Assessment of a standard treatment protocol on visual outcome following presumed bacterial endophthalmitis

AIMS—The aim of this prospective study was, firstly, to judge the effect of early aggressive treatment with a standardised regimen of high dose broad spectrum intraocular and systemic antibiotics on visual outcome and, secondly, to assess the sensitivity of isolated organisms to the treatment regimen utilised.
METHODS—Thirty two consecutive patients presenting with presumed bacterial endophthalmitis were treated and completed follow up. In every case, intraocular sampling was undertaken and treatment with intraocular vancomycin, amikacin, and systemic ciprofloxacin was commenced immediately, followed by systemic steroids 1 day later.
RESULTS—In 69% of patients vision improved with 47% achieving a final visual acuity of 6/36 or better and 31% achieving 6/12 or better. Of the intraocular samples taken from post-surgical and post-traumatic cases, 10/27 (37%) and 3/5 (60%) were culture positive, respectively. All the bacteria isolated were sensitive to at least one of the three antibiotics used.
CONCLUSIONS—The study demonstrated that the combination of vancomycin, amikacin, and ciprofloxacin is adequate as a standard regimen for the treatment of most patients with suspected bacterial endophthalmitis. The prognosis for a good visual outcome, however, remains poor with 15/27 (55%) post-surgical and 2/5 (40%) post-traumatic cases achieving a final acuity of 6/60 or less.

     

Successful management of presumed Candida endogenous endophthalmitis with oral voriconazole

Endogenous fungal endophthalmitis is most commonly caused by Candida species and usually occurs in patients with chronic diseases such as diabetes mellitus and renal insufficiency. Voriconazole, a broad-spectrum triazole antifungal agent, attains therapeutically significant concentrations in the vitreous cavity after systemic administration. We report, the successful management of presumed endogenous Candida endophthalmitis in a patient with multiple diseases and unstable systemic status with oral voriconazole. Though fungal endophthalmitis has been successfully treated with a combination of intravenous and intravitreal voriconazole, to the best of our knowledge this is the first report in ophthalmic literature (Medline Search) on the treatment of fungal endophthalmitis with only the oral route of administration of voriconazole.     

Microbiologic spectrum and visual outcome of posttraumatic endophthalmitis

PURPOSE: To identify the microbiologic spectrum and visual outcome of infectious endophthalmitis after open globe injuries. METHODS: We reviewed the medical records of all patients with culture-positive endophthalmitis after open globe injuries who were treated at King Khaled Eye Specialist Hospital and King Abdulaziz University Hospital (Riyadh, Saudi Arabia) between January 1, 1993, and December 31, 2003. RESULTS: Sixty-seven patients were identified. There were 55 males and 12 females (mean age +/- SD, 23.3 +/- 18.3 years; range, 2-65 years). The mean follow-up +/- SD was 18.8 +/- 23.9 months (range, 1-120 months). Twenty-nine eyes (43%) had intraocular foreign bodies (IOFBs). A single species was isolated from 59 eyes, and multiple organisms were isolated from 8 eyes (total number of infecting organisms, 78). The most common isolates were coagulase-negative staphylococci and Streptococcus species (26.9% of isolates each). Gram-negative organisms and fungi comprised 12.8% and 3.8% of isolates, respectively. Staphylococcus epidermidis comprised 37.1% of isolates in the group with IOFBs and 16.3% of isolates in the group without IOFBs (P = 0.0358). Streptococcus species comprised 41.8% of isolates in the group without IOFBs and 8.6% of isolates in the group with IOFBs (P = 0.0024). Final visual acuity was 20/200 or better in 30 eyes (47.6%). Visual acuity of 20/200 or better at presentation (P = 0.0474) and time from injury to presentation to our institutes of <1 day (P = 0.0348) were significantly associated with better visual acuity outcome. Final visual acuity of 20/200 or better was achieved in 61.9% of patients infected with nonvirulent organisms compared with 40.5% of patients infected with virulent organisms. CONCLUSIONS: The most common organisms identified were coagulase-negative staphylococci and Streptococcus species. Clinical features associated with better visual acuity outcomes included better presenting visual acuity, early presentation to our institutes, and isolation of a nonvirulent organism. Posttraumatic endophthalmitis is associated with a poor visual prognosis.     

Clinical profile and visual outcome in cluster endophthalmitis following cataract surgery in Central India

The purpose of this study was to determine clinical presentation, microbiological spectrum and visual outcome of cluster endophthalmitis patients after cataract surgery in central India. The records of cluster endophthalmitis patients were retrospectively reviewed. Three clusters of patients were identified who had undergone vitreous biopsy followed by three-port pars plana vitrectomy with intraocular antibiotics and steroids. Good visual outcome was seen in eight (33%) of 24 patients. Six patients had corneal infiltration. Smear positivity was 58% and culture positivity was 42%. There was significant association ( P P = 0.006) with poor visual outcome. The association between type of surgery ( P = 0.6), duration of symptoms ( P = 0.64) and corneal infiltration ( P = 0.06) with visual outcome was not significant. Pseudomonas aeruginosa was the organism isolated in vitreous cultures. Thirty three percent patients benefit after appropriate vitreoretinal intervention in cluster endophthalmitis.     

Experimental bacterial endophthalmitis following extracapsular lens extraction

The rapid increase in popularity of extracapsular cataract extraction may predispose the eye to postoperative bacterial infections by introducing viable organisms through the additional instrumentation and irrigation necessary for the extracapsular technique. Lens protein released into the aqueous humor of the anterior and posterior chambers may enhance or inhibit the ability of organisms to grow in the aqueous humor. In the intact eye the lens acts as a significant protective barrier restricting the posterior extension of the infectious processes. This study was undertaken to determine if extracapsular lens extraction enhances the ability of common bacteria to infect the anterior segment of the eye and if the posterior lens capsule acts as a protective barrier denying the infectious process access to the vitreous body. Approximately 1000 colony forming units (CFU) of Staphylococcus aureus were required to produce bacterial endophthalmitis in less than one-half of normal rabbit eyes and eyes following extracapsular lens extraction. Discission of the posterior lens capsule tripled the number of eyes infected. As few as fourteen CFU could produce infections in some eyes if the posterior capsule was incised. Extracapsular lens extraction does not predispose the eye to bacterial endophthalmitis if the posterior lens capsule remains intact. Interruption of the posterior lens capsule does allow a small number of organisms to establish an intraocular infective process. Lens protein and other constituents released into the aqueous humour appear to have little effect on the growth of the test organisms.     

Late bacterial endophthalmitis following retinal detachment surgery

We report two cases of late postoperative bacterial endophthalmitis that occurred following retinal detachment repair. Both patients presented months after their scleral buckling procedures with a subacute uveitis. Over a period of one to two weeks, the inflammation gradually increased, until the classic clinical appearance of fulminant bacterial endophthalmitis was present. In an effort to treat the infection, a pars plana vitrectomy was performed in both cases. At the time of vitreous surgery, intrusion of the scleral buckling elements into the globe was observed, suggesting a possible means of entry for the infectious agent. Removal of the buckling elements, repair of the scleral defects, and injection of intravitreal antibiotics were performed as therapeutic interventions. Vitreous cultures were positive in both cases for Proteus mirabilis. Postoperatively the retina remained attached in both instances, and, in one case, the visual acuity returned to 20/20.     

Post-traumatic endophthalmitis: causative organisms and visual outcome

PURPOSE: Post-traumatic endophthalmitis makes up a distinct subset of intraocular infections. The purpose of the present study was to identify the causative organisms and record the visual outcome after infectious endophthalmitis in eyes with penetrating trauma. METHODS: We reviewed 18 consecutive cases of culture-positive endophthalmitis that developed after penetrating ocular trauma. All cases were treated with pars plana vitrectomy and intravenous and intraocular antibiotics. RESULTS: The 15 males and 3 females ranged in age from 4 to 43 years (mean 25.1 +/- 11 years). Nine (50%) had intraocular foreign bodies. A single species was isolated in 16 cases, and multiple organisms in two. Staphylococcus epidermidis and gram-negative organisms were the most frequent and were cultured either alone or in association with other organisms in respectively five (27.7%) and four cases (22.2%). Clostridium perfringens was isolated in three cases (16.6%). Bacillus was not found as a cause of endophthalmitis. Final visual acuity was better than 20/400 in eight cases (44%). In five cases (27.7%), the eye was saved but visual acuity was counting fingers. Two eyes (11%) had no light perception. The remaining three eyes (16.6%) were enucleated or eviscerated. Clostridium perfringens was isolated from two eyes and Aspergillus niger from one. Postoperative retinal detachment developed in four eyes, which were successfully operated. CONCLUSIONS: Organisms isolated in this series were similar to those in previous reports of post-traumatic endophthalmitis from other parts of the world, except that the frequency of Clostridium perfringens isolation was high and no Bacillus species were cultured. In view of its devastating outcome, post-traumatic endophthalmitis must be treated promptly with vitrectomy and intravitreal antibiotics.     

人工晶状体术后慢性细菌性眼内炎的治疗效果观察

目的 通过对白内障超声乳化摘除联合人工晶状体植入术后慢性细菌性眼内炎的治疗效果观察,提出治疗建议。方法 回顾分析2004-2009年收治的4例4眼人工晶状体术后慢性细菌性眼内炎,观察其发生时间、眼部体征。经平坦部玻璃体切除、晶状体后囊膜环形撕囊联合眼内注入万古霉素作为首选治疗方法。切除的玻璃体和撕下的晶状体后囊膜进行涂片和培养微生物检查。复发病例联合全身应用大环内酯类抗生素治疗。术后观察其眼部情况、视力。结果 4例平均发病时间是人工晶状体术后8周（5～11周）。其中女性3人、男性1人,年龄平均75岁（67～81岁）。玻璃体切除前视力分别是眼前手动1眼、数指2眼、1眼0.06。丙酸痤疮杆菌感染3跟,表皮葡萄球菌感染1眼。其中两眼分别于术后7周和5周复发。复发的两眼间断结膜下注射地塞米松和妥布霉素,联合全身应用罗红霉素和阿奇霉素8周,炎症控制。随访16～36月,无复发。最后随访眼部无炎症表现,晶状体囊膜清晰和玻璃体腔均清澈,最佳矫正视力分别是0.8、0.5、0.2和0.3。结论 人工晶状体植入术后慢性眼内炎玻璃体切除和晶状体后囊膜环形撕除术后,局部和全身应用抗生素时间要适当延长以防治复发,大环内酯类抗生素的治疗作用应受到重视。     

Associated factors and treatment outcome of presumed noninfectious endophthalmitis occurring after intravitreal triamcinolone acetonide injection

Background

To investigate the associated factors and treatment outcomes in patients with presumed noninfectious endophthalmitis after intravitreal triamcinolone acetonide (IVTA) injection.

Methods

Among 219 consecutive cases of 186 patients who had undergone IVTA injection for macular diseases, presumed noninfectious endophthalmitis was diagnosed if the patient showed severe inflammation in the anterior chamber and vitreous cavity within 7 days after injection but no organism was isolated on microbiological examination. Clinical features and previously performed surgical procedures were evaluated to assess their association with presumed noninfectious endophthalmitis using logistic regression. After surgical or medical treatment for endophthalmitis, the visual outcome was evaluated in all patients.

Results

Noninfectious endophthalmitis developed in six of 219 eyes (2.7 %). Previous vitrectomy, history of IVTA injection, and pseudophakia were significantly associated with the occurrence of presumed noninfectious endophthalmitis after IVTA injection (p?=?0.049, 0.034, and 0.009, respectively). Internal limiting membrane (ILM) peeling during vitrectomy also showed statistically significant association (odds ratio?=?13.6, p?=?0.017). Five of six patients (83.3 %) regained pre-injection vision.

Conclusion

In addition to previous vitrectomy, history of IVTA injection, internal limiting membrane (ILM) peeling, and pseudophakia may render the eye vulnerable to presumed noninfectious endophthalmitis following IVTA injection. Visual outcome shows generally good prognosis after treatment.     

Clinical and visual outcome of endophthalmitis patients: a single-center experience

Graefe's Archive for Clinical and Experimental Ophthalmology - To report the clinical and visual outcome and the therapeutical management in a large cohort of endophthalmitis patients. In a...     

Biofilm formation and its effect on the management of culture-positive bacterial endophthalmitis

Purpose:To compare the clinicomicrobiological features and outcomes in patients with infectious endophthalmitis caused by biofilm-positive (BP) and biofilm-negative (BN) bacteria.Methods:This was a prospective, interventional, comparative, nonrandomized, consecutive case series. Culture-positive bacterial endophthalmitis cases from August 1, 2018 to July 31^st 31, 2019 were included. All vitreous samples were tested for biofilm using crystal violet plate and XTT (2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide) methods and classified as BN and BP. The antibiotic susceptibility of all organisms was determined. Anatomic and functional success was defined as intraocular pressure >5 mm Hg and final best-corrected vision ≥20/400, respectively, at last visit.Results:There were 50 eyes in the BN group and 33 eyes in the BP group. BN group eyes required 2.86 ± 1.45 surgical interventions, and BP group eyes needed surgical 6.36 ± 2.89 interventions, P < 0.0001, 95% Confidence Interval, CI: 2–4. Median follow-up was 6 and 5 months, respectively (P = 0.33). Final logMAR vision was a median of 1.2 and 1.9 respectively; P = 0.0005, 95% C.I.: 0.4–1.7. Functional success was achieved in 44% and 21.2% (P = 0.03, 95% C.I.: 1.86%–40.08%) and anatomic success was achieved in 68% and 42.42%, respectively (P = 0.02, 95% C.I.: 3.85%–45.47%). The antimicrobial resistance patterns between the two groups were comparable.Conclusion:Endophthalmitis caused by the biofilm-forming bacteria needs a greater number of surgical interventions. The anatomic and functional outcomes are poorer than non-biofilm-forming bacterial endophthalmitis. The increased virulence and poorer outcomes can be hypothesized to be due to the physical barrier effect of the biofilm on the antibiotics.     

Staphylococcus epidermidis endophthalmitis. Visual outcome following noninvasive therapy

Staphylococcus epidermidis has been reported with increasing frequency as a cause of bacterial endophthalmitis. Over the past eight years 18 consecutive postsurgical cases have been treated by combined antibiotic-corticosteroid therapy without intravitreal antibiotics or vitrectomy. Fourteen (78%) achieved a final visual acuity of 20/50 or better. When these cases were added to similarly reported cases in the literature, 72% achieved this level of vision. By contrast, 42% of adequately documented cases in the literature treated by intravitreal antibiotics, and 42% treated additionally by vitrectomy, achieved a vision of 20/50 or better. S. epidermidis is an organism with a low order of virulence. The use of intravitreal antibiotics and vitrectomy do not appear to be necessary for effective treatment.     

Incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies

Purpose To determine the risk factors and visual outcome of endophthalmitis associated with traumatic intraocular foreign body (IOFB) removal and its allied management. Methods A retrospective review was conducted of patients with penetrating eye trauma and retained IOFB with associated endophthalmitis managed at King Khaled Eye Specialist Hospital over a 22 year period (1983 to 2004). Results There were 589 eyes of 565 patients (90.3% male; 9.7% female) which sustained ocular trauma and had retained IOFB that required management. Forty-four eyes (7.5%) developed clinical evidence of endophthalmitis at some point after trauma. From these 44 eyes, initial presenting visual acuity (VA) of 20/200 or better was recorded in 8 eyes (18.1%) and the remaining 36 eyes (81.9%) had VA ranging from 20/400 to light perception. Eleven eyes (25%) underwent IOFB removal and repair within 24 hours after trauma while 33 eyes (75%) had similar procedures done 24 hours or more after trauma. Thirty-one eyes (70%) underwent primary pars plana vitrectomy (PPV) at the time of removal of posteriorly located IOFBs. Definite positive cultures were obtained from 17 eyes (38.6%). Over a mean follow-up of 24.8 months, 21 eyes (47.7%) had improved VA, 6 eyes (13.6%) maintained presenting VA while 17 eyes (38.7%) had deterioration of their VA, including 10 eyes (22.7%) that were left with no light perception (NLP) vision. After the treatment of endophthalmitis, 20 eyes (45.4%) had VA of 20/200 or better at their last follow-up. Four eyes (12.9%) from the vitrectomy group (31 eyes) and 5 eyes (45.4%) from non-vitrectomy (11 eyes) group had final VA of NLP. Predictive factors for the good visual outcome included good initial presenting VA, early surgical intervention to remove IOFB (within 24 hours), and PPV. Predictors of poor visual outcome included IOFB removal 48 hours or later, posterior location and no PPV for the posteriorly located IOFB. Conclusions Delayed removal of IOFB following trauma may result in a significant increase in the development of clinical endophthalmitis. Other risk factors for poor visual outcome may include poor initial presenting VA, posterior location of IOFB and no vitrectomy at the time of IOFB removal.