肝脓肿眼内炎的临床特点及治疗

感染性眼内炎系指以主要累及玻璃体、葡萄膜与视网膜的急性化脓性炎症,起病急,病情凶险,早期诊断和有效治疗尤为重要.依据眼内感染途径可以将感染性眼内炎分为内源性眼内炎和外源性眼内炎,在东亚地区肝脓肿是内源性眼内炎的主要来源,而肺炎克雷伯菌是其主要致病菌.肝脓肿性眼内炎是由位于肝脏的感染灶通过血源性播散而引起的严重致盲性眼内感染,其原发病灶隐匿,易将其与免疫相关的葡萄膜炎混淆,造成较高的误诊率.本文将对肝脓肿性眼内炎的病原学研究、临床特征、诊断要点以及治疗和预后进行综述,旨在提高临床工作者对肝脓肿眼内炎的认知水平.     

Intravitreal voriconazole for the treatment of endogenous endophthalmitis caused by Scedosporium apiospermum

Scedosporium apiospermum is an increasingly recognized cause of endogenous fungal endophthalmitis in immunocompromised patients. The authors describe two patients with endogenous S. apiospermum endophthalmitis treated with intravitreal and systemic voriconazole. Despite a prolonged course of systemic antifungal treatment, both patients subsequently required enucleation for intractable ocular pain due to secondary scleritis. Histological examination of the globes demonstrated the presence of fungal hyphae. Endogenous S. apiospermum endophthalmitis need to be considered in the differential diagnosis of necrotizing retinitis. Despite its efficacy in suppressing disseminated S. apiospermum infection, voriconazole may be ineffective in the treatment of endogenous S. apiospermum endophthalmitis especially if treatment is delayed.     

Unmasking the mask: the role of personal protective equipment for ophthalmologists caring for asymptomatic patients during the COVID-19 pandemic

AIM: To identify the clinical features and treatment outcomes of endogenous Klebsiella pneumoniae endophthalmitis and investigate prognostic factors of poor visual outcome. METHODS: The clinical records of all patients diagnosed with endogenous Klebsiella endophthalmitis between January 2007 to December 2018 in Prince of Wales Hospital, Hong Kong, China were retrospectively reviewed. Thorough ophthalmological examination findings were recorded in the case note, including visual acuity testing, slit-lamp examination, indirect ophthalmoscopy and B-scan ultrasonography if media opacity precluded fundus viewing. RESULTS: A total of 18 eyes in 14 patients were identified. Bilateral involvement was noted in 4 patients (28.6%). Hepatobiliary sepsis was the source in 9 patients (64.3%). Culture of intraocular fluid was positive in 5 out of 18 eyes (27.8%). Mortality was noted in 2 patients (14.3%). Mean final visual acuity was 20/1500. Six out of 16 eyes had total loss of sight (37.5%) and 3 eyes required evisceration (18.8%). Multivariate linear regression revealed poor presenting visual acuity (P=0.031) and lack of fundus view due to vitritis (P=0.02) as prognostic factors of poor visual outcome. CONCLUSION: Visual outcome of endogenous Klebsiella endophthalmitis is poor. Poor presenting visual acuity and lack of fundus view predict poor visual outcome. High index of suspicion for endophthalmitis is important in Klebsiella sepsis patients with complaints of ocular symptoms. Ophthalmological screening is recommended in non-communicable patients with Klebsiella sepsis.     

匍行性脉络膜炎的临床特征与治疗

目的 探讨匍行性脉络膜炎的临床表现、荧光素眼底血管造影(FFA)特征和治疗结果.方法 自1999年11月至2006年7月,连续收集行FFA检查的匍行性脉络膜炎患者14例26只眼,观察其临床表现、FFA特征和治疗效果.结果 14例患者中,男性6例,女性8例,平均年龄45.6岁.双眼12例,单眼2例.根据眼底病变部位及其临床特征分为典型性视乳头周围地图状脉络膜炎11例和黄斑部匍行性脉络膜炎3例.FFA早期表现为病灶区由于脉络膜毛细血管萎缩而呈低荧光,病灶边缘呈高荧光,非活动病变晚期出现纤维瘢痕和巩膜染色.经糖皮质激素治疗后,8例14只眼视力提高,3例6只眼视力稳定,3例6只眼视力恶化.结论 匍行性脉络膜炎是一种少见的双眼慢性进行性眼内炎症,主要累及视网膜色素上皮和脉络膜毛细血管层,早期发现和及时治疗可防止发生永久性视力损害.     

Cyclosporine-A in the treatment of serpiginous choroiditis

Summary Seven patients affected by bilateral inflammatory serpiginous choroiditis have been treated with Cyclosporine-A for 6-21 months. Nine outof the fourteen eyes showed a significant improvement in their visual acuity; five eyes did not change.Cyclosporine-A may, therefore, be considered effective in the treatment of this disease.Its usefulness seems to be greater when the serpiginous choroiditis is in its acute stage; chronic stages, however, also seem to improve under treatment.Its main indication is, in our opinion, the involvement of the macular region of the second eye, when the first eye is already damaged. We consider Cyclosporine-A, in these situations, to be a first choice treatment.     

Endogenous Endophthalmitis Caused by Carbapenem-Resistant Hypervirulent Klebsiella Pneumoniae: A Case Report and Literature Review

Purpose: To report a rare case of endogenous endophthalmitis caused by carbapenem-resistant hypervirulent Klebsiella pneumoniae (CR-hvKP).

Methods: A retrospective chart review was conducted. The isolates were characterized by hypermucoviscosity, resistance genes, virulence genes, and multilocus sequence typing.

Results: A 47-year-old diabetic woman acquired carbapenem-resistant K. pneumoniae (CRKP) nosocomial pneumonia. Metastatic endophthalmitis occurred in the right eye a week after the occurrence of CRKP bloodstream infection (BSI). Visual acuity decreased to light perception within 3 days. Although vitrectomy relieved ocular pain, endophthalmitis deteriorated due to uncontrollable BSI, and developed to corneal perforation. The strains isolated from bronchoalveolar lavage fluid, blood, and intraocular pus originated from the same clone. The pathogen was hypermucoviscous, belonged to sequence type 11, harbored resistance genes bla_KPC-2, bla_TEM, bla_SHV, rmtB, and virulence genes rmpA2, iucABCD, iroBCD.

Conclusions: Endogenous endophthalmitis caused by CR-hvKP has emerged, which is a treatment challenge for both ophthalmologists and physicians.     

Macula toxicity after intravitreal amikacin

Background: Although intravitreal aminoglycosides have substantially improved visual prognosis in endophthalmitis, macular infarction may impair full visual recovery.
Methods: We present a case of presumed amikacin retinal toxicity following treatment with amikacin and vancomycin for alpha-haemolytic streptococcal endophthalmitis.
Results: Endophthalmitis resolved with improvement in visual acuity to 6/24 at three months. Fundus fluorescein angiography confirmed macular capillary closure and telangiectasis.
Conclusions: CurrentIy accepted intravitreal antibiotic regimens may cause retinal toxicity and macular ischaemia. Treatment strategies aimed at avoiding retinal toxicity are discussed.     

匍行性脉络膜炎诊治新进展

匍行性脉络膜炎是一种罕见的双眼慢性进行性脉络膜炎症,易反复发作,主要侵犯脉络膜毛细血管层和视网膜色素上皮.常见于中青年人,男性略多于女性.根据眼底表现可分为视盘周围型匍行性脉络膜炎、黄斑型匍行性脉络膜炎、广泛型匍行性脉络膜炎.视力的预后主要取决于病灶是否累及黄斑中心凹、旁中心凹以及是否继发脉络膜新生血管膜.病因及发病机制尚不明确,可能与自身免疫、感染因素、血管病变有关.眼底自发荧光、荧光素眼底血管造影及吲哚青绿血管造影对病灶的位置、大小及活动性的评估具有重要意义.由于本病少见、病程隐匿进展,目前仅从小样本中观察到使用免疫抑制剂和烷化剂能较好地控制病情,稳定视力,但治疗方法的有效评估需要大样本长期随访,因此尚需要多中心随机临床试验证实,才能确定最佳的治疗策略.     

Successful treatment of serpiginous choroiditis with alkylating agents

OBJECTIVE: To describe the management and long-term outcomes of patients with serpiginous choroiditis treated with alkylating agents. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Nine patients with active, vision-threatening serpiginous choroiditis who had progressive inflammation while on steroids and/or immunosuppressive agents other than alkylating agents treated at three tertiary care uveitis referral centers. METHODS: Patients received systemic immunosuppression with an alkylating agent, either chlorambucil or cyclophosphamide. Prednisone also was given initially and was tapered and discontinued. MAIN OUTCOME MEASURES: Visual acuity, clinical disease activity, duration of treatment, duration of drug-free disease remission, and side effects of alkylating agent therapy. RESULTS: No patients had recurrences while on therapy. No further visual loss was encountered after starting the therapy. Six of the patients regained vision. All but two patients achieved prolonged drug-free remissions, ranging in duration between 15 and 96 months (median, 78 months). Side effects included transient bone marrow suppression, nausea, and fatigue. Secondary malignancy was encountered in one patient, whose carcinoma of the urinary bladder was treated successfully. CONCLUSIONS: Adequate immunosuppression with alkylating agents may favorably alter the long-term prognosis of patients with serpiginous choroiditis.     

玻璃体腔注药治疗外因性眼内炎

目的 :评估玻璃体腔注药治疗外因性感染性眼内炎的疗效。方法 :回顾 1999年 7月～ 2 0 0 2年 2月我院收治的首诊时即给予玻璃体腔注药的外因性感染性眼内炎患者19例 19眼 ,平均年龄为 42 .4岁。其中白内障摘除联合人工晶体植入术后 5眼 ,眼球穿孔伤后 14眼。结果 :随访 5～ 35个月 ,玻璃体腔注药后炎症控制 9眼 ,治疗后视力在 0 .0 5以上者 8眼 ,有效率为 42 .1%。结论 :玻璃体腔注药治疗感染性眼内炎仍有一定的疗效     

Combination of azathioprine and corticosteroids in the treatment of serpiginous choroiditis

BACKGROUND: Although therapy with immunosuppressive agents is currently accepted as the best option for treating active serpiginous choroiditis (SC), there is no consensus on the most effective immunosuppressive drug to use. In this paper, we describe the clinical course of patients with active SC treated with azathioprine (AZA) in combination with corticosteroids. METHODS: This retrospective study included 4 patients (5 eyes) with active, vision-threatening SC who received systemic immunosuppression with AZA at 1.5 to 2.0 mg/kg per day. In combination with oral AZA, patients also received 1 mg/kg oral prednisone per day. Information collected included Snellen visual acuity (VA), clinical disease activity, duration of follow-up, rate of inflammation recurrence, and side effects of AZA. RESULTS: Within 3 weeks of treatment, all patients experienced decreased ocular inflammation and improved VA. One patient, however, had a recurrence in both eyes while oral prednisone was being tapered. In this case, once the dosage of oral prednisone was increased and methotrexate was added to the therapeutic scheme, inflammation was controlled within 1 month. The other 3 patients presented no further visual loss while on AZA and were able to taper and then discontinue oral prednisone. Nevertheless, SC recurred in 1 of these patients 40 months after the initial treatment. AZA was reintroduced but the patient complained of gastrointestinal problems, and it was then successfully replaced by mycophenolate mofetil. None of the 4 patients presented serious systemic side effects secondary to AZA. INTERPRETATION: This study suggests that when AZA is used in combination with corticosteroids it is a safe and acceptable option for treating patients with active SC. Side effects and recurrences while on AZA therapy can occur, requiring either replacement of the drug or addition of another immunosuppressive agent.     

Endogenous Endophthalmitis in Patients with MRSA Septicemia: A Case Series and Review of Literature

Purpose: To report the presentation, predisposing factors, clinical features and outcome in 6 eyes of 3 patients with endogenous endophthalmitis secondary to methicillin resistant staphylococcus aureus (MRSA) septicaemia.

Methods: Retrospective review of case records of 3 patients who were treated for endogenous endophthalmitis secondary to MRSA septicaemia in a tertiary referral institution.

Results: All three patients had systemic predisposition to endogenous endophthalmitis (diabetes, urosepsis). Two patients presented within 1 week of onset of visual symptoms and the third after 3 months. Blood culture was positive for MRSA in all patients. Visual and anatomical improvement was noted in two patients who presented early. The third patient’s visual outcome despite early treatment with intravitreal antibiotics and vitrectomy was not satisfactory.

Conclusion: Endogenous endophthalmitis by MRSA is a rare but serious condition. Early and specific therapy based on reliable detection of the underlying microorganism is needed for good anatomical and functional outcome.     

内源性肺炎克雷伯杆菌性眼内炎的研究现状

内源性肺炎克雷伯杆菌性眼内炎（EKE）是目前亚洲最常见的内源性细菌性眼内炎,近年来发病率明显提高,但国内对其认识不足,仅见散在病例报道。EKE总体预后极差,国际上对其发病危险因素、预后因素及治疗也存在较大争议。现就EKE的研究现状和发展趋势,从流行病学及易感因素、治疗措施和预后因素等三方面对其进行综述,以提高认识、指导临床。     

Infectious endophthalmitis: clinical features, management and visual outcomes

Aim: To identify the clinical features and outcomes of infectious endophthalmitis in New Zealand. Methods: A retrospective review was performed on all patients presenting at Auckland Public Hospital with presumed infectious endophthalmitis between 1996 and 2004. Results: One hundred and six patients were diagnosed with infectious endophthalmitis over the 9‐year study period. More than half the infections occurred in the perioperative setting (58.5%), with the next most common group being patients with a history of ocular trauma (18.9%). Endogenous endophthalmitis accounted for 16.0% of the cases while a small percentage arose from other causes. The mean interval between the onset of symptoms and presentation was 4.2 ± 7.9 days. There was no significant difference in outcomes between clinical settings (P = 0.616) or between gram‐positive, gram‐negative and fungal infections (P = 0.090). Evisceration/enucleation was more likely in Pacific peoples and those with poor presenting visual acuity. Conclusions: The most common clinical scenario for patients presenting with presumed infectious endophthalmitis in this series was in the perioperative setting. We did not find that the prognosis was influenced by the microbiological isolate or clinical setting. However, those patients presenting with poor acuities typically had the worst outcomes. Pacific ethnicity was also associated with increased rate of complications.     

玻璃体切割术治疗外伤性眼内炎

目的:评价玻璃体切割联合眼内药物灌注治疗严重的外伤性眼内炎的临床效果.方法:回顾性分析30例(30眼)因外伤性眼内炎行玻璃体切除术,术中联合药物玻璃体腔灌注的患者.结果:术后 3mo 29 眼炎症得到控制,眼球得以保留,28眼视力有不同程度提高.眼内异物是最常见的受伤原因,金黄色葡萄球菌是最常见的细菌.结论:及时行玻璃体切割术联合眼内药物灌注是治疗外伤性眼内炎的有效方法.     

Vitrectomy for the treatment of posttraumatic endophthalmitis

AIM: To evaluate the efficacy of vitrectomy in combination with intravitreal dexamethasone and vancomycin perfusion in the management of severe posttraumatic endophthalmitis. · METHODS: Thirty eyes of 30 cases diagnosed as posttraumatic infectious endophthalmitis were analyzed retrospectively from April 2004 to April 2006. All the patients underwent vitrectomy in combination with intravitreal drugs perfusion and were followed up for 12 to 24 weeks. The visual acuity, traumatic causes and microorganisms culture were analyzed. · RESULTS: There are significant reduction in inflammation at 3 months after surgery. Infectious symptoms were completely controlled in 97% of the cases(29/30). Final visual acuity were improved in 93% of cases (28/30). Among traumatic causes, foreign body is the most common cause (57%). Staphylococcus aureus is the commonest microorganism. · CONCLUSION: Vitrectomy in combination with intravitreal dexamethasone and vancomycin perfusion is the most effective method in the treatment of severe posttraumatic endophthalmitis.