Visual outcome of 25 Gauge vitrectomy for acute post operative infectious endophthalmitis

BACKGROUND

The correlation between the change in foveal thickness measured using optical coherence tomography (OCT) following surgery for infectious endophthalmitis and preoperative and postoperative visual acuity is uncertain, and there are few pertinent studies on this topic.

OBJECTIVE

We explored the variations in macular thickness using OCT after emergency vitrectomy for post-cataract infectious endophthalmitis and the relationship between macular thickness with changes in visual function.

METHODS

We included 10 cases of post-cataract infectious endophthalmitis. Each patient underwent 25-G vitrectomy.

RESULTS

The infection in all 10 patients was under control and visual function improved. Postoperative vitreous humor culture was positive in 8 patients, including 7 cases of coagulase-negative Staphylococcus epidermidis and 1 case of Lactobacillus acidophilus. The average age of these 10 patients was 71.60 ± 8.71 years (P< 0.05, two-tailed). There was no significant correlation between time 2 (the time of onset after cataract surgery) and visual prognosis. The average time 1 (the time of the vitrification surgery caused by the onset of the disease) was 1.45 ± 0.76 days (P< 0.05, two-tailed). The postoperative 3dVA ranged from 0.20 to 3.00, with an average visual acuity of 1.87 ± 1.12, which was superior to the preoperative value (P< 0.01, two-tailed). The correlation between the post3dVA and post 1mVA was significant. The post 1mVA ranged from 0.05 to 2.20, with an average visual acuity of 0.94 ± 0.74 (P< 0.05, two-tailed). The correlation between post 1mVA and post3mVA was significant. Also, paired t-tests comparing preoperative and postoperative visual acuity revealed a significant correlation (P< 0.05, two-tailed). The post3mVA was 0-1.00 with an average visual acuity of 0.44 ± 0.41. The postoperative foveal thickness ranged from 176.00 to 514.00 μm, with an average thickness of 281.10 ± 113.12 μm.

CONCLUSION

Emergency 25-G minimally invasive vitrectomy can improve visual acuity and decrease the reoperation rate for patients who have acquired post-cataract infectious endophthalmitis. There were significant correlations between age, disease onset to operation time, preoperative and postoperative visual acuity, and postoperative macular thickness.

Pediatric Pars Planitis: A Review

PURPOSE

To provide an overview of pediatric pars planitis.

METHODS

Narrative literature review.

RESULTS

Pars planitis refers to the idiopathic subset of intermediate uveitis in which there is vitritis along with snowball or snowbank formation occurring in the absence of an associated infection or systemic disease. It is thought to be a T-cell mediated disease with a genetic predisposition. Pars planitis accounts for 5-26.7% of pediatric uveitis cases. Presentation is commonly bilateral but asymmetric, often with insidious onset of floaters and blurred vision. Although pars planitis is known to be a benign form of uveitis in most cases, severe complications secondary to chronic inflammation may arise, with cystoid macular edema being the most common cause of visual morbidity. Mild vitritis in the absence of symptoms, vision loss, or macular edema may be observed. Patients with severe vitritis and/or associated vision-threatening complications require prompt aggressive treatment. A stepladder approach including corticosteroids, immunosuppressive agents, anti‑tumor necrosis factor‑alpha and pars plana vitrectomy and/or laser photocoagulation is the most commonly used method for treatment of pars planitis.

CONCLUSION

Timely diagnosis and adequate treatment of pediatric pars planitis and associated complications are crucial in order to improve visual outcomes.

Ultrasound-Guided Pars Plana Vitrectomy

PURPOSE

To assess the feasibility of a novel surgical technique that combines B-scan ultrasound with modern vitrectomy techniques.

METHODS

Patients with a clinical diagnosis of infectious keratitis endophthalmitis, which were scheduled for pars plana vitrectomy and ruled out as candidates for transient keratoprosthesis, were enrolled. The ultrasound probe was placed over the eye to use the images to witness the vitreous movement around the cutter and to establish its position in relation to the retinal wall. The procedure was performed in at least four ultrasound projections (longitudinal-9,6, 3, and 12). All patients were followed for three months, and in each visit, the visual acuity and the presence of adverse effects were assessed.

RESULTS

Overall, 12 patients (mean age: 56.2 ± 18.4 years) were enrolled. Visual acuity at baseline was 2.3 ± 0.25 logarithm of the minimum angle of resolution. Sixty-six percent achieved inactivation of endophthalmitis. Two patients had evisceration caused by uncontrolled infection, and two more had retinal detachment during follow-up. Visual acuity at the end of follow-up was 2.1 ± 0.3 logarithm of the minimum angle of resolution ( P = 0.5).

CONCLUSION

Ultrasound-guided vitrectomy is a feasible surgical technique. More studies are needed to assess its safety profile and optimize outcomes.

Endogenous endophthalmitis caused by urinary tract infection: A case report

RATIONALE

Endogenous endophthalmitis is a vision-threatening intraocular infection caused by hematogenous spread of infectious organisms from distant sites.

PATIENT CONCERNS

A 71-year-old man with a history of fever and dysuria 5 days prior to presentation presented with sudden loss of vision in his left eye. The patient had no history of ocular surgery or trauma, and ocular examination revealed a large amount of exudative plaque covering the pupil. Therefore, fundus examination was not feasible. B-scan ultrasonography revealed a dome-shaped subretinal mass with an exudative retinal detachment.

DIAGNOSIS

Endogenous endophthalmitis was diagnosed on the basis of these findings.

INTERVENTIONS

The patient underwent pars plana vitrectomy and the early postoperative course was favorable.

OUTCOMES

Vitreous cultures grew gram-negative bacilli, identified as Klebsiella pneumonia. Urinalysis revealed white blood cells (++) and urinary tract infection was the only identifiable risk factor for endogenous endophthalmitis.

LESSONS

Urinary tract infection is an independent risk factor for endogenous endophthalmitis.

EFFICACY OF VITRECTOMY COMBINED WITH INTRAVITREAL ANTIBIOTICS FOR SEVERE POST-TRAUMATIC ENDOPHTHALMITIS

PURPOSE

To explore clinical efficacy of vitrectomy combined with intravitreal antibiotics in treating severe endophthalmitis after open-globe trauma in patients.

METHODS

The records of all patients who received vitrectomy combined with intravitreal for the severe post-traumatic endophthalmitis with light perception or worse between 2010 and 2022 were retrospectively reviewed. Patients received vitrectomy combined with intravitreal antibiotics, repeated intravitreal antibiotics with or without vitreous aspiration, and retinal repair after the infection was controlled. Efficacy of severe post-traumatic endophthalmitis was analyzed.

RESULTS

One hundred and twenty-one patients (121 eyes) were included in this study. The mean BCVA improved from 4.03 ± 0.18 logarithm of the minimum angle of resolution to 1.75 ± 1.41 logarithm of the minimum angle of resolution ( P < 0.001) at the end of the follow-up period, which increased in 106 eyes (87.60%). Infection was successfully controlled in all eyes, 88 eyes within two operations. Pathogens including streptococci (odds ratio [OR] = 6.68, P < 0.001), fungi (OR = 15.23, P < 0.001), and mixed infection (OR = 6.67, P < 0.05) were related to the number of operations. Finally, 60 eyes (49.59%) received silicone oil filling, 25 received gas tamponade, and the remaining 36 received no tamponade; complete vitrectomy was performed in all eyes with intraocular tamponade. All eyes for gas tamponade and no tamponade had been remained stable without retinal detachment and proliferative vitreoretinopathy after 6-month follow-up. The rate of recurrent retinal detachment after silicone oil tamponade was 4.96% (six eyes), including 1.65% (two eyes) of proliferative vitreoretinopathy; these eyes underwent reoperation of retinal detachment repair.

CONCLUSION

Vitrectomy combined with intravitreal antibiotics may be an effective treatment option for severe post-traumatic endophthalmitis.

Double-flanged polypropylene technique: 5-year results

PURPOSE

To assess the long-term (5-year) results and complications of the double-flanged polypropylene technique in patients with capsular tension segment fixation, nonfoldable intraocular lens (IOL) scleral fixation, and foldable IOL scleral fixation.

SETTING

Santa Casa de Belo Horizonte and Centro Oftalmológico de Minas Gerais.

DESIGN

Prospective case series.

METHODS

Eyes that underwent treatment using the double-flanged polypropylene technique between September 2016 to September 2021 were included. LogMAR visual acuity was recorded, as well as complications such as long-term polypropylene resistance, conjunctival erosion, conjunctival inflammation, flange exposure, internalization, endophthalmitis, retinal detachment, and cystoid macular edema.

RESULTS

71 eyes of 61 patients were evaluated. The mean follow-up period for these eyes was 28.2 ± 14.3 (min: 4; max: 60; median: 26) months. 173 flanges were performed. 13 cases with sub-Tenon flanges (7.5%) were observed. 5 exposed flanges (2.89%), presented after a mean of 1.8 weeks postoperatively, were observed. 1 patient with large flanges presented with conjunctival inflammation and hyperemia. 2 late internalized flanges (1.1%) and 2 recently internalized flanges (1.1%) were observed. 3 eyes (4.22%) had retinal detachment. Moreover, cystoid macular edema was detected in 3 eyes (4.22%). No cases of endophthalmitis were observed.

CONCLUSIONS

The double-flanged technique was proven to be stable when the correct technical procedure was followed. However, complications can be observed, especially with short scleral tunnels and in eyes where the flanges were not buried inside the sclera.

Surgical outcomes of orbital evisceration with primary orbital implant placement in patients with endophthalmitis

OBJECTIVES

This study reports the surgical outcomes of evisceration with primary orbital implant placement in patients with endophthalmitis and analyses the association with implant exposure and extrusion.

METHODS

A retrospective, multicentre, Chinese cohort study. Review of medical records and orbital images of patients who underwent evisceration with primary orbital implant placement between January 2005 and January 2021.

RESULTS

Out of 79 patients who underwent orbital evisceration with primary orbital implant placement, 26 (26 eyes) of them (male = 13) suffered from endophthalmitis. The duration from endophthalmitis diagnosis (19 = exogenous, 7 = endogenous) to evisceration was 9 standard deviation ± 5 (range: 1-15) days. The follow-up was 70 ± 46 (24-180) months after operation. The orbital implant size was 17 ± 3 (14-20) mm, and silicone was the most used material (69%, 18/26 of patients). The most frequent post-operative complication was orbital implant exposure (42%, 11/26), followed by orbital implant extrusion (12% 3/26) and ptosis (8%, 2/26). Implant exposure or extrusion was more commonly associated with endophthalmitis in comparison to non-endophthalmitis patients that required evisceration and primary orbital implant placement (54% versus 17%, P < 0.05). Univariate analysis showed single scleral closure technique (100% versus 58%, P < 0.05) and endogenous endophthalmitis (50% versus 0%, P < 0.05) were associated with implant exposure or extrusion, and only endogenous endophthalmitis was significant with multivariate analysis (P < 0.05).

CONCLUSIONS

Primary implant placement during evisceration should be avoided in eyes with endophthalmitis especially in those with an endogenous source, and double scleral closure technique may be a better alternative for primary orbital implant placement in infected eyes.

Case Report: Poor Outcome Despite Aggressive Management in Pythium insidiosum Endophthalmitis

Pythium insidiosum is a parasitic oomycete that can cause keratitis and closely resembles fungus, both clinically and morphologically. It requires a trained microbiologist for its differentiation from fungal filaments and has poor response to antifungal therapy. We present a case of primary isolation of the organism from the vitreous cavity in a case of endophthalmitis. The infection spread quickly and involved all the ocular tissues. The eye had poor visual outcome despite a sequence of rapidly completed retinal and corneal surgeries along with initiation of anti-Pythium therapy.

Silicone oil tamponade in managing recalcitrant endophthalmitis after cataract surgery secondary to Clostridium intestinale

A woman presented two weeks after uncomplicated cataract surgery with decreased visual acuity from endophthalmitis. One week after initial management with intravitreal antibiotics, her visual acuity decreased further, undergoing pars plana vitrectomy with intravitreal and intravenous antimicrobial coverage with preliminary improvement. Three days after vitrectomy, her vision decreased with recurrent inflammation. Initial cultures grew Clostridium intestinale She underwent repeat vitrectomy with silicone oil tamponade with no subsequent recurrence. The silicone oil was removed after 4 months and her visual acuity returned to 20/20 after 1 month and through 1 year of follow-up. Postoperative endophthalmitis is rare, with cases due to Clostridium species particularly destructive. In this first reported case of C. intestinale endophthalmitis, conventional management did not achieve lasting quiescence until silicone oil tamponade was employed. Pars plana vitrectomy with silicone oil tamponade should be considered in the management of recurrent endophthalmitis or endophthalmitis secondary to a recalcitrant microbe.

Early vitrectomy for exogenous endophthalmitis following surgery

BACKGROUND

Endophthalmitis is a sight-threatening emergency that requires prompt diagnosis and treatment. The condition is characterised by purulent inflammation of the intraocular fluids caused by an infective agent. In exogenous endophthalmitis, the infective agent is foreign and typically introduced into the eye through intraocular surgery or open globe trauma.

OBJECTIVES

To assess the potential role of combined pars plana vitrectomy and intravitreal antibiotics in the acute management of exogenous endophthalmitis, versus the standard of care, defined as vitreous tap and intravitreal antibiotics.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5); Ovid MEDLINE; Ovid Embase; the International Standard Randomised Controlled Trial Number registry; ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. There were no restrictions to language or year of publication. The date of the search was 5 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared pars plana vitrectomy and intravitreal injection of antibiotics versus intravitreal injection of antibiotics alone, for the immediate management of exogenous endophthalmitis.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Two review authors independently screened search results and extracted data. We considered the following outcomes: visual acuity improvement and change in visual acuity at three and six months; additional surgical procedures, including vitrectomy and cataract surgery, at any time during follow-up; quality of life and adverse effects. We assessed the certainty of the evidence using the GRADE approach.  MAIN RESULTS: We identified a single RCT that met our inclusion criteria. The included RCT enrolled a total of 420 participants with clinical evidence of endophthalmitis, within six weeks of cataract surgery or secondary intraocular lens implantation. Participants were randomly assigned according to a 2 x 2 factorial design to either treatment with vitrectomy (VIT) or vitreous tap biopsy (TAP) and to treatment with or without systemic antibiotics. Twenty-four participants did not have a final follow-up: 12 died, five withdrew consent to be followed up, and seven were not willing to return for the visit.  The study did not report visual acuity according to the review's predefined outcomes. At three months, 41% of all participants achieved 20/40 or better visual acuity and 69% had 20/100 or better acuity. The study authors reported that there was no statistically significant difference in visual acuity between treatment groups (very low-certainty evidence). There was low-certainty evidence of a similar requirement for additional surgical procedures (risk ratio RR 0.90, 95% confidence interval 0.66 to 1.21). Adverse effects included: VIT group: dislocated intraocular lens (n = 2), macular infarction (n = 1). TAP group: expulsive haemorrhage (n = 1). Quality of life and mean change in visual acuity were not reported.  AUTHORS' CONCLUSIONS: We identified a single RCT (published 27 years ago) for the role of early vitrectomy in exogenous endophthalmitis, which suggests that there may be no difference between groups (VIT vs TAP) for visual acuity at three or nine months' follow-up.   We are of the opinion that there is a clear need for more randomised studies comparing the role of primary vitrectomy in exogenous endophthalmitis. Moreover, since the original RCT study, there have been incremental changes in the surgical techniques with which vitrectomy is performed. Such advances are likely to influence the outcome of early vitrectomy in exogenous endophthalmitis.

Immediate vitrectomy for acute endophthalmitis in patients with a visual acuity of hand motion or better

Purpose

To determine the efficacy of immediate pars plana vitrectomy as the primary treatment for acute endophthalmitis in patients with a visual acuity (VA) of hand motion (HM) or better.

Methods

A total of 149 patients who were referred to a single center for acute endophthalmitis after cataract surgery over the 13-year study period were retrospectively analyzed. Only patients presenting with a VA of at least HM were included. Patients were initially treated with either primary vitrectomy or intravitreal antibiotic injection alone, and their visual outcomes and reintervention rates after initial treatment were compared.

Results

There was no significant difference in the proportion of good (final VA ≥20 / 40) and poor (VA ≤ counting finger) visual outcomes between the groups. However, subgroup analysis of patients with a VA of HM (92 eyes) showed that the incidence of reintervention (14 of 72 eyes [19.4%] vs. 9 of 20 eyes [45.0%]) and poor visual outcomes (10 of 72 eyes [13.9%] vs. 8 of 20 eyes [40.0%]) were lower after prompt vitrectomy than after intravitreal antibiotic injection alone (p = 0.019 and p = 0.022, respectively). For those with a VA of at least counting finger, no significant difference was observed between the groups.

Conclusions

For patients with endophthalmitis presenting with a VA of HM, performing a prompt vitrectomy reduced the incidence of reintervention and poor visual outcomes than the administration of intravitreal antibiotics alone. Our results suggest that primary vitrectomy for patients with endophthalmitis presenting with a VA of HM could be more beneficial than intravitreal antibiotic injection alone.

Outcomes of evisceration or enucleation by resident trainees in patients with recalcitrant endophthalmitis or panophthalmitis

To evaluate the surgical outcomes and complications of evisceration or enucleation with primary implantation, performed by ophthalmology resident trainees, in regards to patients with recalcitrant endophthalmitis or panophthalmitis. We also compared the surgical outcomes and complications between resident trainees and experienced staff. In this retrospective analysis, the clinical records of all patients diagnosed with endophthalmitis or panophthalmitis who underwent enucleation or evisceration with primary implantation over a 13-year period were reviewed. The factors predicting implant exposure or extrusion in regards to patients who underwent eye removal by trainees were identified using multivariate analysis. The percentages of successful prosthesis fittings and complications were also reported. Sixty-six patient records, median age of 46.8 years, who underwent eye removal by resident trainees were reviewed. Thirty-six (55%) out of 66 patients were diagnosed with panophthalmitis. Four patients (6%) had implant exposure, and 4 patients (6%) had implant extrusion. Multivariate analysis demonstrated that Pseudomonas aeruginosa infection (P = .02, adjusted odd ratio [aOR] = 33.75) and not receiving intravitreal antimicrobial drugs before the eye removal procedure (P = .02, aOR = 30.11) were associated with implant exposure or extrusion. Patients with panophthalmitis who underwent evisceration had a higher rate of implant exposure or extrusion than those who underwent enucleation (P = .03, aOR 38.38). At the last visit, 65 patients had a successful prosthesis fitting. Furthermore, there were similar rates of complications and successful prosthesis fittings between experienced staff and resident trainees. This study suggests that evisceration or enucleation with primary implant placement in patients with recalcitrant endophthalmitis or panophthalmitis can be performed by resident trainees with acceptable surgical outcomes and a low rate of serious complications.

A Case of Post-cataract Surgery Endophthalmitis Successfully Treated with Conservative Therapy

BACKGROUND

Postoperative endophthalmitis after cataract surgery often requires emergency surgery if caused by an infection. However, early reoperation after the surgery put a heavy mental burden on the patient. Here we report a relatively mild case of postoperative endophthalmitis in which emergency surgery was avoided through careful observation including gram stain and culture test.

CASE

87-year-old male. The patient had a sudden decrease in visual acuity on the 4th day after cataract surgery of the left eye performed at another hospital and visited his previous doctor on the following day. Postoperative endophthalmitis was suspected, so he was referred to our department on the same day. The inflammation was observed in the anterior segment of the left eye. The gram staining results for collected anterior aqueous humor were negative. The patient was followed up with continued medication and careful observation without undergoing emergency surgery. The inflammation of the anterior segment subsequently improved. The patient underwent a left vitrectomy three months later to remove residual vitreous opacity.

CONCLUSION

Postoperative endophthalmitis after cataract surgery is often indicated for emergency surgery, but there can be cases in which conservative therapy with thorough observation succeeds in retaining visual function.

INCIDENCE AND RISK FACTORS OF POSTOPERATIVE ENDOPHTHALMITIS AFTER PRIMARY SURGICAL REPAIR COMBINED WITH INTRAOCULAR FOREIGN BODY REMOVAL

PURPOSE

To analyze the incidence and risk factors of postoperative endophthalmitis after primary surgical repair and intraocular foreign body (IOFB) removal within 24 hours of injury.

METHODS

The records of all patients treated surgically for open globe injury and IOFB removal at the Eye Hospital of Shandong First Medical University between January 1, 2015, and June 30, 2020, were retrospectively reviewed. Variables included time from injury to operation, cause of injury, details of surgical repair, and follow-up. The incidence and risk factors of endophthalmitis after IOFB removal were studied.

RESULTS

During 5 years, 99 patients with IOFB were reviewed. Of these, 19 patients were diagnosed with endophthalmitis on admission, and 5 were suspected of having endophthalmitis during operation. Fifty-four cases had no clinical signs of endophthalmitis on admission and during operation and were treated with operation within 24 hours after the injury. Two patients (2 of 54; 3.70%) developed endophthalmitis after IOFB removal, and the causative agent in both cases was Bacillus cereus.

CONCLUSION

The incidence of infectious endophthalmitis after primary surgical repair combined with IOFB removal (≤24 hours) was 3.70% in patients who received a series of standard treatments, and B. cereus infection might be a risk factor.

Postoperative Pseudomonas aeruginosa endophthalmitis associated with asymptomatic bacteriuria

An 86-year-old man with diabetes and a history of prostate cancer, indwelling urinary catheter and Pseudomonas aeruginosa bacteriuria presented on day 4 post left phacoemulsification cataract extraction and intraocular lens implant with signs and symptoms of postoperative endophthalmitis. Vitreous sample was positive for P. aeruginosa Prompt treatment with intravitreal antibiotics was initiated followed by anterior chamber washout with pars plana vitrectomy; however, the visual outcome was poor.

Early Pars Plana Vitrectomy in Acute Endophthalmitis: The Manchester Series

BACKGROUND AND OBJECTIVE

Current literature lacks good-quality evidence regarding the outcomes of early pars plana vitrectomy (PPV) for acute exogenous endophthalmitis. The aim for this study was to analyze and discuss the outcomes of PPV for endophthalmitis in a UK tertiary hospital.

PATIENTS AND METHODS

This study was a retrospective case series. The clinical records of consecutive patients who had PPV for acute exogenous endophthalmitis were reviewed. Demographic data, etiology, timing of onset, timing of PPV, intraand postoperative complications, baseline and final best-corrected visual acuity (BCVA), therapeutic regimens, and microbiology details were collected. Primary efficacy and safety outcome measures were BCVA improvement of two or more logMAR lines and intra- or postoperative complications, respectively.

RESULTS

Forty-one patients with a median age of 76 (interquartile range, 64 to 82) years were studied. The most common etiology was intravitreal injection (41%), followed by phacoemulsification (34%). Median interval to PPV was 1.0 (interquartile range, 1.0 to 3.0) days. In a multivariate model controlling for age, baseline BCVA, microbiology positivity, and etiology (post-intravitreal injection), PPV after 24 hours was seven times more likely to achieve significant BCVA improvement (odds ratio, 7.47; 95% confidence interval, 1.12 to 49.66; P = .038). PPV within 24 hours of presentation was associated with more intraoperative complications.

CONCLUSIONS

Favorable outcomes may be achieved with current antibiotic regimens and PPV for endophthalmitis. The series suggests that an early surgical intervention may be associated with poorer functional outcomes. Tap and inject at presentation, followed by a semi-urgent PPV as required, seems to be a sensible approach. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:96-102.].

Intraocular Povidone Iodine During Pars Plana Vitrectomy for Severe and Atypical Endophthalmitis

BACKGROUND AND OBJECTIVE

To describe the experience and clinical outcomes of povidone iodine (PI) infusion in the setting of pars plana vitrectomy for the treatment of endophthalmitis.

MATERIALS AND METHODS

This was a retrospective case series of 12 patients with clinical and/or culture evidence of endophthalmitis requiring pars plana vitrectomy with 0.025% PI used in vitreous irrigation solution during vitrectomy. The primary endpoint was clinical resolution of the infection. Secondary endpoints included visual recovery, need for repeat surgery, and ocular toxicity RESULTS: There were 11 eyes that showed clinical or culture evidence of resolution of infection postoperatively (91.7%); 10 eyes had improvement in vision postoperatively (83.3%). Overall uncorrected visual acuity improved from 20/5321 (2.43 ± 0.58 logMAR) to 20/375 (1.27 ± 1.05 logMAR) (P = .0003). No clinical evidence of ocular toxicity or unexplained vision loss due to PI was observed.

CONCLUSIONS

PI infusion during pars plana vitrectomy for endophthalmitis appears safe and led to excellent post-surgical results in a traditionally high-risk cohort. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:485-490.].

Clinical outcomes of posterior segment intraocular foreign bodies: The volume effect

PURPOSE

To assess the effect of foreign body volume on visual and anatomic outcomes in patients with a posterior segment intraocular foreign body (IOFB).

METHODS

Patients were divided into three groups according to the volume of the IOFB; group 1 (n=18 eyes) with IOFBs<2mm³, group 2 (n=15 eyes) with 2mm³≤IOFBs<6mm³, group 3 (n=18 eyes) with IOFBs≥6mm³. All eyes underwent pars plana vitrectomy (PPV) for removal of the IOFB. Demographic characteristics, features of the injury and IOFB, findings of the initial and final ophthalmological examinations, and timing of IOFB removal were studied.

RESULTS

The mean age was 38.8±12.0years, and the median follow-up period was 12.0 (range: 6-98) months. Initial visual acuity (VA) was significantly lower in group 3 (P=0.005), while final VA was similar between the three subgroups. Frequencies of primary globe repair, initial vitreous hemorrhage (VH), corneoscleral entry, and IOFB removal through the cornea were significantly higher in eyes with large volume IOFBs (P<0.05). Siderosis was only seen in 4 patients in group 1 (22.2%). No patients developed postoperative endophthalmitis.

CONCLUSION

Large volume posterior segment IOFBs are associated with poor initial VA, initial VH and corneoscleral injury. Nevertheless, PPV and IOFB extraction under favorable conditions may provide significant visual improvement in eyes with large volume IOFBs.

Early Pars Plana Vitrectomy for Treatment of Acute Infective Endophthalmitis

PURPOSE

To evaluate the efficacy and safety of early pars plana vitrectomy (PPV) for the treatment of acute infective endophthalmitis, and identify prognostic factors for better visual outcome.

DESIGN

Retrospective cohort study.

METHODS

Consecutive patients who underwent early PPV within 72 hours of presentation for the treatment of acute infective bacterial endophthalmitis and presented to a large tertiary referral center in New South Wales, Australia, between January 2009 and December 2013 were included. Changes in best-corrected visual acuity (VA) from baseline to 1 year were examined.

RESULTS

A total of 64 patients were included. The inciting events were cataract surgery (53%), intravitreal injection (36%), trabeculectomy (3%), and endogenous (3%). The mean VA improved from 3.1 logMAR (hand motion) at baseline to 1.02 (approximately 20/200) at 1 year, with 42% achieving final VA equal to or better than 0.477 logMAR (20/60) following early PPV. Positive prognostic factors were negative microbial cultures (P < 0.01) and etiology of post-cataract surgery (P < 0.01). In multivariable analyses adjusting for age and prognostic factors, patients with baseline VA of light perception and hand motion achieved greater visual gains than those with counting fingers, with gains of logMAR of -2.68, -2.09, and -0.85, respectively (P < 0.0001).

CONCLUSIONS

Most patients who undergo early PPV experience substantial VA improvement. Negative microbial cultures and endophthalmitis after cataract surgery were associated with better final visual outcome. Patients with presenting VA of light perception or hand motion achieved higher visual gains than those with counting fingers, suggesting the possibility that early PPV may be beneficial in both groups.

Treatment of Bacillus cereus endophthalmitis with endoscopy-assisted vitrectomy

To evaluate the use of endoscopy-assisted vitrectomy in patients with sight-threatening Bacillus cereus endophthalmitis.A retrospective analysis was conducted in 15 eyes with Bacillus cereus endophthalmitis. Patients were divided into 2 groups: endoscopy-assisted vitrectomy (5 eyes) and conventional vitrectomy (10 eyes). The following clinical data were recorded and analyzed: sex, age, latent period, symptom duration, follow-up time, visual acuity pre- and postsurgery, recurrence of endophthalmitis, incidence of phithisis bulbi, and incidence of enucleation.In the conventional vitrectomy group, postoperative visual acuity ranged from no light perception in 5 patients (50%), light perception in 3 patients (30%), 20/1000 in 1 patient (10%), and 20/50 in 1 patient (10%). In the endoscopy-assisted vitrectomy group, postoperative visual acuity ranged from no light perception in 2 patients (40%), light perception in 1 patient (20%), and hand movements in 2 patients (40%). There was no statistically significant difference between the 2 groups in terms of the final postoperative visual acuity (F = 0.006, P = .937). There is no difference between the 2 groups in terms of the incidence of enucleation. The median symptom duration was 4 hours (range: 2-6 hours) in the conventional group and 9 hours (range: 7-11 hours) in the endoscopy-assisted vitrectomy group. The difference in the symptom duration between the 2 groups was statistically significant (P = .002).There is no statistical significant difference between the 2 groups in terms of visual acuity and incidence of enucleation. Therefore, endoscopy-assisted vitrectomy can be considered as an alternative treatment for treatment of B cereus endophthalmitis particularly for cases when symptom duration was more than 6 hours.

Outcomes of 23-gauge transconjunctival sutureless vitrectomy for acute postoperative endophthalmitis

BACKGROUND

To report our 3-year experience of 23-gauge transconjunctival sutureless vitrectomy (TSV) for acute postoperative endophthalmitis at a tertiary referral center in southern Taiwan.

METHODS

This retrospective chart review study included 19 patients with acute postoperative endophthalmitis who underwent 23-gauge TSV from January 2011 to January 2015 at Kaohsiung Veterans General Hospital, Taiwan. Bacterial and fungal cultures from aqueous samples, vitreous samples, or both were performed.

RESULTS

Nineteen patients (12 male; 7 female) were included. The mean age was 72.4 ± 8.29 years. Acute postoperative endophthalmitis was noted in 18 patients after cataract surgery and in 1 patient after 23-gauge vitrectomy for a rhegmatogenous retinal detachment. Upon presentation, visual acuity was less than hand movement for 80% of the patients. Chief complaints included blurred vision (19 patients, 100%), followed by pain (10 patients, 52.6%) and red eye (4 patients, 21%). All patients were administered an intravitreal injection (IVI) of antibiotics and 23-gauge TSV, and the average number of IVIs was 2.68 ± 1.73 (1-9 IVIs). The interval between their initial eye symptoms and vitrectomy was 4.11 ± 4.73 days (0-2 days), and the interval between diagnosis with endophthalmitis and a vitrectomy was 1.11 ± 1.52 days (0-6 days). The final visual acuity was no light perception for 1 patient (5.3%), between 6/60 and 6/12 for 8 patients (42.1%), and 6/12 or better for 9 patients (47.4%). No retinal detachment or hypotony was noted postoperatively in any case.

CONCLUSION

23-gauge vitrectomy is safe and effective for the management of acute postoperative endophthalmitis. Early diagnosis and treatment with 23-gauge vitrectomy may provide a good visual outcome.

Endophthalmitis after intravitreal injections. Incidence, management and prognosis

OBJECTIVE

To assess the rate of endophthalmitis after intravitreal injection (IVI) in a «clean room» of a single health centre, following the guidelines of the Spanish Vitreo-Retinal Society (SERV). An analysis was performed on the culture specimens, response to treatment, and final outcomes (guidelines).

MATERIAL AND METHODS

A retrospective, observational study was conducted on a consecutive case series of patients diagnosed with infectious endophthalmitis after IVI in a single health centre between 2010 and 2015. Intravitreal and systemic treatment was given following the SERV guidelines. The patients were followed up the case was resolved.

RESULTS

There were 5 cases of endophthalmitis out of 9467 IVI (incidence 0.053%). Positive cultures were obtained in aqueous and/or vitreous fluid in all cases, with Staphylococcus epidermidis being involved in 4 out of 5 cases. In 2 cases, final visual acuity was non-light perception due to intractable retinal detachments after resolution of the infectious process.

CONCLUSIONS

IVI performed in a «clean room» have a low incidence of endophthalmitis. The most common infectious agent was Staphylococcus species. In 2 cases the functional prognosis was poor.

Postoperative Endophtalmities: therapeuthic results and Early vitrectomy

BACKGROUND

Postoperative endophthalmitis is a public health issue due to its bad prognosis; its treatment is both surgical and medical. Classically, surgical treatment was done if visual acuity is limited to light perception only.

AIM

To evaluate therapeutic results Of postoperative endophtalmitieS and to Compare therapeutics almost used intravitreal injection of antibiotics versus early vitrectomy.

METHODS

It's a retrospective comparative study  includIng 120 cases of acute postoperative endophthalmitis hospitalized in a referral ophthalmology department between July 2007 and June 2013. A comparison was conducted between two groups of 24 and 94 patients; the first-line treatment was early vitrectomy for the first group and intravitreal antibiotic injection alone for the second group.

RESULTS

The overall incidence rate was 0.38 %, Streptococcus and Staphylococcus Epidermidis where the most common bacterial strain (16 patients each). The treatment outcome was very favorable for 11 patients with final visual acuity  higher or equal to 2/10, the outcome was intermediate for 43 patients and poor for 66 patients because of final visual acuity lower than or equal to 1/20, loss of media transparency or anatomical or functional loss of the eye. The prognostic factors statistically correlated to treatment outcome where intense initial inflammation (p<0.001), high bacterial virulence (p=0.002), bacteria culture positive to Streptococcus (p=0.024), a defectuous operative incision (p= 0.012), age over 80 (p=0.022) and posterior capsule rupture (p=0.013). Early vitrectomy group (group1) achieved a higher percentage of good outcome (60% vs 41.5%,  p=0.098 ).

CONCLUSION

Functional result is better in the Vitrectomy group than in the antibiotic intravitreal injections group whereas not Statically signifiant.

Endogenous Endophthalmitis in the American and Korean Population: An 8-year Retrospective Study

PURPOSE

To study the clinical features of endogenous endophthalmitis (EE) in sample patient populations from the USA and South Korea over an 8-year period.

METHODS

We reviewed data from 128 eyes of 60 American and 48 Korean patients diagnosed with EE and compared their clinical characteristics.

RESULTS

Fungemia and liver abscess were the most common extraocular infection sources among American (26.7%) and Korean patients (33.3%), respectively. Klebsiella pneumoniae and Candida species were the most common pathogens of EE in the Korean and the American patients, respectively. Endophthalmitis caused by fungi had a better visual prognosis than that caused by bacteria (p = 0.001). Vitrectomy was beneficial for eyes with EE due to virulent bacteria presenting with worse than counting finger vision.

CONCLUSIONS

The predisposing conditions and responsible organisms for EE vary in different regions of the world. The visual prognosis was strongly influenced by the underlying pathogen.

Association of Genotyping of Bacillus cereus with Clinical Features of Post-Traumatic Endophthalmitis

Bacillus cereus is the second most frequent cause of post-traumatic bacterial endophthalmitis. Although genotyping of B. cereus associated with gastrointestinal infections has been reported, little is known about the B. cereus clinical isolates associated with post-traumatic endophthalmitis. This is largely due to the limited number of clinical strains available isolated from infected tissues of patients with post-traumatic endophthalmitis. In this study, we report successful isolation of twenty-four B. cereus strains from individual patients with different disease severity of post-traumatic endophthalmitis. Phylogenetic analysis showed that all strains could be categorized into three genotypes (GTI, GTII and GTIII) and the clinical score showed significant differences among these groups. We then further performed genotyping using the vrrA gene, and evaluated possible correlation of genotype with the clinical features of B. cereus-caused post-traumatic endophthalmitis, and with the prognosis of infection by conducting follow-up with patients for up to 2 months. We found that the disease of onset and final vision acuity were significantly different among the three groups. These results suggested that the vrrA gene may play a significant role in the pathogenesis of endophthalmitis, and genotyping of B. cereus has the potential for predicting clinical manifestation and prognosis of endophthalmitis. To the best of our knowledge, this is the first report of isolation of large numbers of clinical isolates of B. cereus from patients with endophthalmitis. This work sets the foundation for future investigation of the pathogenesis endophthalmitis caused by B. cereus infection.

Effect of Prior Anti-VEGF Injections on the Risk of Retained Lens Fragments and Endophthalmitis after Cataract Surgery in the Elderly

PURPOSE

To investigate the effect of prior intravitreal anti-vascular endothelial growth factor (VEGF) injections on surgical and postoperative complication rates associated with cataract surgery in a nationally representative longitudinal sample of elderly persons.

DESIGN

Retrospective, longitudinal cohort analysis.

PARTICIPANTS

A total of 203 643 Medicare beneficiaries who underwent cataract surgery from January 1, 2009, to December 31, 2013.

METHODS

By using the 5% sample of Medicare claims data, the study assessed risks of 3 adverse outcomes after receipt of cataract surgery for beneficiaries with a history of intravitreal injections. Risks of these outcomes in beneficiaries with a history of intravitreal injections relative to those without were calculated using the Cox proportional hazard model.

MAIN OUTCOME MEASURES

The primary outcome was the risk of subsequent removal of retained lens fragments (RLFs) within 28 days after cataract surgery. Secondary outcomes were a new diagnosis of acute (<40 days) or delayed-onset (40+ days) endophthalmitis and risk of a new primary open-angle glaucoma (POAG) diagnosis within 365 days after cataract surgery.

RESULTS

Prior intravitreal anti-VEGF injections were associated with a significantly increased risk of subsequent RLF removal within 28 days after cataract surgery (hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.19-4.30). Prior injections were also associated with increased risk of both acute (HR, 2.29; 95% CI, 1.001-5.22) and delayed-onset endophthalmitis (HR, 3.65; 95% CI, 1.65-8.05). Prior injections were not a significant indicator of increased risk of a new POAG diagnosis.

CONCLUSIONS

A history of intravitreal injections may be a risk factor for cataract surgery-related intraoperative complications and endophthalmitis. Given the frequency of intravitreal injections and cataract surgery, increased preoperative assessment, additional intraoperative caution, and postoperative vigilance are recommended in patients with a history of intravitreal injections undergoing cataract extraction.

POSTCATARACT ENDOPHTHALMITIS TREATED WITH SMALL GAUGE VITRECTOMY

PURPOSE

To discuss the use of minimally invasive, small gauge vitrectomy for acute postcataract endophthalmitis in patients with better than light-perception vision.

PATIENT

71-year-old man presented with redness, pain, and decreased vision of his left eye 11 days after cataract extraction. His visual acuity was counting fingers at 1 foot and slit-lamp examination revealed severe conjunctival injection, corneal edema, and hypopyon. The clinical impression was of acute postcataract endophthalmitis.

METHODS

Patient was taken for immediate vitrectomy with simultaneous vitreous tap for culture, PCR, and injection of intravitreal vancomycin and ceftazidime.

RESULTS

Culture and PCR of vitreous sample were positive for Staphylococcus epidermidis. Vision improved to 20/20 1 month postoperatively with complete resolution of vitreous inflammation and retinal vasculitis.

CONCLUSION

In postcataract endophthalmitis with dense vitritis and diffuse retinal vasculitis, immediate, 25-gauge vitrectomy may result in return of baseline visual acuity.

ENDOGENOUS ENDOPHTHALMITIS CAUSED BY BRUCELLA MELITENSIS

PURPOSE

Brucella is an intracellular gram-negative pathogen that acts as a facultative parasite. B. Melitensis endogenous endophthalmitis is quite rare. We herein report an unusual case of B. melitensis endophthalmitis with a good outcome after appropriate management.

METHODS

A retrospective interventional case report of an 18-year-old boy who had unexplained interrupted fever and malaise for the past 4 months and was being treated as a case of fever of unknown origin. He presented with a 10-day history of pain and loss of vision in the left eye. Visual acuity in the left eye at time of presentation was counting fingers near face. Extensive anterior chamber reaction and flare, as well as, vitritis were found on examination. All blood and urine investigations and radiological imaging were negative.

RESULTS

A diagnostic/therapeutic vitrectomy with antibiotic injection helped in identifying the offending organism and controlling the inflammation. Vitrectomy sample revealed B. melitensis with no sensitive result. Patient recovered vision in his eye to 20/150. Eye examination revealed a quiet eye, with flat retina and some retinal pigment epithelial changes at macula.

CONCLUSION

B. melitensis endophthalmitis is a rarely encountered disease entity. High suspicion and prompt management with vitrectomy and appropriate antibiotic injection was successful in salvaging the patient's eye.

Aggressive Surgical Therapy With Early Vitrectomy, Panretinal Photocoagulation, and Silicone Oil Tamponade for Streptococcus mitis Endophthalmitis

An 87-year-old woman presented with acute, painful vision loss in her right eye after intravitreal injection. Examination disclosed hypopyon and vitritis, as well as discrete inflammatory collections in the vitreous and widespread retinal hemorrhages. The patient underwent vitrectomy with injection of intravitreal antibiotics. Vitreous cultures were positive for Streptococcus mitis, a pathogen associated with severe tissue damage and poor clinical outcomes. Clinical deterioration prompted repeat vitrectomy with silicone oil tamponade and panretinal photocoagulation two weeks later, resulting in more favorable anatomic and visual outcomes. Endophthalmitis caused by exotoxin-producing bacterial species such as S. mitis is often associated with severe vision loss or loss of the eye. Aggressive surgical intervention--prompted by concerning clinical findings and vitreous cultures--may play a role in improving outcomes in these patients.

Recent Clinical Manifestation and Prognosis of Fungal Endophthalmitis: A 7-Year Experience at a Tertiary Referral Center in Korea

This study analyzed the recent causes, prognosis, and treatment strategies for fungal endophthalmitis. A retrospective review of patients who were diagnosed with fungal endophthalmitis at our center was conducted. The fungal organisms isolated from each patient and the visual prognosis according to the route of infection and treatment method were analyzed. A total of 40 eyes from 30 patients with fungal endophthalmitis were included in this study. Candida species were the most common causative organisms in 35 of 40 eyes. Endogenous and exogenous endophthalmitis were observed in 33 and 7 eyes, respectively. Pre- and post-treatment best-corrected visual acuity (BCVA) was not significantly different between endogenous endophthalmitis and exogenous endophthalmitis. The 40 eyes were treated using the following modalities: intravitreal antifungal agent injection with intravenous antifungal agent (16 eyes), vitrectomy with intravenous antifungal agent (14 eyes), intravenous antifungal agent alone (9 eyes), and evisceration (1 eye). Post-treatment BCVA only significantly improved after treatment in the vitrectomy group. Candida species were the most common cause of fungal endophthalmitis, irrespective of the route of infection. The visual prognosis of fungal endophthalmitis was generally poor. In conclusion, if the general condition of the patient tolerates a surgical procedure, prompt vitrectomy and intravitreal injection of antifungal agents can improve visual acuity.

Nursing Care after Surgical Treatment of Fungal Endophthalmitis in Children

PURPOSE

To explore the nursing care following surgical treatment of fungal endophthalmitis in children.

METHODS

Thirty two children (32 eyes) with fungal endophthalmitis were enrolled in this study. After receiving antifungal medication, the children underwent either intravitreal injection, intravitreal injection of medicine combined with vitrectomy, or intravitreal injection in combination with vitrectomy and intraocular C3F8 tamponade. Prior to surgery, psychological and quarantine nursing, and medication use was properly prepared. After the surgery, the changes in the severity of diseases were strictly observed. A suitable body posture was selected and the eyes were protected from infection.

RESULTS

Among 32 patients with fungal endophthalmitis, 8 (25% ) cases presented with alleviated inflammation and no changes in visual acuity. The visual acuity of 18 cases (56.25%) was improved to different extents postoperatively. The inflammation in 6 children (18.75%) was properly controlled and the visual acuity declined. No cross-infection was noted in any patient.

CONCLUSION

Prior to surgery, quarantine nursing and drug administration should be properly prepared. Postoperatively, the changes in the severity of diseases should be tightly monitored. The patients should be treated with effective therapies in a proper position, aiming to enhance the surgical efficacy.

Fungal endophthalmitis associated with compounded products

Fungal endophthalmitis is a rare but serious infection. In March 2012, several cases of probable and laboratory-confirmed fungal endophthalmitis occurring after invasive ocular procedures were reported nationwide. We identified 47 cases in 9 states: 21 patients had been exposed to the intraocular dye Brilliant Blue G (BBG) during retinal surgery, and the other 26 had received an intravitreal injection containing triamcinolone acetonide. Both drugs were produced by Franck's Compounding Lab (Ocala, FL, USA). Fusarium incarnatum-equiseti species complex mold was identified in specimens from BBG-exposed case-patients and an unopened BBG vial. Bipolaris hawaiiensis mold was identified in specimens from triamcinolone-exposed case-patients. Exposure to either product was the only factor associated with case status. Of 40 case-patients for whom data were available, 39 (98%) lost vision. These concurrent outbreaks, associated with 1 compounding pharmacy, resulted in a product recall. Ensuring safety and integrity of compounded medications is critical for preventing further outbreaks associated with compounded products.

Vitreoretinal complications and vitreoretinal surgery in osteo-odonto-keratoprosthesis surgery

PURPOSE

To describe the indications for and approaches to vitreoretinal surgery in patients with osteo-odonto-keratoprosthesis (OOKP).

DESIGN

Retrospective case series.

METHODS

This was a retrospective review of all patients who had undergone OOKP surgery between 2003 and 2012 at our center. OOKP procedures were performed for severe ocular surface disease according to the indications and techniques described in the patient demographics of the Rome-Vienna Protocol. Indications for retinal surgery, surgical outcomes, and intraoperative and postoperative complications were documented. Operative techniques were reviewed from the surgical records, and any subsequent surgeries were also recorded.

RESULTS

Thirty-six patients underwent OOKP, and retinal surgery was indicated in 13 (36%). The indications for and approaches to surgery were retinal detachment repair using an Eckardt temporary keratoprosthesis; assessment of retina and optic nerve health prior to OOKP surgery, using either a temporary keratoprosthesis or an endoscope; endoscopic cyclophotocoagulation for intractable glaucoma; endoscopic trimming of a retroprosthetic membrane; or vitrectomy for endophthalmitis with visualization through the OOKP optic using the binocular indirect viewing system. In all cases, retinal surgical aims were achieved with a single procedure. Postoperative vitreous hemorrhage occurred in 16 patients (44%), but all resolved spontaneously.

CONCLUSIONS

OOKPs represent the last hope for restoration of vision in severe ocular surface disease, and the retinal surgeon is frequently called upon in the assessment and management of these patients. Temporary keratoprostheses and endoscopic vitrectomies are valuable surgical tools in these challenging cases, improving functional outcomes without compromising OOKP success.

[Clinical and functional considerations in some cases of postoperative endophthalmitis]

We present 3 cases of postsurgery endophthalmitis, with good initial operatory technique, which were admitted in our hospital within variable time, to which a second surgery was performed, with good postoperative evolution, without any inflammatory signs and preserving the eye. We analyse the pre and post-operative treatment of endophthalmitis, but also the ways to prevent the appearance of this post-operative complication.

[Surgery for posterior segment intraocular foreign bodies -- anatomical and functional results]

PURPOSE

To assess the anatomical and visual outcome and also the retinal complications following vitreoretinal surgery for posterior segment intraocular foreign bodies (IOFBs).

METHODS

Retrospective analysis of 59 IOFBs, with different locations within posterior segment,removed during pars plana vitrectomy (PPV) between January 1999 and January 2011, by the same surgeon, in Eye Clinic 1 Iasi. 47 out of 59 IOFBs (79.66%) were removed immediately after primary wound closure and 12 with a delay ranging from 48 hours to 5 years. All IOFBs were metallic. Total 20G pars plana vitrectomy with IOFB removal by forceps or intraocular magnet, careful membrane peeling and laser photocoagulation around the retinal injury (if present) was performed. Relaxing retinotomy was necessary in 3 cases of retinal incarceration. Endotamponade with SF6 (26 cases) or silicone oil (8 cases) were performed, if needed, at the end of surgery. The average follow-up period after surgery was 17.9 month (ranging 6 - 36 months).

RESULTS

18 out of 59 IOFBs (30.5%) were intraretinal. 39 out of 59 eyes (66.10%) showed signs of endophthalmitis at the time of surgery. Preoperative visual acuity ranged from light perception to 0.6. The mean visual acuity significantly increased after surgery from 0.16 preoperatively to 0.5 at the end of follow-up (range hand movements--1). 51 out of 59 cases (86.44%) had stable anatomical result. A final visual acuity equal or better than 0.1 was obtained in 45 cases (76.27%). Mild retinal folding could be noticed in some cases around the laser-treated retinal injury. In 8 out of 59 cases (13.56%) visual acuity remained low or decreased due to macular injury or PVR associated retinal detachment requiring additional surgery.

CONCLUSIONS

IOFBs, and especially those intraretinal, require an early, complex and customized approach during PPV. Functional results do not match anatomical restoration if macula or optic nerve are impacted. Main postoperative complications were represented by retinal folds and PVR associated retinal detachment.

[Bilateral blindness in endogenous endophthalmitis with fulminant course -- a clinical case]

We present the case of man with endogenous endophtalmitis AO, with Insulin-dependent Diabetes Mellitus type 2 and Viral hepatitis type C. The prognosis was reserved in the context of the underlying disease, with loss of his visual acuity OD and evisceration OS. Despite the correct treatment and many clinical, laboratory, imaging and interclinical examinations, etiologic diagnosis was established with great difficulty and very late.

[Vitreal surgery and etiological diagnosis of bacterial endophthalmitis]

OBJECTIVE

To evaluate the clinical effects of vitreal surgery and the importance of etiological diagnosis in the treatment for bacterial endophthalmitis.

METHODS

Retrospective series case study. 20 cases (20 eyes) of bacterial endophthalmitis that were treated in Peking Union Hospital were enrolled. 14 eyes were post-traumatic endophthalmitis, and 6 eyes were postoperative endophthalmitis. Twenty cases of aged 3 to 83 years [mean (40.5 ± 23.9) years] were enrolled, including 12 male and 8 female patients. Pre-operative visual acuity: 2 cases were able to count fingers, 6 cases were able to perform hand movement, 11 cases had light perception, light projection were uncertain in all cases, and there was no light perception in 1 case. Hypopyon was seen in 13 eyes. Severe anterior chamber inflammatory reaction was seen in the other 7 eyes. The fundus could not be observed in all 20 eyes. B-Scan ultrasound examination indicated that all 20 eyes displayed moderate to severe vitreous opacity; proliferation and organization were apparent in 12 eyes, and retinal detachment in 2 eyes. Vitrectomy and intravitreal injection of antibiotics were performed in 18 eyes, and only intravitreal injection of antibiotics was administered in the other 2 eyes. At the beginning of operation, vitreous fluids were smeared and Gram stained. To eyes that showed a positive result in Gram staining, 1 mg of Vancomycin was injected into the vitreous cavity or added in the perfusion fluid (balanced salt solution, BSS) in the eyes. To eyes that showed a negative result in Gram staining, 2 mg or 4 mg of Ceftazidime was injected into the vitreous cavity or added in the perfusion fluid (BSS) in the eyes, respectively. Additionally, we examined the vitreous specimens and performed drug susceptibility testing of the bacteria cultured from the specimens. The antibiotics that the bacteria were susceptible to were chosen according to the drug sensitivity tests. The follow-up period is from 1 to 102 months (average 16.6 months).

RESULTS

Thirteen eyes presented with a positive Gram staining result, and 3 eyes presented a negative result; the other 4 eyes were not infected. Bacteria were cultured in 15 eyes. The detection rate of pathogen was 75%. The result for 11 eyes was consistent with the smear results. The bacteria detected were Staphylococcus aureus in 3 eyes, Staphylococcus epidermidis in 3 eyes, and Bacillus spp in 2 eyes. Streptococcus pneumoniae, Streptococcus mitis, Plesiomonas, Pseudomonas cepacia, Klebsiella oxytoca, Loffi Acinetobacter and Pseudomonas fluorescens were detected in 1 eye. The remaining 5 eyes did not have bacterial growth. The intraocular infection of all 20 eyes was controlled, and the intraocular inflammation was relieved. The visual acuity was significantly elevated. Postoperative visual acuity achieved were ≥ 0.3 in 4 eyes, 0.1 to 0.2 in 4 eyes, 0.02 to 0.09 in 6 eyes, CF in 2 eyes, HM in 3 eyes and LP in 1 eye. The retinas of 17 eyes were normal, but recurrent retinal detachment occurred in the other 3 eyes, postoperatively.

CONCLUSIONS

Vitrectomy combined with antibiotics and intravitreal injection of antibiotics were an effective treatment of bacterial endophthalmitis. We obtained the vitreous fluid smears at the beginning of surgery to quickly and accurately obtain etiological diagnoses by Gram staining. It is crucial to use etiological diagnosis to choose the susceptible antibiotics.

Bleb-associated endophthalmitis treated by sclera patch graft, vitrectomy and endoscopic cyclophotocoagulation

BACKGROUND

Bleb-associated endophthalmitis (BAE) is a rare but severe complication of trabeculectomy with poor outcome. Various surgical methods were explored to treat such patients. However, there is no defined protocol. The aim of this study was to describe a new combined operation, and to demonstrate the outcome of the treatment.

METHODS

Nine patients with BAE were enrolled in our study. The combined operation including pars plana vitrectomy (PPV), sclera patch graft (SPG) and endoscopic cyclophotocoagulation (ECP) was used to treat these patients.

RESULTS

In the follow-up of 18 - 24 months, all patients with the endophthalmitis were cured, the useful visual acuity was preserved in 7 patients, and the intraocular pressure (IOP) of 8 patients was controlled just after first operation, only one needed another trans-scleral cyclophotocoagulation.

CONCLUSION

This combined operation is a useful method for treating the patients with BAE, with SPG and vitrectomy to control the endophthalmitis and ECP to balance the postoperative IOP.

Community acquired Klebsiella pneumoniae, K1 serotype. Invasive liver abscess with bacteremia and endophthalmitis

A community-acquired syndrome of cryptogenic invasive Klebsiella pneumoniae (K. pneumoniae) liver abscess (CIKPLA) has been emerging worldwide over the past 3 decades, particularly in Taiwan and Korea. It is caused by highly virulent hypermucoviscous, rmpA positive K. pneumoniae serotype K1. This condition occurs in predominantly diabetic persons with no underlying hepatobiliary disease. Metastatic infections of the brain, meninges, lungs, pleura, bones, soft tissues, and eyes are unique features of this syndrome. We report a laboratory-confirmed regulator of mucoid phenotype (rmp)A-positive, K1 serotype K. pneumoniae from Saudi Arabia in 2 diabetic native Saudis presenting with community acquired, invasive liver abscess complicated in one by endogenous endophthalmitis. Following medical and surgical treatment, both patients were cured from liver abscesses, however there was unilateral permanent visual loss in one patient.

[Endophthalmitis in course of candidosis--a case report]

PURPOSE

Description of a rare case of bilateral fungal endophthalmitis in a patient and the associated diagnostic and therapeutic difficulties.

MATERIAL AND METHODS

Patient 28 years old was diagnosed because of bilateral deterioration in endophthalmitis. Therefore, the diagnostic possibilities were run down and material taken from the vitreous chamber were handed to determine the Candida spp. antigen using Elisa test, standardized for serum and cerebrospinal fluid. Combination therapy including drugs and surgery were performed.

RESULTS

Ophthalmoscopy OP/OL showed the presence of "clusters of cotton" in vitreous body characteristic for ocular candidosis. Targeted treatment for Candida spp. with voriconazole were based on a very high concentration of mannan antigen in the resulting of the test. The final diagnosis was established after microbiological examination of material taken during vitrectomy.

CONCLUSIONS

High level of mannan antigen Candida spp 4259.83 in vitreous body may indicate a fungal endophthalmitis. fungal endophthalmitis, ocular candidosis, endogenic infection of the eye.

Early vitrectomy and diagnostic testing in severe infectious posterior uveitis and endophthalmitis

BACKGROUND

To determine the therapeutic and diagnostic value of vitreoretinal surgery in various types of severe viral retinitis and endogenous endophthalmitis.

MATERIAL/METHODS

Pars plana vitrectomy with silicon-oil tamponade was performed on 12 eyes (12 patients) with severe viral retinitis and endogenous endophthalmitis. The mean age of the patients was 35.2 years (range, 18-56 years). Investigations consisted of chest radiography, RT 23, serology (for toxoplasmosis, cytomegalovirus, herpes simplex virus, and human immunodeficiency virus), and routine blood tests and urinalysis. Examination of vitreous samples consisted of polymerase chain reaction for cytomegalovirus, herpes simplex virus, and Mycobacterium tuberculosis, and cultures for fungi and bacteria. The results were analyzed 7 days and 6 months after surgery.

RESULTS

Analysis of vitreous samples showed cytomegalovirus in 3 patients, herpes simplex virus in 2, tuberculosis in 2, and Candida albicans in 5. All patients had improvement in visual acuity and severity of clinical signs seven days after surgery and in 10 cases after long-term follow-up. Final visual acuity was compromised by chronic macular edema, postinflammatory macular scarring, optic atrophy, subcapsular cataract formation, and capsular opacification after cataract surgery.

CONCLUSIONS

Modern laboratory tests are useful for quick and accurate diagnosis of atypical cases of severe infectious posterior uveitis. Early pars plana vitrectomy with silicon oil tamponade is valuable in diagnosing and treating severe infectious posterior uveitis and endophthalmitis.

Trichophyton Spp. fungal keratitis in 22 years old female contact lenses wearer

Fungal keratitis represents one of the most difficult forms of microbial keratitis to diagnose and treat successfully. It is difficult to obtain correct diagnosis and topical antifungal preparations. Fungi can cause severe stromal necrosis and enter the anterior chamber by penetrating an intact Descemet membrane. The most common pathogens are filamentous fungi (Aspergillus and Fusarium spp.) and Candida albicans. The incidence of Trichophyton spp. keratitis is 5%. A 22 years old female contact lenses wearer after keratitis developed corneal melting syndrome, spontaneous perforation of the cornea and complicated cataract of the left eye. Conjunctival swab was sterile as well as first sample of corneal tissue and sample from the anterior chamber. Urgent therapeutic perforating keratoplasty (PK), was performed together with extracapsular cataract extraction and the implantation of the intraocular lens in the posterior chamber. The patient was treated with ciprofloxacin and diflucan (systemic therapy); with dexamethason and atropin (subconjunctivaly) and chlorhexidine, brolene, levofloxacin, polimyxin B, and dexamethason/neomycin (topically). Microbiology evaluation was performed once again following excisional biopsy of the intracameral portion of the lesion. The presence of Trichophyton spp. was finally confirmed. Itraconazole and garamycin were included in the systemic therapy. Corneal graft was clear for 17 days but decompensated 28 days after the PK. After two weeks microorganisms invaded the vitreous and caused endophthalmitis. Despite urgent pars plana vitrectomy patient developed endophthalmitis, lost light sensation and developed phthysis. Evisceration and the implantation of silicon prosthesis was done. Perforating keratoplasty is a method of choice in treating severe infectious keratitis unresponsive to conservative treatment but without the eradication of microorganisms it cannot restore the vision or save the eye. Trichophyton spp. may cause a severe disease of the anterior and posterior part of the eye which may finish with the lost of vision/eye. Prompt diagnosis and treatment of Trichophyton spp. keratitis are essential for a good visual outcome.

[Traumatic endophthalmitis--terapeutical indications and results]

PURPOSE

The purpose of our study is to analyze the outcome of traumatic endophthalmitis, as revealed by our own experience.

MATERIAL METHOD

We conducted a clinical retrospective study including all the consecutive cases with traumatic endophthalmitis that have been hospitalized in the University Ophthalmology Department from Cluj-Napoca (Romania), for a 28 months period of time (September the 1st 2007 - December the 31st 2009).

RESULTS/DISCUSSION

The overall incidence of traumatic endophthalmitis has been 4.76% (5 out of 105 open globe injuries). The presence of an Intra Ocular Foreign Body has been associated with the highest risk of endophthalmitis (8%), followed by the penetrating ocular injuries (6.52%). We performed posterior vitrectomy combined with intravitreal antibiotic and steroid injections in 4 of the 5 traumatic endophthalmities (80%). Injection alone of the above mentioned drugs has been indicated in one early traumatic endophthalmitis (20%), with immediate positive response and the complete recovery of the visual acuity. The technical features of the posterior vitrectomy in the infected eyes are discussed, in comparison with the other clinical conditions in which it is indicated. Our results prove the achievement of visual acuities better than 20/40 in 80% of the post-traumatic endophthalmitis eyes. The failure in one case is explained mainly by the delayed vitrectomy (48 hours from the debut), but also by the circumstances of trauma (soil contamination, in a rural setting).

CONCLUSION

Immediate action in traumatic endophthalmitis is crucial for the final visual prognosis.

[Postoperative endophthalmitis after non-pentrating deep sclerectomy]

This is a case report concerning a patient that was subject to non-penetrating deep sclerectomy (with intraoperative Mytomicin C) for the management of advanced open angle glaucoma in the only functional eye. The surgery was uneventful, the visual acuity was preserved and the intraocular pressure was reduced. After 2 months the patient presented with symptoms of postoperative bleb-related endophthalmitis. The treatment of this condition (including pars plana vitrectomy) did not succeed in preventing a severe retinal necrosis that resulted in the loss of visual acuity This is, to our knowledge, the first published case of endophthalmitis after non-penetrating deep sclerectomy.

[Treatment of postoperative endophthalmitis following cataract surgery without intraocular lens removal]

OBJECTIVE

To explore the effects of vitrectomy combined with silicone oil injection on the treatment of postoperative endophthalmitis following cataract surgery without intraocular lens removal, and to analyze the relative factors.

METHODS

This was a retrospective case series study. Clinical data of 7 eyes of 7 patients with postoperative endophthalmitis following cataract surgery underwent the treatment of vitrectomy combined with silicone oil injection without intraocular lens removal from 2003 to 2008 were collected. The outcomes of vision, slit lamp examination, direct and indirect ophthalmoscopy, IOP, and B-scan were observed, and the surgical effects were analyzed.

RESULTS

Five patients were male, and 2 patients were female. The age ranged from 67.0 to 84.0 years with a mean of 70.0 + or - 4.5. The onset of endophthalmitis ranged from 1 to 3 days with a mean of 2 days. Silicone oil was removed in 5 eyes 3 to 6 months postoperatively. Preoperative visual acuity ranged from non light perception to hand moving. The mean preoperative intraocular pressure (IOP) was (35.0 + or - 0.5) mmHg with a range from 35.0 to 56.0 mmHg. Follow-up periods ranged from 6 to 43 months with a mean of (10 + or - 6) months. Postoperative visual acuity ranged from non light perception to 0.8. Postoperative vision increased in 6 eyes (86%), and was stable in 1 eye (14%). The mean postoperative IOP was (18.0 + or - 1.5) mmHg with a range from 10.0 to 20.0 mmHg, this was significantly lower than that preoperatively (t = 1.94, P < 0.05). Postoperative complications mainly included fibrous exudates in the anterior chamber at early stage after the surgery (7 eyes) and temporary intraocular pressure elevation (1 eye). There was no retinal detachment and atrophia bulbi.

CONCLUSION

Vitrectomy combined with silicone oil injection may be a safe and effective method in treating postoperative endophthalmitis following cataract surgery without intraocular lens removal.

Aspergillus endophthalmitis in orthotopic liver transplantation

In this report, we describe a patient with drug-induced liver failure who developed endogenous endophthalmitis after liver transplantation. Our patient's clinical course was so fulminant that the eye was lost in less than 1 month, without any response to therapy. Recognition of this infection is important because many patients die of disseminated Aspergillus infection, which may be detected early with bedside funduscopic examination by an ophthalmologist. Probably if the patient had referred to us earlier, it may have been possible to save the eye.

Prognostic factors in severely traumatized eyes with posterior segment involvement

BACKGROUND

To determine the prognostic indicators of functional outcome in eyes with severe posterior segment trauma managed with pars plana vitrectomy.

METHODS

One hundred and six eyes of 101 patients were retrospectively reviewed to determine the accuracy of a number of factors in predicting functional outcome after surgery. These potential prognostic indicators included initial visual acuity (VA), retinal detachment (RD), type of trauma, presence of intraocular foreign body (IOFB), type of IOFB, posttraumatic endophthalmitis, hyphema, choroidal detachment, initial hypotonia, accompanying lens subluxation/dislocation, and severe vitreous hemorrhage. In our study, functional success was defined as VA > or =5/200. Fisher's exact and chi-square tests were used for statistical analysis.

RESULTS

The mean follow-up time was 12.8+/-0.52 (8-18) months. Thirty-three eyes (31.13%) had functional success. Forty-four (68.7%) of 64 eyes with preoperative RD had anatomical success (total retinal reattachment). Predictors of poor visual outcome (VA < or =5/200) were found to be poor initial VA (p<0.0001), presence of RD (p<0.001), and presence of endophthalmitis (p<0.05). No statistically significant correlation was found between the other predictors surveyed and visual outcome (p>0.05).

CONCLUSION

Vitreoretinal surgery can improve anatomical and functional success in eyes with severe posterior segment trauma. Poor initial VA, RD, and posttraumatic endophthalmitis are poor predictors of visual outcome.