Bleb-associated Endophthalmitis Research Articles

Clinical analysis of infectious endophthalmitis following glaucoma filtration surgery

BackgroundThis study aimed to evaluate the clinical correlative factors and outcomes of treatment of bleb-associated endophthalmitis (BAE) following glaucoma filtration surgery in a Chinese population from the year 2012 to 2022, and to compare them with the clinical course during the coronavirus disease (COVID-19) pandemic period.MethodsThis was a retrospective analysis of consecutive cases of BAE treated at the Eye & ENT Hospital of Fudan University, Shanghai, China, between January 1, 2012, and December 31, 2022. The clinical presentation, treatment modality, microbiological data, clinical course, and outcomes of visual acuity (VA) and intraocular pressure (IOP) in all BAE cases were collected and analyzed.ResultsA total of 28 eyes with BAE were examined, predominantly in male patients (71.4%, p = 0.023). Most patients underwent trabeculectomy (89.3%, p ≤ 0.001), while a smaller proportion underwent Ex-PRESS implantation (10.7%). Primary open-angle glaucoma (POAG) was the most common type of glaucoma (39.3%, p ≤ 0.001). Most patients (96.4%) presented with poor visual acuity, worse than 20/400, and IOP ranged from 3–60 mmHg. Treatment, including initial tap-and-inject procedure of antibiotics (Ceftazidime and Norvancomycin) or initial pars plana vitrectomy (PPV), was initiated 5.0 ± 7.1 days after BAE onset. Streptococcus was the most common causative organism (53.6% of cases, p ≤ 0.001). The visual acuity significantly improved from 2.58 ± 0.27 to 2.14 ± 0.85 (reported in logMAR) after treatment (p ≤ 0.001), and most patients maintained normal tension during follow-up. Poisson regression model analysis showed the annual incidence of BAE during the COVID-19 pandemic period was significantly twice greater than that of previous years.ConclusionsBAE may cause irreversible visual impairment. POAG filtering surgery with male sex and the COVID-19 pandemic period might be potentially relevant factors for BAE. Culture positivity was closely related to BAE prognosis, with Streptococcus species being the leading pathogenic organisms. Online outpatient services, early diagnosis, and timely treatment may rescue vision and maintain IOP control in the presence of BAE.

LATE-ONSET, BLEB-ASSOCIATED ENDOPHTHALMITIS CAUSED BY STAPHYLOCOCCUS AUREUS

Introduction: Bleb-associated endophthalmitis (BAE) is a potentially sight-threatening complications of trabeculectomy and is associated with poor visual outcome. BAE denotes an ocular infection with involvement of the vitreous, which usually develops months or years after glaucoma filtering surgery. The purpose of this case report was to present a case about late onset BAE caused by Staphylococcus aureus. Methods: A 55-year-old male presented with a 3-days history of left eye pain, redness, hypopion decreased visual acuity and hypotony with Seidel test positive. He had a history of primary open angle glaucoma that was treated with a combined procedure of cataract surgery and trabeculectomy in the left eye ten years earlier. His visual acuity had decreased from 6/20 to light perception. This patient showed signs of hypotony, endophthalmitis, leak, and pain but no previous history of using anti-fibrotic agents. BAE causative organisms cultures grew the S.aureus, that frequent cause of acute-onset endophthalmitis. The patient underwent treatment with pars plana vitrectomy, vitreous taps, administered intravitreal antibiotic, and prescribed hourly topical antibiotic. Six months after his last treatment, his left eye shows no residual infection, and visual acuity increase to 1/60. Results: One case of late onset BAE with visual improvement after early vitrectomy, intravitreal, oral and topical antibiotic treatment. Conclusion: Despite the poor prognosis of BAE caused by S.aureus infection, after proper treatment can yield an adequate result, as demonstrated in this case.

A Rare Case of Abiotrophia defectiva Bleb Associated Endophthalmitis.

To report a rare case of Abiotrophia defectiva bleb associated endophthalmitis (BAE). In this case report of a patient with BAE, the authors describe the features of severe and rapid onset, associated retinitis, and a favorable outcome after aggressive early intervention. A 75-year old female presented that decreased visual acuity of hand motions with elevated intraocular pressure of 39 mm Hg in the left eye. Her past ocular history was notable for severe primary open angle glaucoma with uneventful trabeculectomy and cataract surgery in both eyes 7 years prior. Examination revealed conjunctival injection and an opaque avascular cystic bleb along with anterior chamber cellular reaction with a B-scan ultrasound concerning for vitritis. Abiotrophia defectiva was isolated from the vitreous tap within 48 hours and confirmed later with 16S ribosomal RNA sequencing. After initial vitreous tap and inject and subsequent PPV, her BCVA had improved to 20/500 at post operative week 1 and then improved to 20/40 at post-operative month 2. Her exam was notable for resolved corneal edema, a deep and quiet anterior chamber, and resolved intraretinal hemorrhages. This is one of the first BAE cases with rapid identification of Abiotrophia defectiva. Abiotrophia defectiva was isolated from the initial vitreous tap within 48 hours and confirmed with 16S ribosomal RNA sequencing. This case highlights that rapid identification of Abiotrophia defectiva may be indicative of a greater bacterial load and should prompt aggressive intervention and that the visual prognosis can be favorable.

Late-onset Endophthalmitis Caused by Streptococcus Cristatus after Trabeculectomy

Purpose: To report a case of late-onset bleb-associated endophthalmitis caused by <i>streptococcus cristatus</i> (<i>S. cristatus</i>) after trabeculectomy.Case summary: A 59-year-old woman presented with left ocular pain and visual disturbance. She had undergone trabeculectomy of the left eye 2 years ago. At the initial visit, she was only able to count fingers from the left eye. Whitish thin bleb, conjunctival injection, and inflammation were observed in the left anterior chamber, and the fundus could not be visualized. Despite administering topical and systemic antibiotics, the chamber reaction worsened, and hypopyon and inflammatory membrane were noticed the next day. Vitrectomy with phacoemulsification and intravitreal antibiotic injection was performed, and the intravitreal antibiotic injections were repeated over the next two days. Bacterial culture of vitreous fluid showed a growth of <i>S. cristatus</i> 5 days after the surgery, and inflammation improved after 7 days. One month later, she was still only able to count fingers from the left eye, but there were no signs of endophthalmitis.Conclusions: Postoperative endophthalmitis after glaucoma filtering surgeries caused by <i>S. cristatus</i> has not been reported previously from Korea. To the best of our knowledge, this is the first Korean case of late-onset bleb-associated endophthalmitis caused by <i>S. cristatus</i>. If gram-positive cocci are grown in samples from the patients with endophthalmitis after trabeculectomy, resident oral microflora such as <i>S. cristatus</i> should be considered as the causative pathogen.

Infectious endophthalmitis at a Philippine tertiary hospital: a ten-year retrospective study

BackgroundEndophthalmitis is a sight-threatening disease characterized by marked progressive inflammation of the vitreous and/or aqueous humors. Limited information is currently available regarding endophthalmitis in the Philippines. This study aimed to provide long-term summary data on endophthalmitis cases seen at the largest tertiary referral hospital in the Philippines.MethodsAll endophthalmitis cases diagnosed at the Philippine General Hospital from January 1, 2007 to December 31, 2016 were retrieved and classified by etiology. Data pertaining to history, associated risk factors, isolated microorganisms, management, and final visual outcomes for each patient were reviewed.ResultsA total of 202 cases diagnosed within the audit period were included in the study. These were classified as post-traumatic (55.94%), endogenous (14.36%), acute post-operative (10.40%), keratitis-induced (6.93%), chronic post-operative (5.44%), bleb-associated (3.96%), and suture-associated (2.97%) endophthalmitis. Males comprised 71.29% of the population, while the largest age group affected was 0–10 years (24.75%). The culture-positive rate was 57.89%. The predominant etiology was Gram-positive bacteria (38.18%), followed by Gram-negative bacteria and mixed pathogens (21.82% each), and fungi (18.18%). The most common organisms were Streptococcus, Staphylococcus, Pseudomonas, Aspergillus, and Candida, accounting for 56.45% of isolates. Pars plana vitrectomy was done for 62.87% of patients, intravitreal and other antibiotic therapy in 23.27%, and primary enucleation/evisceration in 10.89%. The final outcomes and best corrected visual acuities were: anophthalmia 11.86%, no light perception/no dazzle 27.84%, light perception 8.76%, hand motions 24.23%, counting fingers 5.15%, 3/200 to 20/50 12.89%, and 20/40 to 20/20 9.28%.ConclusionsThere was a higher proportion of post-traumatic endophthalmitis cases compared to traditional estimates but consistent with studies from China and Thailand. The majority of these cases involved younger children as well as young to middle-aged males engaged in carpentry and construction work, implying a need for increased public health awareness and strengthening of childcare and workplace safety policies. Our microbiologic profile showed a lower proportion of Gram-positive infections and a higher proportion of mixed pathogen infections compared to other studies. There was also a higher proportion of fungi associated with post-operative and keratitis-induced endophthalmitis. The best outcomes were seen in acute post-operative and bleb-associated endophthalmitis, and the worst outcomes in endogenous and keratitis-induced endophthalmitis. Visual outcomes were poorer compared to other Western and Asian countries, with only 21.7% of patients improving from presentation.

Bleb-associated endophthalmitis: Proportion, presentation, management and outcomes in Victoria, Australia.

Bleb-associated endophthalmitis is a potentially vision-threatening complication of trabeculectomy. With improvements in surgical technique and changing patterns of intraoperative antimetabolite use, a re-evaluation of the incidence of bleb-associated endophthalmitis is warranted. To investigate changes in the incidence, presentation, management and outcomes of bleb-associated endophthalmitis between 1997 and 2015 in Victoria, Australia. A retrospective cohort analysis. Consecutive cases of bleb-associated endophthalmitis managed at the Royal Victorian Eye and Ear Hospital (RVEEH) between 1997 and 2015. Medical record review of consecutive cases of bleb-associated endophthalmitis and statistical analysis were performed. Visual acuity, including loss of light perception, intraocular pressure, and need for further surgery. Sixty-seven eyes with bleb-associated endophthalmitis (BAE) were identified. Of these, 41 had trabeculectomy performed in Victoria during the study period, over which time 11 129 trabeculectomies were performed. The proportion of BAE was stable over time (0.4%). The mean age at presentation was 73.7 ± 12.1 years old and the majority of patients were Caucasian (79.1%). The mean duration between glaucoma filtration surgery and the development of bleb-associated endophthalmitis was 3 years (Interquartile Range = 0.4-6.0 years). The cultures were positive in 71.6% of cases. Approximately 1 in 8 patients required enucleation. The final visual acuity was poor with a Snellen Visual Acuity (VA) of 6/60 or worse in two-thirds of patients. Bleb-associated endophthalmitis is an uncommon complication following glaucoma filtration surgery. The proportion has remained stable over time. Visual outcomes remain poor.

Analysis of clinical and pathogenic bacteria of bleb associated endophthalmitis after glaucoma surgery

Objective To observe the clinical features, pathogenic bacteria distribution and drug sensitivity of bleb-related endophthalmitis after trabeculectomy. Methods The data of 28 eyes of 28 cases with bleb-associated endophthalmitis after trabeculectomy from Jan.2011 to Jun.2017 were analyzed retrospectively.The age of onset, duration of endophthalmitis to operation and visual acuity were recorded. The samples of aqueous humor and vitreous were sent to microbiological culture and drug sensitivity test. Results The average occurrence time of endophthalmitis was 16 d-16 years, average (54.2±39.1) months after the last operation. The samples were positive to the bacteria culture in 11 eyes. The positive rate of bacteria was 42.3%. Streptococcus and Staphylococcus were the main pathogenic bacteria. Streptococcus and Staphylococcus were sensitive to Vancomycin. Inflammation was controlled after intravitreal injection of antibiobics or vitrectomy in 25 eyes(89.3%). The visual acuity ≥0.05 was in 10 eyes(35.7%). There were 8 eyes (28.6%) with no light perception. Three cases(10.7%) eventually underwent enucleation of eyeball. Conclusion Most of the endophthalmitis associated with filtering bleb is delayed endophthalmitis. Streptococcus and Staphylococcus are the most common pathogens. Although the infection is successfully treated, but the visual acuity is poor. Key words: Endophthalmitis, infectious; Glaucoma; Pathogen

Late-onset bleb-associated endophthalmitis and continuous positive airway pressure

PurposeTo raise awareness of a possible association between continuous positive airway pressure (CPAP) devices and postoperative bleb-related infection. ObservationsA 57-year old patient on CPAP presented with unilateral bleb-associated endophthalmitis 32 months after routine ExPress Trabeculectomy with mitomycin C. The offending organism, Streptococcus mitis, is a nonmotile and generally non-virulent pathogen which predominates in the normal human respiratory flora. Conclusions and importanceThis conceptual report underscores a potential relationship between CPAP use and bleb-associated endophthalmitis. Streptococcal species are the most commonly reported causative organisms in bleb-associated endophthalmitis, and S. mitis is of particular concern as the most abundant microbe among all human oral flora. A logical risk factor for infection, the CPAP device may inadvertently deliver such organisms to the vulnerable conjunctival filtering bleb.

Incidence of bleb-associated endophthalmitis in the United States.

PurposeTo evaluate the 5-year incidence rate of blebitis and bleb-associated endophthalmitis in the United States.MethodsIn this retrospective cross-sectional study, we utilized a large commercial health insurance claim-based database during 2007–2011 and identified all patients who had a record of trabeculectomy in 2007. These patients were followed until the end of 2011. During the follow-up period, all incidences of blebitis, confirmed bleb-associated endophthalmitis, and presumed bleb-associated endophthalmitis were recorded. Kaplan–Meier survival analysis was utilized to calculate 5-year cumulative incidence rates of blebitis and bleb-associated endophthalmitis following trabeculectomy procedures.ResultsAmong the 1,461 trabeculectomies included in our analysis, eight cases of blebitis, five cases of confirmed bleb-associated endophthalmitis, and eight cases of presumed bleb-associated endophthalmitis were identified. We found that the 5-year cumulative incidence of blebitis was 0.55%±0.19%. The 5-year cumulative incidence of bleb-associated endophthalmitis was 0.45%±0.2% when only confirmed cases were included and 1.3%±0.34% when presumed cases were also added to the analysis. The mean time from procedure to diagnosis was 45 months for blebitis and 33 months for bleb-associated endophthalmitis.ConclusionBlebitis and bleb-related endophthalmitis are uncommon in the United States. The 5-year cumulative incidence was 0.55% for blebitis and 0.45%–1.3% for bleb-associated endophthalmitis.

Abiotrophia defectiva Bleb-associated Endophthalmitis Confirmed With 16S Ribosomal RNA Sequencing

One recognized complication of trabeculectomy with visually devastating potential is blebitis. We present a case of a 74-year-old woman with a culture and polymerase chain reaction-positive Abiotrophia defectiva bleb-associated endophthalmitis. Abiotrophia defectiva is a rare but possible cause of endophthalmitis secondary to blebitis and should be considered in culture-negative cases. Prompt identification, hence directed eradication, of the causative organism in such visually threatening cases may be facilitated by requesting polymerase chain reaction and 16S ribosomal RNA sequencing.

Bleb-associated endophthalmitis in a Chinese population (2003-2010): clinical characteristics and visual outcome

To analyze the clinical characteristics and treatment outcomes of patients with bleb-associated endophthalmitis (BAE) in a Chinese population. A retrospective review of patients treated for BAE between January 2003 and December 2010 in a single institution was performed. Data on visual acuity (VA), clinical characteristics, causative organisms, and treatment outcomes were collected and analyzed. Thirty-one eyes from 31 patients with BAE were identified during the study period. Primary open-angle glaucoma was the most common type of glaucoma in this series (18 eyes, 58.1%). The time between glaucoma filtering surgery and diagnosis of endophthalmitis ranged from 18 days to 32 years, with a mean of 6.95 ± 8.22 years. Nine eyes (32.1%) were culture positive, and the most common organisms identified were Staphylococcus species (6/9, 66.7%). Best-corrected VA at 12 months after treatment ranged from 20/30 to no light perception (NLP). Twelve (38.7%) eyes achieved VA of 20/400 or better, and 7 (22.6%) eyes had NLP. In patients undergoing initial tap-and-inject treatment, the eyes with presenting VA of finger count or better were associated with a higher treatment success rate (87.5%) than those of hand movement (33.3%) or light perception or NLP (9.1%). Primary open-angle glaucoma was the most common type of glaucoma, and Staphylococcus species was the most common causative organism in this case series of BAE. Despite prompt treatment with appropriate intravitreal antibiotics, BAE still carries a poor visual prognosis.

Ocular Inflammation and Infection

The eye is a unique and necessary organ that is constantly exposed to the environment. In an immune-privileged environment such as the eye, a delicate balance exists between immune responses that limit damage and those responses that can result in irreversible damage. Ocular inflammation and infection are therefore potentially blinding events. Efforts to analyze the delicate balance between helpful and harmful immune responses in the eye have involved a variety of animal studies and models which analyze not only the specific etiologic agents of infection and the contributions of their products in inflammation and vision loss but also the underlying host factors responsible for those responses. Other studies have probed the development of novel therapeutics based on endogenous host factors as well as pathogen-specific targets and have tested these with routinely used therapeutics in improved regimens in an effort to improve visual outcome. The ultimate goal is to provide patients with the appropriate treatment that rescues vision regardless of disease. The scope of this special issue involves a wide variety of areas in ocular infection and inflammation highlighting recent developments in the epidemiology, pathogenesis, and treatment of various types of ocular infections and inflammation. The first paper of this special issue reviews the challenges of cataract surgery and visual rehabilitation in patients with uveitis. This discussion also includes management pearls in combating complications that arise in this particular group of patients. The second and third papers continue the theme of inflammation, analyzing chemotactic cytokine production in the cornea. The second paper reports a time course effect in the synthesis of IL-8 and MCP by stromal cells stimulated with LPS. The third paper uses an ex vivo model of herpes simplex virus 1 (HSV1) corneal infection to demonstrate that neutrophils are important in T-cell recruitment and control of HSV1 replication via synthesis of IP-10. The following three papers address epidemiological issues with studies on microbiological profiles and treatment outcomes of scleritis, chronic postoperative endophthalmitis, and fungal ocular infections. The key message of these studies is the importance of early identification and determination of drug susceptibility and proper therapeutic and/or surgical intervention in saving useful vision. The seventh and eight papers discuss the use of corticosteroid therapy in endophthalmitis and other types of ocular inflammation. The seventh paper reviews the visual outcome of cases of filtering bleb-associated endophthalmitis treated with or without intravitreal dexamethasone, while the eighth paper reviews the clinical use of loteprednol etabonate in a variety of ocular inflammatory conditions. The final paper of the special issue discusses hyperactivation of the renin-angiotensin system in inflammation and retinal neural dysfunction. The authors suggest that inhibition of this system may be a novel therapeutic approach to preventing or treating inflammation-based ocular diseases. This special issue includes the following papers: “Cataract surgery in uveitis,” “IL-8 and MCP gene expression and production by LPS-stimulated human corneal stromal cells,” “Resident corneal cells communicate with neutrophils leading to the production of IP-10 during the primary inflammatory response to HSV-1 infection,” “Clinico-microbiological profile and treatment outcome of infectious scleritis: experience from a tertiary eye care center of India,” “Chronic postoperative endophthalmitis: a review of clinical characteristics, microbiology, treatment strategies, and outcomes,” “Support of the laboratory in the diagnosis of fungal ocular infections,” “Intravitreal dexamethasone in the management of delayed-onset bleb-associated endophthalmitis,” “Advances in corticosteroid therapy for ocular inflammation: loteprednol etabonate,” and “Renin-angiotensin system hyperactivation can induce inflammation and retinal neural dysfunction.” Michelle Callegan Meredith Gregory-Ksander Mark Willcox Susan Lightman

Intravitreal Dexamethasone in the Management of Delayed-Onset Bleb-Associated Endophthalmitis

Purpose. To report the visual acuity (VA) outcomes and culture results of delayed-onset bleb-associated endophthalmitis (BAE) with and without intravitreal dexamethasone (IVD). Methods. Retrospective nonrandomized comparative case series of BAE at Bascom Palmer Eye Institute between January 1, 1996 and December 31, 2009. Clinical data were compared using the 2-sided Student's t-test for patients who received IVD and patients who did not receive IVD. Results. 70/83 (84%) received IVD, and 13/83 (16%) did not receive IVD. Mean baseline VA was 20/90 in the IVD group and 20/70 in the group that did not receive IVD (P = 0.57). Mean presenting VA was 0.9/200 in the IVD group and 1.7/200 in the group that did not receive IVD (P = 0.23). Repeat cultures were positive in 2/70 (3%) IVD cases and 1/13 (8%) cases that did not receive IVD (P = 0.57). Mean VA at 1 month was 5/200 in the IVD group and 1.8/200 in the group that did not receive IVD, logMARΔ of 0.85 and 1.56, respectively (P = 0.02). Mean VA at 3 months was 7/200 in the IVD group and 3/200 in the group that did not receive IVD, logMARΔ of 0.74 and 1.33, respectively (P = 0.14). Conclusion. In the current study of BAE, IVD was associated with improved short-term VA outcomes without an increased rate of persistent infection.

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

To report the conjunctival and corneal findings in delayed onset glaucoma filtering bleb-associated endophthalmitis (BAE), by using in vivo confocal microscopy (IVCM). 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. 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. 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.

Clinical analysis of glaucoma bleb-associated endophthalmitis

To investigate the clinical characteristics, causative organisms, treatment procedures and prognosis of glaucoma bleb-associated endophthalmitis. It was a retrospective case series study. All cases were patients with glaucoma bleb-associated endophthalmitis treated at Shandong Eye Institute, Qingdao Eye Hospital between January 1, 1997 and December 31, 2009. All patients had prior glaucoma filtering surgery. Nineteen patients (20 eyes) were identified. There were 16 males (17 eyes, 85%) and 3 females (3 eyes, 15%). The mean age at presentation was (46.9 ± 16.1) years (ranged 15 to 71 years). In 14 patients (15 eyes) the glaucoma operation was performed in our hospital, and an antifibrotic agent was used (mitomycin, 0.5 g/L, 2 min), shallow anterior chamber and hypotony occurred in early postoperative period in 8 eyes (53.3%). Glaucoma operation was performed in other hospitals in 5 patients (5 eyes). Eight cases (8 eyes) received glaucoma operation more than two times. The mean interval between the last filtering surgery and the diagnosis of endophthalmitis was 29.5 ± 32.2 months (ranged 15 days to 10 years). Mainly clinical features included bleb infection, anterior chamber inflammatory exudation, hypopyon and vitreous opacities. Bleb leakage occurred in 63.6% eyes and bleb was located inferiorly in 5 eyes (25.0%). The incidence of inferior bleb-related endophthalmitis was higher than that of the superior bleb (19.2% versus 0.6%). The most common causative organisms were staphylococcus species. The initial treatments included intravenous and topical antibiotics, intravitreal injection of antibiotics, pars plana vitrectomy. These treatments could effectively control the endophthalmitis. The visual prognosis was good, 80% patients achieved increase of vision after treatment and 55% patients regained original visual acuity. Eye ball was preserved in 13 (68.4%) of 19 eyes, intraocular pressure (IOP) was controlled at last follow-up after the treatment of endophthalmitis. IOP was controlled by 1 or 2 drugs in 5 eyes (26.3%) and 1 eye (5.3%) received trabeculectomy. Glaucoma bleb-associated endophthalmitis is a serious complication following glaucoma filtering surgery which threats patients visual acuity significantly. It can occur at any time after the operation. Staphylococcus species is the most common causative organisms. Bleb leakage and inferior bleb location are the possible causative factors. Patients should be immediately treated by intra-vitreal injection and/or vitrectomy. If the treatment is timely and effective, the visual prognosis is good.

DELAYED-ONSET BLEB-ASSOCIATED ENDOPHTHALMITIS (1996–2008)

The purpose of this study was to report the clinical features, organisms, and outcomes of patients with delayed-onset bleb-associated endophthalmitis. Retrospective consecutive case series. Patients who were treated for delayed-onset bleb-associated endophthalmitis between January 1, 1996, and July 1, 2008, at a single institution were included. Information on visual acuities, clinical characteristics, causative organisms, and treatment outcomes were collected. Infections within 1 month of glaucoma filtering surgery, inadvertent filtering blebs after cataract surgery, and patients with glaucoma drainage devices were excluded. A total of 71 eyes from 68 patients were identified. An adjunctive antifibrotic agent was used in 48 eyes (68%). The mean time between surgery and endophthalmitis was 4.8 years (range, 0.1-16; standard deviation, 3.6). The average follow-up time after initial treatment was 37 months (range 1-144; standard deviation, 41). At presentation, 17 eyes (24%) had a bleb leak. Fifty-seven eyes (83%) were culture positive. The most common causative organisms were Streptococcus species in 20 eyes (30%), gram-negative organisms in 19 eyes (28%), and coagulase-negative Staphylococcus in 12 eyes (18%). All gram-positive isolates were sensitive to vancomycin. Nine eyes (13%) eventually underwent evisceration or enucleation secondary to pain and/or poor vision. The main outcome measure was best-corrected visual acuity at the last follow-up examination. Final visual acuities in the initial tap/inject group (n = 45) versus the initial vitrectomy group (n = 24) were as follows: ≥ 20/40 (29% vs. 4.2%), 20/50 to 20/400 (36% vs. 29%), and <5/200 (36% vs. 62%). Streptococcus species and gram-negative organisms were the most common causative isolates identified in this case series of delayed-onset bleb-associated endophthalmitis. Despite treatment of the infection, visual outcomes were generally poor.

Delayed-onset bleb-associated endophthalmitis: presentation and outcome by culture result

Purpose:To determine how culture results are associated with clinical presentations and outcomes in delayed-onset bleb-associated endophthalmitis (BAE).Methods:Retrospective consecutive case series of BAE at Bascom Palmer Eye Institute between January 1, 1996 and December 31, 2009. All patients had prior glaucoma filtering surgery. BAE was defined as intraocular infection with vitreous involvement receiving treatment with intravitreal antibiotics. Visual acuity (VA) outcomes and other clinical data were grouped by culture result and compared using the 2-sided Student’s t-test.Main outcome measure:Mean logMAR change at 3 months after treatment (3-month logMARΔ).Results:Eighty-six eyes of 85 patients were identified. Two eyes were primarily eviscerated. Fifty-three (63%) eyes were culture-positive with the following organisms: Streptococcus, 21 (25%); coagulase-negative Staphylococcus, 9 (11%); Enterococcus, 6 (7%); Gram-negative, 15 (18%); Moraxella, 8 (10%); Pseudomonas, 3 (4%); and Serratia, 3 (4%). Presenting logMAR VA: culture-positive worse than culture-negative cases (2.45 vs 2.19, P = 0.05). Presenting intraocular pressure (IOP): culture-positive higher than culture-negative cases (24 mmHg vs 14 mmHg, P = 0.002). Poor presenting view of the fundus: Streptococcus worse than coagulase-negative Staphylococcus cases (90% vs 44%, P = 0.006), Pseudomonas and Serratia worse than Moraxella cases (100% vs 50%, P = 0.04). Three month logMARΔ: culture-positive worse than culture-negative cases (1.03 vs 0.43, P = 0.02), Streptococcus worse than coagulase-negative Staphylococcus cases (1.44 vs 0.31, P = 0.004), Pseudomonas and Serratia worse than coagulase-negative Staphylococcus cases (2.41 vs 0.31, P = 0.001), Pseudomonas and Serratia worse than Moraxella cases (2.41 vs 0.04, P = 0.001). A culture result of Streptococcus or Serratia was present in 6 of 7 eyes that received an additional treatment of enucleation or evisceration (P = 0.01).Conclusion:Culture-positive cases were associated with worse presenting VA, higher presenting IOP, and worse VA outcomes than culture-negative cases. Streptococcus, Pseudomonas, and Serratia cases were associated with poor presenting view of the fundus and worse VA outcomes than coagulase-negative Staphylococcus and Moraxella cases.

Bleb-associated infections after intravitreal injection.

The purpose of this study was to describe two cases of bleb-associated infections after intravitreal injection. Case reports of two patients. Case 1: A 41-year-old man with choroidal neovascular membrane received intravitreal injections of ranibizumab. Case 2: A 56-year-old man with cystoid macular edema after retinal detachment surgery received intravitreal triamcinolone acetonide. In Case 1, the patient developed a culture-negative blebitis 3 days after intravitreal ranibizumab and was treated with intravitreal, subconjunctival, and oral antibiotics. The infection resolved after 3 weeks, with stable 20/100 vision and preservation of bleb function. In Case 2, a bleb-associated endophthalmitis (positive for Streptococcus pneumoniae) occurred 3 weeks after intravitreal triamcinolone acetonide, requiring repeated intravitreal antibiotics and two vitrectomy procedures to control the infection, with final vision of hand motions. Bleb-associated infections can be a complication of intravitreal injection. The potentially severe results of bleb-associated endophthalmitis warrant monitoring in patients with previous trabeculectomy who undergo intravitreal injection therapies.

Microbiology and Visual Outcome of Bleb-associated Endophthalmitis

Purpose: To identify the microbiological spectrum and visual outcome of bleb-associated endophthalmitis.Methods: The medical records of patients treated for bleb-associated endophthalmitis were reviewed.Results: Seventy-five patients were identified. Vitreous cultures were positive in 48 (64%) patients. The most common isolates were Streptococcus species in 24 (50%) eyes, gram-negative bacteria in 10 (20.8%) eyes, and Staphylococcus epidermidis in 7 (14.6%) eyes. Good visual outcome was achieved in 33 (44%) patients. On univariate analysis, shorter interval from onset of symptoms and treatment (p = .005), better initial visual acuity (p = .004), clear cornea at presentation (p = .048), isolation of less virulent organisms (p < .001), and absence of diabetes mellitus (p = .048) were significant positive predictors for good visual outcome.Conclusions: Bleb-associated endophthalmitis is associated with severe visual impairment. Clinical features associated with better visual outcome include early presentation, better presenting visual acuity, clear cornea at presentation, culture of a less virulent organism, and absence of diabetes mellitus.

Gemella Species-associated Late-onset Endophthalmitis After Trabeculectomy With Adjunctive Mitomycin C

To report 2 cases of delayed-onset, bleb-related endophthalmitis induced by Gemella species. Interventional case report. Two patients developed bleb-related ocular infection attributable to Gemella haemolysans and Gemella morbillorum after trabeculectomy with adjunctive mitomycin C. Both patients had thin-walled cystic filtering blebs before ocular infection. One patient underwent urgent vitrectomy with intravitreal injection of ceftazidime and vancomycin. The other received an intraocular injection of vancomycin and ceftazidime. After surgical intervention, 2 cases were administered topical levofloxacin and sulfobenzylpenicillin, and intravenous cefpirome. The DNA from the microorganism was sequenced and identified as G. haemolysans and G. morbillorum. Gemella species should be added to the long list of organisms that may rarely cause bleb-associated endophthalmitis.