To report a case of recalcitrant Actinomyces neuii (A. neuii) chronic postoperative endophthalmitis (CPE) successfully treated with prolonged systemic penicillin therapy and intraocular lens (IOL) explantation, with pharmacokinetic confirmation of therapeutic intravitreal drug levels. Retrospective case report with focused literature review. A 77-year-old male developed recurrent anterior uveitis and cystoid macular edema after uncomplicated cataract surgery. Vitreous cultures grew A. neuii. Despite repeated intravitreal antibiotics and vitrectomies, inflammation recurred over several years. Following infectious disease consultation, intravenous penicillin G (4 million units every 4 hours for 4 weeks) was administered, followed by intramuscular benzathine penicillin G (2.4 million units every 2 weeks for 6 months), in conjunction with IOL explantation. Intravitreal sampling four hours after intravenous dosing demonstrated penicillin G concentration of 3.5 μg/mL, exceeding published minimum inhibitory concentrations for Actinomyces species. Inflammation remained quiescent at long-term follow-up with visual acuity limited due to secondary complications from chronic macular edema. This case highlights the importance of systemic therapy and interdisciplinary management in recalcitrant CPE caused by unusual pathogens. Our approach, including prolonged intravenous and intramuscular antibiotic courses with confirmed therapeutic intraocular concentrations and IOL removal, proved effective for sustained resolution.

Relevance In chronic postoperative endophthalmitis, the clinical picture develops 1.5–2 weeks after surgery and resembles sluggish uveitis [1–4]. Diagnosis of chronic postoperative endophthalmitis is a difficult task, especially when fungal flora acts as an etiologic factor [2, 5, 6]. Electron microscopy, which has recently received a good evidence base, can be used as an additional diagnostic tool for chronic postoperative endophthalmitis. Objective To demonstrate the possibility of using electron microscopy in the diagnosis of chronic postoperative endophthalmitis of fungal etiology using a clinical example. Material and methods Patient P., 67 years old, developed a picture of chronic endophthalmitis 10 days after PEC with IOL. Endovitreal intervention was performed with intraoperative OCT control [7]: vitrectomy, anterior chamber lavage, capsular bag lavage, intravitreal administration of a combination of antibacterial solutions (vancomycin and ceftazidime). Before the operation, cultures were taken from the fluid of the anterior chamber and vitreous cavity for bacteriological examination and light electron microscopy (SEM) with material fixation using a patented technology. Results According to the results of the bacteriological examination on the 5th day, a colony of Corinebact. Xerosis grew in samples from the vitreous cavity. According to the SEM results obtained on the day of the operation, fungi with a micellar structure were detected in the material from the vitreous cavity. When the patient was discharged from the hospital on the 7th day after the operation, obvious positive dynamics were observed against the background of antibiotic therapy. Three weeks after the surgery, against the background of discontinuing antibiotic therapy and reducing anti-inflammatory therapy, the patient noticed the previous symptoms, and therefore returned to the institute. A repeated endovitreal intervention was performed with extraction of the IOL with the capsular bag and intravitreal administration of antibacterial drugs. Samples were taken from the fluid of the anterior chamber, vitreal cavity, capsular bag and sent for bacteriological examination and SEM. According to the results of the first study, no pathogen was detected, according to the SEM results, a fungal agent was detected. Considering the long course of the process, relapses, despite systemic antibacterial therapy, repeated SEM results with the detection of fungal flora, a diagnosis was made - chronic postoperative endophthalmitis of fungal etiology. In this connection, systemic antifungal therapy was prescribed. After 1 month of treatment, stable visual functions were noted, and biomicroscopy showed no inflammatory reactions in the anterior and posterior segments of the eye. Conclusion Based on our clinical example, it can be assumed that SEM: 1) allows for a short preliminary determination of the etiology of endophthalmitis, which plays a key role in the implementation of appropriate etiotropic therapy; 2) SEM makes it possible to suspect a particular pathological agent that caused endophthalmitis even against the background of previously administered antibiotic therapy. Key words: vitrectomy; endophthalmitis; intravitreal administration of antibiotics; postoperative eye inflammation; electron microscopy; bacteriological examination

This study assessed the incidence of postsurgical intraocular inflammation after cataract extraction by phacoemulsification and implantation with AcrySof IQ ReSTOR intraocular lenses (IOLs) produced using an updated manufacturing process. Incidence rates were compared with historical rates of postsurgical intraocular inflammation. This was a prospective, multicenter, post-approval study at 34 sites. Patients aged ≥22 years received a study lens in at least 1 eye. Postsurgical intraocular inflammation (aqueous cell grade ≥3+ within 14 days after surgery, aqueous cell ≥2+ at 14 to ≤60 days after surgery, or aqueous cell ≥1+ at >60 days) was assessed within a 180-day period after implantation. Rates of toxic anterior segment syndrome (TASS), acute postoperative endophthalmitis, chronic postoperative endophthalmitis, and uncategorized cases of postsurgical intraocular inflammation were assessed. Ocular adverse events (AEs) and ocular adverse device effects (ADEs) were evaluated. Historical rates of postsurgical intraocular inflammation were determined from the 2011-2013 Medicare Limited Data Set files (a 5% sample of the Medicare data set representative of patients aged ≥65 years). Final safety analysis set included 3357 eyes (1792 patients; mean age, 68.6 ± 7.9 years). Postsurgical intraocular inflammation (any type) rate was 5.1 per 1000 attempted IOL implants (95% CI, 2.95, 8.10). TASS, acute postoperative endophthalmitis, and uncategorized inflammation rates were 0.6 (95% CI, 0.07, 2.15), 0.3 (95% CI, 0.01, 1.66), and 4.2 (95% CI, 2.28, 6.99) per 1000 attempted IOL implants, respectively. There were no events of chronic postoperative endophthalmitis. Ocular AEs and ADEs were reported in 17% and 1.5% of eyes, respectively. Most common ADEs were halo (0.63%) and glare (0.51%). The historical postsurgical inflammation rate from 221,519 cataract procedures was 10.3/1000 cataract surgeries, and the endophthalmitis rate was 1.2/1000 surgeries. The updated IOL manufacturing process resulted in postoperative intraocular inflammation rates that were substantially lower than the historic rate.

Purpose. To demonstrate the possibility of using electron microscopy in the diagnosis of chronic postoperative endophthalmitis of fungal etiology using a clinical example. Material and methods. A clinical case of chronic postoperative endophthalmitis of fungal etiology is presented in the diagnosis of which light electron microscopy (SEM) was crucial. Results and discussion. The correct diagnosis of fungal chronic endophthalmitis was achieved based on the results of SEM, after which etiotropic treatment was prescribed with a positive clinical result. Conclusion. SEM can act as an additional method for diagnosing chronic postoperative endophthalmitis. Keywords: vitrectomy, endophthalmitis, intravitreal injection of antibiotics, electron microscopy, bacteriological examination

Introduction: To the authors' knowledge, these are 2 of the longest reported time periods between cataract surgery and diagnosis of chronic postoperative endophthalmitis. The clinical course and outcomes are discussed. Patient and Clinical Findings: 2 patients underwent uneventful cataract surgery and presented with recurrent anterior segment inflammation years after the surgery. In the first case, an 88-year-old man presented with granulomatous uveitis in the left eye 4 years after intracapsular cataract extraction and posterior chamber intraocular lens (CE/PC IOL) placement. In the second case, a 79-year-old woman presented with iritis 7 years after CE/PC IOL. Diagnosis, Intervention, and Outcomes: Both patients were treated for presumed idiopathic uveitis for years before the diagnosis of chronic endophthalmitis caused by Cutibacterium acnes. 1 case required endolaser photocoagulation to an infectious nidus. Conclusions: Chronic postoperative endophthalmitis can present many years after uneventful cataract surgery.

ABSTRACT Introduction We describe the case of a postoperative fungal endophthalmitis caused by Wickerhamomyces anomalus, an opportunistic yeast common in nature but rare as a causative agent in ocular infections. This would be the second reported case of W. anomalus endophthalmitis. Case report A patient came to our hospital with a dense hemovitreous caused by an inadvertent ocular perforation and retinal detachment during a cataract surgery. In the days following the first vitreoretinal surgery a chronic postoperative endophthalmitis was evidenced. Only after several surgeries as well as intravitreal antibiotics and sample takings, Wickerhamomyces was detected. The treatment with oral voriconazole and an intraocular lens extraction controlled the infection. Discussion Wickerhamomyces anomalus, despite not being particularly aggressive in our case, was resistant to various consequent vitreoretinal surgeries. The unresponsiveness to treatment led us to contemplate the fungal etiology, and fortunately the cultures were positive for this yeast. In conjunction to antifungal therapy, it is possible that the IOL explantation played an important role in the treatment. Conclusion A high index of suspicion must be held in cases of fungal endophthalmitis. Both IOL explantation and oral antifungal therapy are useful treatment options in cases of W. anomalus endophthalmitis.

Comment on chronic postoperative endophthalmitis with an unusual organism

We report three cases of refractory chronic endophthalmitis after cataract surgery presenting to a referral center, and with repeated negative cultures. Initial treatment consisted of intravitreal and systemic antibiotics, with partial improvement. After subsequent worsening, pars plana vitrectomy, intraocular lens explantation and en bloc capsulectomy were performed. Histopathological examination revealed multiple filamentous fungal structures, sequestered between anterior/posterior lens capsule in all cases. Chronic postoperative fungal endophthalmitis may manifest with negative cultures possibly associated with sequestration of the microorganism into the capsular bag. Careful histopathological examination of lens capsule in these cases may be essential for a definite diagnosis.

Chronic postoperative endophthalmitis (CPE) following cataract surgery with the appearance of distinct plaques is most commonly caused by Propionibacterium acnes and the standard treatment is intraocular lens (IOL) explant and complete capsulectomy. We report a case of CPE who presented with an indolent recurrent course, manifested numerous typical plaques in the capsular bag, and was treated with an IOL explant, re-implant, and two-port 23G pars plana vitrectomy under direct vision with good results. The organism grown was Bacillus species which is the most common known cause of posttraumatic endophthalmitis and typically has a rapidly devastating course. It is very rare to detect Bacillus species as an incriminating organism in CPE.

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.

Chronic postoperative endophthalmitis is a known complication of cataract surgery. Here, we report a case of chronic endophthalmitis following uncomplicated cataract surgery secondary to the atypical bacterium Aquamicrobium terrae . Retrospective case report of a single patient with endophthalmitis secondary to A. terrae. A 61-year-old healthy patient presented with recurrent iridocyclitis following uncomplicated cataract surgery. Repeated attempts to taper off topical steroid eyedrops were unsuccessful. Anterior chamber paracentesis cultures and vitrectomy cultures grew the same gram-negative bacillus, A. terrae , on six different occasions. The patient was treated initially with a series of intravitreal ceftazidime injections and adjuvant oral minocycline with recurrence of inflammation necessitating pars plana vitrectomy with intraocular lens removal and total capsulectomy. Inflammatory episodes recurred until residual capsule fragments were ablated using endoscopic vitrectomy. Since ablation over 18 months ago, no further recurrences have occurred and the patient has excellent visual outcome. A. terrae is a gram-negative bacillus recovered from polluted soil. This is the first case of postoperative endophthalmitis secondary to A. terrae and the first description of human infection caused by this newly identified microbe.

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Background: The assessment of the incidence and characteristic of acute and chronic postoperative endophthalmitis (POE) after cataract surgery in Poland during 2010–2015. Patients and methods: All hospitalizations of patients, in the National Database of Hospitalizations, who underwent cataract surgery alone or in combined procedures in Poland between January 2010 and December 2015, with a billing code of endophthalmitis, were selected. Acute endophthalmitis was identified if symptoms occurred within 1–42 days from the cataract surgery and chronic endophthalmitis if symptoms occurred ≥43 days after cataract surgery, respectively. Results: In total, 1331 cases of POE after 1,218,777 cataract extractions were identified. The overall incidence of POE decreased from 0.125% in 2010 to 0.066% in 2015. In multiple logistic regression analyses, increasing age was significantly associated with acute POE, while type II diabetes mellitus, extracapsular cataract extraction, and one-day surgery were significantly associated with chronic POE. The combined cataract surgery and male sex were significant risk factors for both acute and chronic POE. A total of 62.51% of all eyes affected by POE received antibiotic treatment and 37.49% had vitrectomy treatment. Conclusions: During the study period, the total incidence of postoperative endophthalmitis after cataract surgery decreased significantly.

A clinical case of chronic postoperative endophthalmitis treatment after cataract phacoemulsification is described in the article. The patient received vitrectomy with lens posterior capsule discission and tamponade of vitreal cavity by perfluororganic compound (up to 14 days) and 1mg vancomicin +2.25 mg ceftazidim intravitreally, also anterior chamber washing by 0.5 ml saline containing 5 mg vancomicin. Anterior chamber washing by antibiotics and intravitreal injection of antibacterial medicine combination was repeated on the second and third day after the surgery. This tactics of treatment allowed to save lens capsular bag and intraocular lens. Purpose. To assess efficacy and safety of new treatment method in the patient with chronic postoperative endophthalmitis. Patient B, 65 years old applied to clinic with complaints on the pain in the right eye, visual acuity decrease up to finger counting near face. Symptoms started to disturb in 2 weeks after cataract extraction with IOL implantation. During 6 months courses of antibacterial therapy including vancomicin (antibiotic of reserve) there were no positive dynamics. Cornea edema, multiple precipitates at endothelium and intraocular lens were defined at biomicroscopy; 2.5 mm hypopyon in anterior camera; fibrin in pupil projection; exudation in vitreous cavity. Laser tyndalmetry data (albumen flow in anterior chamber) confirmed inflammation strong enough — 173 f/ms. Surgical treatment according the described method was rendered to the patient. In the postoperative period we saw stable visual functions, uncorrected visual acuity was 0.6, corrected — 0.8. Patient noted the absence of pain and eye’s reddening decrease. At biomicroscopy we observed considerable inflammation decrease, almost total absence of precipitates at cornea endothelium. Laser tyndalmetry data confirmed inflammation decrease, albumen flow in anterior chamber was 17.6 f/ms. Endothelial cells’ loss after surgery was 142 cells/1 mm2 (5.61 %). According to electrophysiologic investigation and ERG there was no deviation from normal values was revealed. This treatment method allows to restore visual functions rather quickly and can be used in case of inefficient lengthy conservative therapy.

A diagnostic dilemma in a patient with delayed onset endophthalmitis

BackgroundThe aim of this study was to report an unusual case of chronic postoperative endophthalmitis following cataract surgery, secondary to Ochrobactrum anthropi that was found to be resistant to vancomycin.FindingsAnterior chamber paracentesis cultures grew gram negative bacilli Ochrobactrum anthropi. The patient was treated with a series of intracameral injections of moxifloxacin, with adjuvant oral moxifloxacin. Posterior sub-Tenon and oral corticosteroids were used to treat cystoid macular edema. Explantation of the intraocular lens (IOL)-capsular bag complex was avoided.ConclusionsChronic postoperative endophthalmitis is a rare entity, often due to indolent pathogens that sequester in the capsular bag. Aggressive surgical intervention may be avoided with the use of adequate intraocular antibiotic, provided that the offending organism demonstrates appropriate antibiotic susceptibilities.

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.

To describe the results of vitrectomy and partial capsulectomy via anterior approach surgical technique in treatment of chronic postoperative endophthalmitis (CPE). Clinical records of 9 patients treated for CPE between 2006 and 2010 were reviewed retrospectively. All of these patients were treated with vitrectomy and partial capsulectomy via anterior approach. Six of 9 patients were male. The average patients' age was (60±8.1) years. The average period between cataract extraction and onset of signs and symptoms was (3.6±1.3) weeks. The average presenting visual acuity was 0.3±0.1 and the average final post operative visual acuity was 0.7±0.2. The mean follow-up period was (28.1±8.9) weeks. In all patients, the inflammation subsided after surgery. Our results suggest that anterior vitrectomy and partial capsulectomy via anterior approach may be considered as potentially useful and relatively less invasive technique to treat CPE.

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

To describe the clinical courses of patients who received intravitreal injections of highly concentrated amphotericin B deoxycholate for suspected fungal endophthalmitis. Retrospective medical record review of 3 cases of intraocular toxicity from highly concentrated amphotericin B. The first patient developed posttraumatic endophthalmitis and received an undiluted dose (500 μg) of amphotericin B. He developed severe intraocular inflammation and required a pars plana lensectomy, vitrectomy, and scleral buckle after developing a cataract and retinal detachment. Six years later, his visual acuity stabilized at 20/30. The second patient developed endogenous endophthalmitis and was treated with 5 intravitreal injections of amphotericin B and underwent 3 surgical procedures. The surgeon later discovered that the patient had received 55 μg of amphotericin B during the second injection. Three months after the injection, the patient's visual acuity was 20/60. The third patient developed chronic postoperative endophthalmitis following cataract extraction. He received 160 μg of amphotericin B and was immediately treated with a vitreous washout. Two years later, his visual acuity improved to 20/30. The vitreous culture results were negative in each case. A key finding was that the amphotericin B solution appeared to be yellow instead of nearly colorless. We present 3 cases of intraocular toxicity from highly concentrated amphotericin B. In every case, the overly concentrated amphotericin B solution was yellow in color. Although severe noninfectious panophthalmitis resulted in every case, the visual acuity outcomes were good. Physicians should examine the color of amphotericin B solution prior to intraocular administration. If the solution appears to be yellow, the medication should not be injected.