic emergency unit through applying the best available evidences from quality literature for managing such conditions.

METHODS

A retrospective cohort study at a tertiary eye care university hospital in Riyadh, Saudi Arabia, involving a two-phase audit of diagnosis-intervention was conducted. The first phase was done retrospectively for the duration from April 1 to May 30, 2014, after disseminating the results of the first phase to King Abdulaziz University Hospital ophthalmology department staff, and the second phase was done retrospectively for the duration from November 1 to December 30, 2015. The validity of outcomes was assessed through a literature search using Medline and the Cochrane Database of Systematic Reviews. The participants were masked on the study objectives to avoid Hawthorne's phenomenon (prescribing bias).

RESULTS

In the first part of the audit, 73.2% out of 355 interventions were found to be evidence based. There was notable improvement of 80.9% in the number of evidence-based interventions in the second part of the audit. This improvement was statistically significant (p = 0.017).

CONCLUSION

Evidence-based medicine audit can be a helpful tool to assess the performance and can lead to quality improve of the provided care by reducing the number of medical errors and refining medical decisions and interventions.

Appraising the spectrum of firework trauma and the related laws during Diwali in North India

PURPOSE

To evaluate the epidemiological characteristics and outcomes of ocular injuries resulting from the use of firecrackers during the Diwali festival in all age groups.

MATERIALS AND METHODS

A single-center, retrospective, hospital-based case series presenting with ocular trauma consequent to fireworks usage in a tertiary eye care center in North India during the 5 days of Diwali festival from 2011 to 2015 was conducted.

RESULTS

A total of 53 eyes of 45 patients were included in the study, out of which the vast majority (39/87%) were males. The mean age was 20.55 years. Almost an equal number of bystanders (25/55.5%) were affected as compared to people handling the fireworks (20/44.44%). Five (9.43%) eyes had open-globe injury, whereas 48 (90.56%) eyes had closed-globe injury. Eighteen (33.96%) eyes underwent surgical intervention. Thirty-three (62.26%) eyes had final vision >20/200 with eight (15.09%) eyes being vision <3/60 in the affected eye.

CONCLUSION

Firework-related ocular trauma can lead to serious visual impairment. Mandatory legislative laws pertaining to the manufacture, sale, and use of fireworks and creating public awareness can reduce the incidence of this preventable cause of blindness in the society. Initiating new policies for retailers involved in sale of these firecrackers can also bring in decrease of such morbidities.

Visual Outcomes and Prognostic Factors after Pars Plana Vitrectomy for Traumatic Endophthalmitis

Purpose. To evaluate visual outcomes and identify prognostic factors after pars plana vitrectomy (PPV) surgery for traumatic endophthalmitis. Methods. Medical records of 121 consecutive patients (121 eyes) diagnosed with traumatic endophthalmitis that had undergone pars plana vitrectomy were retrospectively reviewed. Results. 121 patients, aged from 6 to 71 years, all underwent PPV surgery. 113 cases had improved best corrected visual acuity (BCVA) after surgery and 60% of them obtained BCVA better than fingers counting (FC). Good final visual prognosis was significantly associated with time between trauma and initial treatment less than 12 hrs (40% versus 98%; P < 0.001), time between trauma and PPV treatment less than 24 hrs (62% versus 98%; P < 0.001), laceration length less than 10 mm (63% versus 96%; P < 0.001), and presenting VA better than LP (42% versus 96%; P < 0.001), while gender, type of laceration, presence of IOFB or retinal detachment, and the use of silicone oil tamponade were not significant factors resulting in better BCVA. Bacteria were identified in 43.8% of specimens and most of the microorganisms were identified as nonvirulent ones. Conclusions. Pars plana vitrectomy surgery was preferred as a primary treatment option for traumatic endophthalmitis. A good final visual prognosis was significantly associated with timely treatment, prompt vitrectomy surgery, shorter length of laceration, and better presenting visual acuity.

Pediatric Posttraumatic Endophthalmitis in China for Twenty Years

Pediatric posttraumatic endophthalmitis (PTE) is a rare but serious disease that frequently has a poor visual prognosis. To date, only a few English studies have focused on this disease. We perform a systematic review of the Chinese literature on pediatric PTE and describe the epidemiology, management, causative organisms, and visual acuity outcomes of reported cases in twenty years. We found that Staphylococcus epidermidis was the most common isolated organism and the use of a disposable syringe needle was the most common cause of ocular injuries in pediatric PTE in China. In the last ten years, the time from injury to first presentation for treatment has shortened, the proportion of cases resulting from a disposable syringe needle has decreased, the use of intravitreal antibiotics as the initial treatment has increased, and the use of palliative treatment has decreased. Although these favorable changes have occurred in the last ten years, the visual prognosis of pediatric PTE is still poor.

A new era of uveitis: impact of polymerase chain reaction in intraocular inflammatory diseases

Uveitis is a sight-threatening intraocular inflammatory disorder which may occur from both infectious and non-infectious or autoimmune causes. The frequency of infectious uveitis and autoimmune uveitis varies depending on countries and regions. According to a nationwide survey conducted by the Japanese Ocular Inflammation Society, infectious and non-infectious uveitis accounted for 16.4 and 50.1% of new patients, respectively while the remaining 33.5% of new uveitis cases were not classified or were idiopathic uveitis. Infectious uveitis is particularly important because it causes tissue damage to the eye and may result in blindness unless treated. However, it can be treated if the pathogenic microorganisms are identified promptly and accurately. Remarkable advancements in molecular and immunological technologies have been made in the last decade, and the diagnosis of infectious uveitis has been greatly improved by the application of molecular and immunological investigations, particularly polymerase chain reaction (PCR). PCR performed on a small amount of ocular samples provides a prompt, sensitive, and specific molecular diagnosis of pathogenic microorganisms in the eye. This technology has opened a new era in the diagnosis and treatment of uveitis, enabling physicians to establish new clinical entities of uveitis caused by infectious microorganisms, identify pathogens in the eyes of many patients with uveitis, and determine prompt diagnosis and appropriate therapy. Here we review the PCR process, new PCR tests specialized for ocular diseases, microorganisms detected by the PCR tests, diseases in the eye caused by these microorganisms, and the clinical characteristics, diagnosis, and therapy of uveitis.