Endogenous filamentous fungal endophthalmitis--single-centre survey in patients with acute leukaemia or postallogeneic stem cell transplantation and review of the literature

Endogenous endophthalmitis caused by filamentous fungi has been infrequently described and its prognosis in immunocompromised patients is largely unknown. Patients were identified through a single-centre database containing patients with endophthalmitis. Cases published since 2002 were reviewed. Clinical and treatment features as well as outcomes were analysed. Six patients were identified from the database. Underlying conditions were haematological malignancies (HM) and/or allogeneic haematopoietic stem cell transplantation (HSCT). Three patients underwent vitrectomy. None of the patients survived and the median time from first evidence of endophthalmitis until death was 33 days. The median time from first evidence of an invasive fungal infection to endophthalmitis was only 5 days. Fifty-six patients were identified from the literature. The majority of these patients underwent vitrectomy (27) or enucleation (10) and received intraocular antifungal therapy (28). Only 13 (23%) of 56 patients experienced an improved vision. The survival rate was 52% in all 56 patients but was significantly less in patients with HM or post-HSCT when compared with all others (26% vs. 70%, respectively; P = 0.003). Endogenous endophthalmitis caused by filamentous fungi is frequently associated with a permanent decrease or loss of vision. This type of fungal infection carries a particular poor prognosis in patients with profound immunosuppression, requiring improved treatment strategies.     

白内障术后细菌性眼内炎的早期诊断和治疗

目的　探讨白内障术后细菌性眼内炎的早期诊断和治疗。方法　分析２０１２年８月至２０１３年２月期间本院及合作中心白内障超声乳化术后７例（７眼）细菌性眼内炎的临床表现、诊断和治疗以及预后情况。结果　６眼眼内炎早期表现不典型:仅有突发性前房炎症反映,而无眼痛、明显视力下降及充血、结膜水肿,无或仅有少量前房积脓、无玻璃体积脓,但１～２ｄ后眼内炎症快速发展:前房炎症反应加重、玻璃体出现积脓;１眼早期即有急剧视力下降、明显眼痛及前房、玻璃体积脓的典型表现。４眼经球内抗生素注射、３眼行玻璃体切割联合人工晶状体取出术后炎症控制。微生物培养结果（７眼）:２眼为表皮葡萄球菌,１眼为粪肠球菌,４眼阴性。随访视力均有提高,最高达０．５。结论　白内障术后出现突发性前房渗出性炎症,即便无眼痛及明显充血、视力下降者,仍需高度警惕细菌性眼内炎。早期诊断、及时治疗与病原学检查显得尤为重要,否则一旦炎症加重则错过最佳治疗时机、导致不可逆盲甚至眼球丧失。     

An in Vitro Experimental Study on the Antimicrobial Activity of Silicone Oil against Anaerobic Bacteria

Purpose: To investigate the in vitro antimicrobial activity of silicone oil against anaerobic agents, specifically Propionibacterium acnes, Peptostreptococcus spp., Peptostreptococcus anaerobius, Bacteroides fragilis, Fuobacterium spp., and Clostridium tertium.

Method: A 0.5 McFarland turbidity of Propionibacterium acnes, Peptostreptococcus spp., Peptostreptococcus anaerobius, Bacteroides fragilis, Fuobacterium spp., and Clostridium tertium was prepared, and 0.1?mL was inoculated into 0.9?mL of silicone oil. Control inoculations were performed in anaerobic blood agar and fluid thioglycollate medium without silicone oil.

Results: Propionibacterium acnes retained their viability on the 3rd day in the presence of silicone oil. In total, 9.7?×?10⁶ colonies were enumerated from 1?mL of silicone oil. After a prolonged incubation of 7 days, the number of colonies observed was 9.2?×?10⁶. The other bacteria disappeared after the 3rd day of incubation in silicone oil.

Conclusions: Propionibacterium acnes, which is the most common chronic postoperative endophthalmitis agent, is thought to be resistant to silicone oil.     

Silicone oil in the surgical treatment of endophthalmitis associated with retinal detachment

Purpose: To investigate the useof silicone oil in thepatients who had undergone vitrectomy for the treatment of endophthalmitis associated with retinal detachment.Methods: Six consecutive cases of endophthalmitis associated with retinal detachment were included in the study. The mean age of the 4 males and 2 females was 47.25 ± 23.76 years. Endophthalmitis associated with retinal detachment occurred following perforating injuries in 4 eyes, pneumatic retinopexy in 1 eye and cataract surgery complicated with vitreous loss in 1 eye. Preoperative visual acuity was light perception-only in all eyes. Red reflex was absent in all eyes. All the patients underwent vitreous tapping,encirclement, vitrectomy ,liquid-gasexchange, endolaser photocoagulation and silicone oil injection. Results: Mean follow-up time was 14.3 ± 7.20 months. The microorganisms that were isolated from the vitreous aspiration were Staphylococcus epidermidis in 3 cases, Staphylococcus aureus in 1 case. Remaining cases were culture negative. Retinal breaks could be found in 4 eyes. Inflammation subsided significantly at 5 days in all cases. Final retinal reattachment and treatment of endophthalmitis was achieved in 5 eyes at the end of follow-up . Final visual acuity was 20/40 in 1 case, counting finger in 4 cases and no light perception in 1 case. The postoperative complications were optic atrophy in 1 eye, epiretinal membrane in 2 eyes and phitisis bulbi in 1 eye.Conclusion: Silicone oil, a retinal tamponading agent that has antimicrobial activity, may have benefical effect in the surgical treatment of endophthalmitis associated with retinal detachment.     

Conjunctival and corneal findings in bleb‐associated endophthalmitis: an in vivo confocal microscopy study

Purpose: To report the conjunctival and corneal findings in delayed onset glaucoma filtering bleb‐associated endophthalmitis (BAE), by using in vivo confocal microscopy (IVCM). Methods: This was an observational case series. Four eyes of four glaucomatous patients who previously underwent mytomicin C augmented filtering surgery and affected with delayed onset BAE, underwent IVCM of conjunctival bleb and cornea at diagnosis, after 2 and 8 weeks of therapy. The inflammatory status of the conjunctival epithelium and sub‐epithelium was microscopically investigated. Corneal epithelial cells, stromal and endothelial morphology were also evaluated. A group of eight patients with functioning conjunctival filtering bleb was used as control. Results: At diagnosis, a diffuse inflammatory cell infiltration within the conjunctival epithelium presenting evident microcysts was found; conversely, there were no such alterations in the sub‐epithelium. An evident stromal oedema, keratocytes activation and diffuse endothelial inflammatory precipitates were the major corneal hallmarks. After 2 weeks of therapy, besides a remarkable improvement of epithelial inflammation and an evident reduction in endothelial precipitates, dendritic cells appeared within conjunctival sub‐epithelium and corneal epithelium showed aspects of cellular disruption. After 8 weeks, the conjunctival and corneal features consistently improved, except for the endothelium which still presented high‐reflective residual precipitates. Conclusions: In vivo confocal microscopy proved valuable in the analysis of conjunctival bleb and cornea in patients affected with delayed onset BAE, permitting an evaluation of the course of the disease, the response to therapy and the modulation of dose regimen.     

Povidone-iodine concentration and dosing in cataract surgery

Iodine has been recognized as an effective bactericide since the 1800s, and povidone-iodine (PI) solution has been applied to the ocular surface and periocular skin since the 1980s to prevent endophthalmitis in cataract surgery. In vitro, PI solution kills bacteria quickly at dilute concentrations (0.05%–1.0%). In many instances, PI kills bacteria more quickly at these dilute concentrations than more conventional (5%–10%) concentrations. This is due to greater availability of diatomic free iodine in dilute solution, the bactericidal component of PI. The toxicity of PI, both in vitro and clinically, has been shown to be related to concentration. Current American Academy of Ophthalmology and the European Society of Cataract and Refractive Surgeons recommendations regarding PI use suggest using 5% PI before surgery. An alternative dosing strategy uses dilute PI repetitively throughout cataract surgery (0.25% every 30 seconds). We review the povidone-iodine literature with attention to basic science and use of dilute PI.     

Incidence of Endophthalmitis after Intravitreal Injections: Risk Factors,Microbiology Profile,and Clinical Outcomes

Purpose: To report the incidence and characteristics of endophthalmitis after intravitreal injections (IVI) of antivascular endothelial growth factor agents and triamcinolone acetonide.

Methods: Patients’ medical records were retrospectively reviewed from January 2009 to June 2016, and the incidence, risk factors, clinical and microbiological characteristics of post-IVI endophthalmitis were evaluated.

Results: The total number of intravitreal injections given, which included ranibizumab, bevacizumab, and triamcinolone acetonide, was 20,566, of which 27 cases developed endophthalmitis, giving an overall incidence of 0.131%. Significant reduction (p < 0.003) in incidence of endophthalmitis was observed in patients who received prefilled compounded bevacizumab injections (0.050%) compared to multiple bevacizumab injections from a single vial (0.235%). In the triamcinolone acetonide group, the incidence was 0.26%. Staphylococcus species were isolated from 18 cases (67%), and all strains were sensitive to vancomycin.

Conclusions: Adherence to strict aseptic protocols and use of prefilled compounded bevacizumab injections reduces the rate of post-IVI endophthalmitis.     

Laboratory diagnosis of infectious endophthalmitis

AIM: To analyze the lab diagnosis and etiology of infectious endophthalmitis. METHODS: The medical and microbial records of 36 patients diagnosed with infectious endophthalmitis and 8 patients diagnosed with intraocular lens (IOL)-related inflammation between Nov. 1999 and Dec. 2009 were retrospectively reviewed for lab diagnosis and etiology. RESULTS: The inflammatory cell counts in all aqueous humor specimens from infectious endophthalmitis patients were more than in all aqueous humor specimens from patients with IOL-related inflammation. Sixteen of the 36 aqueous humor samples (44.4%) and 11 of the 24 vitreous humor samples (45.8%) from infectious endophthalmitis patients showed positive results in smears; while 17 aqueous humor samples (47.2%) and 15 vitreous humor samples (62.5%) from infectious endophthalmitis patients showed positive results in culture. CONCLUSION: The inflammatory cell count may be an important index for infectious endophthalmitis; while, smears can show etiological information earlier.     

Mannose-binding lectin as part of the complement pathway: characterization in non-inflamed and inflamed human eyes

Background: Mannose‐binding lectin plays a central effector role in the lectin pathway of complement activation. Frequently occurring MBL2 polymorphisms result in mannose‐binding lectin deficiency, which increases susceptibility to infection. We characterized mannose‐binding lectin levels and function in non‐inflamed and inflamed human eyes, and evaluated its relationship to blood mannose‐binding lectin levels and function. Design: Prospective, observational clinical study with controls and cases. Participants: Twenty‐seven patients with paired blood and ocular samples (aqueous and/or vitreous) including 15 controls (non‐inflamed) and 12 cases (inflamed). Methods: Blood and ocular samples were collected from controls (n = 15) with quiet eyes during elective cataract surgery and cases with inflamed eyes including proven/suspected endophthalmitis (n = 11) and herpetic retinal vasculitis (n = 1). Mannan‐binding and C4 deposition enzyme‐linked quantify mannose‐binding lectin levels and function. Main Outcome Measures: Blood and ocular mannose‐binding lectin levels and function. Results: Of 27 patients, 10 (37%) were mannose‐binding lectin‐deficient (defined as blood mannose‐binding lectin levels <500 ng/mL). Blood mannose‐binding lectin levels (P= 0.16) or function (P= 0.43) were not significantly different between controls and cases. As expected, there was a high correlation between blood mannose‐binding lectin levels and function (r²= 0.74). However, there was significantly more mannose‐binding lectin in inflamed eyes than non‐inflamed eyes measured as level (P < 0.01) or C4 deposition function (P < 0.01). Conclusions: Our study demonstrated that mannose‐binding lectin is significantly elevated in inflamed human eyes but virtually undetectable in non‐inflamed control eyes, suggesting a role in sight‐threatening ocular inflammation.