Endophthalmitis today: a multispecialty ophthalmology department perspective

Controversies in the management of endophthalmitis: a 5-year retrospective cohort study

BACKGROUND AND PURPOSE

Post-operative endophthalmitis has a risk of vision loss if the treatment is delayed. Managing endophthalmitis based on visual outcome has become controversial. This study primarily aimed to evaluate the effectiveness of early pars plana vitrectomy (PPV) combined with intravitreal antibiotics in improving visual acuity and reducing complications in patients with post-operative endophthalmitis. Secondary objectives included identifying prognostic factors influencing visual outcomes after PPV, assessing the effectiveness of different intravitreal antibiotic regimens on visual recovery, and evaluating the role of steroid as adjunctive therapy in influencing visual outcome and controlling inflammation.

METHODS

A 5-year retrospective cohort study was conducted, reviewing medical records of patients diagnosed with post-operative endophthalmitis between 2019 and 2023. Data collected included patient demographics, medical and surgical history, culture results, treatments administered, baseline best-corrected visual acuity (BCVA), and BCVA outcomes within three months after vitrectomy.

RESULTS

40 eyes of 40 patients with acute post-operative endophthalmitis underwent early PPV followed by intravitreal antibiotics. Median logMAR BCVA improved from 2.0 at presentation to 0.4 three months post-vitrectomy (p < 0.05), with a mean final logMAR BCVA of 0.94 ± 1.13. No significant difference was observed in visual outcomes or complication rates between patients treated with intravitreal vancomycin and ceftazidime versus moxifloxacin monotherapy. Univariate analysis identified high intraocular pressure (p = 0.004, β = 2.42), hypopyon (p = 0.01, β = 1.79), and a history of surgery more than seven days prior (p = 0.032, β = 1.74) as significant predictive of visual outcomes. Multivariate analysis confirmed intraocular pressure (p = 0.008, β = 2.55) and surgical history (p = 0.045, β = 1.84) as independent predictors. Baseline BCVA, fibrin, retinal findings, and symptom onset were not significantly associated with outcomes. Neither antibiotics regimen nor steroid use significantly influenced treatment results.

CONCLUSION

This study supports performing early PPV combined with intravitreal antibiotics as an effective primary treatment to improve visual outcomes in post-operative endophthalmitis. Negative prognostic factors included hypopyon, elevated intraocular pressure, and a surgical history of more than seven days. Management should prioritize clinical signs over microbiological culture results to prevent delays in treatment.

Risk Factors for Legal Blindness in 237 Japanese Patients with Exogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential risk factors for visual prognosis in Japanese patients with exogenous endophthalmitis.

METHODS

In this retrospective observational multicenter cohort study, risk factors for legal blindness at 12 weeks after treatment initiation were evaluated based on patient characteristics, initial BCVA, causative events, pathogens, ocular symptoms, duration from symptom onset to initial treatment, and selected treatments.

RESULTS

Overall, 23.1% of eyes developed legal blindness. The six risk factors for legal blindness were presence of eye pain, pathogen identification, poor BCVA at the initial visit, longer duration from symptom onset to initial treatment, type of causative event, and type of causative pathogen. Regarding the type of causative pathogen, coagulase-negative staphylococci was associated with a better visual impairment outcome.

CONCLUSION

Exogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatment, as well as other advances in medical knowledge and technology.

Infection prevention and control factors associated with post-cataract surgery endophthalmitis - a review of the literature from 2010 - 2023

Patients undergoing cataract surgery are at risk of post-cataract surgery endophthalmitis (PCSE), a sight-threatening complication. Cataract surgery is a relatively straightforward and quick procedure often performed under local anaesthetic. It is therefore simple to scale up to reduce the currently long waiting times, but it is important to maintain patient safety when considering high throughput surgery. This literature review aimed to identify appropriate infection prevention and control (IPC) measures to support increased throughput of cataract surgery in Scotland. Database searches were conducted using Medline and Embase from 2010 to 2023. Further hand-searching was also performed. The organisms associated with PCSE and IPC factors relevant to PCSE were analyzed. A range of microorganisms was associated with PCSE, where outbreak reports were most associated with Gram-negative bacteria and fungi, whereas retrospective chart reviews were most associated with Gram-positive bacteria. IPC risk factors identified were related to the built environment and issues with sterilization. Specifically, the sources of outbreaks included failures in the ventilation system, as well as contaminated ophthalmic solutions, surgical instruments, and medications. The factors identified in this review should be considered when implementing high throughput cataract surgery to ensure that patient safety is maintained.

Risk Factors for Legal Blindness in 77 Japanese Patients with Endogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential predictive factors for visual prognosis in Japanese patients with endogenous endophthalmitis.

DESIGN

Retrospective observational multicenter cohort study.

METHODS

We examined the characteristics of 77 Japanese patients with endogenous endophthalmitis and performed statistical analyses of these real-world data. The primary endpoint was the identification of factors associated with visual prognosis. We examined differences between patients in the better vision and legal blindness groups at 12 weeks after treatment initiation.

RESULTS

The five risk factors for visual impairment at 12 weeks after treatment initiation were presence of pressure injuries, severe clinical symptoms (presence of eye pain and ciliary injection), pathogen identification, and poor best-corrected visual acuity at baseline. Staphylococcus aureus and fungus were associated with a better visual impairment outcome.

CONCLUSIONS

Endogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatments, as well as other advances in medical knowledge and technology.

Gram-Negative Endogenous Endophthalmitis: A Systematic Review

Background: Gram-negative bacteria are causative agents of endogenous endophthalmitis (EBE). We aim to systematically review the current literature to assess the aetiologies, risk factors, and early ocular lesions in cases of Gram-negative EBE. Methods: All peer-reviewed articles between January 2002 and August 2022 regarding Gram-negative EBE were included. We conducted a literature search on PubMed and Cochrane Controlled Trials. Results: A total of 115 studies and 591 patients were included, prevalently Asian (98; 81.7%) and male (302; 62.9%). The most common comorbidity was diabetes (231; 55%). The main aetiologies were Klebsiella pneumoniae (510; 66.1%), Pseudomonas aeruginosa (111; 14.4%), and Escherichia coli (60; 7.8%). Liver abscesses (266; 54.5%) were the predominant source of infection. The most frequent ocular lesions were vitreal opacity (134; 49.6%) and hypopyon (95; 35.2%). Ceftriaxone (76; 30.9%), fluoroquinolones (14; 14.4%), and ceftazidime (213; 78.0%) were the most widely used as systemic, topical, and intravitreal anti-Gram-negative agents, respectively. The most reported surgical approaches were vitrectomy (130; 24.1%) and evisceration/exenteration (60; 11.1%). Frequently, visual acuity at discharge was no light perception (301; 55.2%). Conclusions: Gram-negative EBEs are associated with poor outcomes. Our systematic review is mainly based on case reports and case series with significant heterogeneity. The main strength is the large sample spanning over 20 years. Our findings underscore the importance of considering ocular involvement in Gram-negative infections.

Clinical Characteristics and Outcomes in 314 Japanese Patients with Bacterial Endophthalmitis: A Multicenter Cohort Study from J-CREST

Bacterial endophthalmitis is an intraocular infection that causes rapid vison loss. Pathogens can infect the intraocular space directly (exogenous endophthalmitis (ExE)) or indirectly (endogenous endophthalmitis (EnE)). To identify predictive factors for the visual prognosis of Japanese patients with bacterial endophthalmitis, we retrospectively examined the bacterial endophthalmitis characteristics of 314 Japanese patients and performed statistics using these clinical data. Older patients, with significantly more severe clinical symptoms, were prevalent in the ExE group compared with the EnE group. However, the final best-corrected visual acuity (BCVA) was not significantly different between the ExE and EnE groups. Bacteria isolated from patients were not associated with age, sex, or presence of eye symptoms. Genus Streptococcus, Streptococcus pneumoniae, and Enterococcus were more prevalent in ExE patients than EnE patients and contributed to poor final BCVA. The presence of eye pain, bacterial identification, and poor BCVA at baseline were risk factors for final visual impairment.

Diagnostic Performance of MALDI-TOF MS Compared to Conventional Microbiological Cultures in Patients with Suspected Endophthalmitis

Purpose: To evaluate the performance and speed of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) when identifying the pathogenic microorganism of endophthalmitis compared to conventional microbiological culturing.Methods: Forty-four patients with suspected endophthalmitis who had undergone vitrectomy were enrolled. Vitreous specimen was analyzed using either conventional culturing or MALDI-TOF MS.Results: The identification rates of the conventional microbiological culture and MALDI-TOF MS were 45.5% (20/44) and 65.9% (29/44), respectively (Kappa value 0.787, P < 0.000). The mean detection times by the standard culturing method and MALDI-TOF MS were 5.39 ± 0.56d and 3.17 ± 0.40d (P < 0.001). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MALDI-TOF MS were 70.59%, 54.17%, 80.00%, and 86.67%, respectively. Polymicrobial endophthalmitis was identified in 6.82% of the patients (3/44) using conventional microbiological culturing. However, MALDI-TOF MS failed to identify any polymicrobial infection.Conclusions: With a higher sensitivity, acceptable specificity and a shorter detection time, MALDI-TOF MS was an efficient technique for the rapid identification of a pathogenic microorganism in endophthalmitis.

Bactec™ blood culture bottles allied to MALDI-TOF mass spectrometry: rapid etiologic diagnosis of bacterial endophthalmitis

Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (MS) has been used for direct identification of pathogens from blood-inoculated blood culture bottles (BCBs). We showed that MALDI-TOF MS is an useful technique for rapid identification of the causative agents of endophthalmitis from vitreous humor-inoculated BCBs with a simple protocol.