Intraocular Antibiotics Research Articles

Rationale Antibiotikatherapie in der Augenheilkunde

Bacterial infections can affect all structures of the eye. In most cases, infections of the ocular surface are treatable with topical antibiotics, whereas intraocular infections need a combined treatment with intraocular and systemic antibiotics. Localisation, severity, expected microorganisms, and possible consequences of the infection lead to the appropriate therapy. Unwarranted use of antibiotic substances for prophylaxis or treatment of nonbacterial infection should be avoided, especially because of possible selection of multiresistant microorganisms.

Resolution of Pigmented Keratic Precipitates Following Treatment of Pseudophakic Endophthalmitis Caused by Propionibacterium Acnes.

Propionibacterium acnes is a well-recognized cause of chronic postoperative endophthalmitis after cataract surgery. The subtle clinical signs of this infection and its initial favorable response to topical steroids may lead to delayed diagnosis and treatment. Two patients with culture proven P. acnes endophthalmitis after cataract surgery that presented with prominent pigmented keratic precipitates (KPs) and low-grade iritis in the involved eye were managed. Both cases had initial treatment with diagnostic pars plana vitrectomy (PPV) with intraocular antibiotic (IOAB) injection. Secondary treatment for recurrence was required in both patients. The KPs and iritis resolved after removal of intraocular lens (IOL) and capsular bag.

Incidence and outcome of endophthalmitis over a 13-year period

Objective: The aim of the study was to assess the functional results and long-term visual prognosis in patients treated for acute endophthalmitis (AE). Design: Observational clinical series. Participants: Evaluation of 120 eyes of 114 patients with AE treated between 1991 and 2004. Methods: This retrospective institutional analysis included 120 eyes of 114 patients (52 male, 68 female) with AE and a minimum follow-up of half a year. The patients had a mean follow-up of 23 months (6–135 months) and a mean age of 61 years (8 months-94 years) at the time of treatment. Treatment included intraocular injection of antibiotics alone ( n = 18, 15%) and vitrectomy combined with intraocular and topical postoperative antibiotics ( n = 85, 70%). Results: The most frequent complications were vitreous or retinal hemorrhages ( n = 17, 14%), retinal detachment ( n = 17, 14%), choroidal detachment ( n = 3, 3%), secondary glaucoma ( n = 7, 6%), and recurrent endophthalmitis ( n = 3, 3%). Four eyes had to be enucleated because of recurrent and uncontrollable infection. Positive microbiological results were achieved in 67 of 88 specimens (76%). The most common isolate was Staphylococcus. At the end of follow-up, visual acuity was reduced (more than 2 lines) in 18 eyes (15%), stable in 22 (18%), and improved (more than 2 lines) in 72 eyes (60%). Conclusions: AE is a rare but severe disease with a potentially deleterious outcome in affected eyes. In our series, 78% of all eyes had stable or improved postoperative visual acuity following various treatment regimens, depending on the severity of each case.

Methicillin-resistant Staphylococcus aureus infectious scleritis after vitrectomy for endophthalmitis.

To report a case of methicillin-resistant Staphylococcus aureus infectious scleritis after vitrectomy for endophthalmitis. Retrospective chart review of one patient referred to a tertiary academic center for management of methicillin-resistant S. aureus infectious scleritis. Antecedent history, clinical course, response to treatment, and final visual acuity were documented. Methicillin-resistant S. aureus infectious scleritis required combination systemic, periocular, intraocular, and topical antibiotics for complete resolution. Visual recovery was limited. Methicillin-resistant S. aureus infectious scleritis can complicate vitrectomy for endophthalmitis and requires long-term and multiple-route administration of antibiotics for resolution. Greater awareness of this serious complication along with preventive measures may reduce future occurrences.

A Case of Polymicrobial Keratitis Violating an Intact Lens Capsule

To report a case of polymicrobial keratitis resistant to topical and intraocular antibiotics with recurrence after penetrating keratoplasty. Case report. We report a case of polymicrobial keratitis caused by Phialophora verrucosa, Candida tropicalis, and Propionibacterium acnes. Initial treatment included topical vancomycin, tobramycin, amphotericin B, voriconazole, and oral fluconazole, as well as subconjunctival amphotericin B. Penetrating keratoplasty was performed, and the infection seemed to have resolved until 4 weeks after keratoplasty. A second penetrating keratoplasty was performed, followed by 4 weekly intracameral injections of voriconazole. Two weeks after the fourth intracameral injection, the infection manifested as an active anterior-chamber reaction. The patient's eye was subsequently enucleated. Histopathologic evaluation showed penetration of the crystalline lens by fungus at the site of synechiae between the intact lens capsule and iris. To our knowledge, this is the first documented case of a polymicrobial keratitis caused by a bacterium, yeast, and a fungus. It is the first histopathologic demonstration of fungal penetration of intact lens capsule from infected iris.

Endophthalmitis: A rare complication of arteriovenous fistula infection

Vascular access infection is a frequent problem in patients undergoing maintenance hemodialysis. Infection of arteriovenous fistula (AVF) is less common than dialysis catheter-associated infection. Previous case reports described endophthalmitis secondary to hemodialysis catheter-related infection, but not secondary to native AVF infection. We report a rare patient of endophthalmitis as a metastatic infection of AVF cannulation site abscess. A 19-year-old girl on maintenance hemodialysis for the past 2 years has presented with a history of fever, chills, and rigor of 3-days duration and painful dimness of vision in the left eye of 1-night duration. It was followed by redness of the eye, photophobia, and ocular discharge. On examination, the patient was febrile with an abscess near cannulation site of AVF. There was no perception of light in the left eye, conjunctiva was congested, cornea was clear, hypopyon present, and pupil was mid-dilated, not reacting to light. Lens was clear. Vitreitis and exudative retinal detachment was present. Methicillin sensitive Staphylococcus aureus was isolated from blood, pus from AVF abscess and vitreous fluid. Diagnosis of endophthalmitis was confirmed by B-scan ultrasound. She was treated with both intravenous and intraocular antibiotics and drainage of pus from AVF abscess and therapeutic vitrectomy. Though arteriovenous abscess responded to sensitive antibiotics and drainage, vision has not improved much. Strict aseptic precautions during regular AVF cannulation are required. Lapses may lead to loss of vision apart from described complications like access closure, endocarditis, and osteomyelitis.

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

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

Antibiotics Concentrations in a Patient with Postoperative Endophthalmitis

We report a case of endophthalmitis who underwent a vitreous biopsy to assess sensitivity and to inject broad-spectrum intraocular antibiotics. Minimal inhibitory concentration (MIC) values of antibiotics against a coagulase-negative staphylococcus and Proprionibacterium acnes were also assessed.

Primäre Vitrektomie mit intraokularer Antibiotikaapplikation bei akuter postoperativer Endophthalmitis

Pars plana vitrectomy with intravitreal antibiotic application is an established procedure for treating postoperative endophthalmitis. The presented study analyzes our own results with this treatment as well as the role of adjuvant systemic steroid treatment. We analyzed the data of 34 consecutive patients with postoperative endophthalmitis from January 2000 to March 2006. Thirty-two patients underwent vitrectomy and intravitreal application of antibiotics, and two patients received intravitreal antibiotics only. All patients received intravitreal dexamethasone and systemic antibiotics, and 12 patients received the systemic treatment with prednisolone. The effect of vitrectomy with respect to final visual acuity and the rate of postoperative complications were analyzed. The vitreous was microbiologically examined. Postoperative follow-up time ranged from 2 weeks to 24 months. Endophthalmitis followed cataract surgery with intraocular lens implantation in 30 patients (89%) and followed pars plana vitrectomy in four patients (11%). Positive cultures were obtained in 19 (56%) patients. Visual acuity improved in 31 (91%) patients. At their final examinations, 27 (79%) patients had gained visual acuity of 0.05 or better. Immediate vitrectomy in combination with intraocular antibiotics and steroid administration resulted in preservation of ambulatory vision in most of the patients. Systemic postoperative therapy with steroids seems to be associated with better final visual acuity.

Risk Factors for Post-Traumatic Endophthalmitis in Patients with Positive Intraocular Cultures

To determine the risk factors for post-traumatic endophthalmitis in patients with positive intraocular culture. An institutional-based prospective nonrandomized interventional study of patients older than 15 years who presented for primary repair of open globe injury between June 2003 and April 2005 was undertaken. The main outcomes measured were initial and final visual acuity, type of injury, presence of uveal and vitreous prolapse, time interval between injury and primary repair of the globe, length of wound, location of wound, and virulence of organism. Statistical analysis tests used were Student t-test, Fisher exact test, and chi-square test. Fifty patients were included in the study. They were divided into two groups: Group 1 (n=19) patients, who developed clinically significant endophthalmitis; and Group 2 (n=31) patients, who did not develop clinically significant endophthalmitis. Delay in primary repair more than 36 hours (p=0.042), length of wound more than 8 mm (p=0.050), and isolation of organisms like fungus (p=0.006, OR=14), Bacillus cereus (p=0.01, OR=11.25), and Pseudomonas aeruginosa (p=0.05-0.10, OR=11.3) significantly increased the risk of endophthalmitis. Mean initial and final visual acuity was better in Group 2 but was not statistically significant (p=0.21). Final visual outcome in the presence of positive intraocular culture is poor. Isolation of virulent organisms, longer length of laceration, and delayed primary repair of open globe injuries have high risk of developing endophthalmitis. Prophylactic intraocular antibiotics should be considered in cases with longer length of wound and delayed primary closure.

Microbial cultures in open globe injuries in southern India

To determine the risk factors leading to positive intraocular culture in patients with open globe injury. A prospective interventional study involving 110 eyes of 110 patients of more than 15 years of age, presenting with open globe injury, was undertaken. Emergency repair of the injured globe was done. Prolapsed intraocular tissue or aqueous humour was sent for microbial work up before repair. In endophthalmitis cases intravitreal antibiotics were given according to the antimicrobial sensitivity. Chi-square and logistic regression analysis were used to determine the risk factors. Fifty-six patients showed microbial contamination. Bacteria were cultured in 42 patients and fungi in 14 patients. Nineteen patients developed endophthalmitis, of which 18 patients showed microbial growth initially. In univariate analysis, initial visual acuity (<6/360, P = 0.002), presence of uveal tissue prolapse (P < 0.001), vitreous prolapse (P < 0.001) and length of laceration (>8 mm, P < 0.001) were significantly associated with positive microbial culture, however, in the multivariate stepwise logistic regression delay in surgical intervention (>72 h, P < 0.001), uveal tissue prolapse (P = 0.004) and corneosclearal laceration (>8 mm, P = 0.013) were associated with increased risk of positive microbial culture. Six patients had intraocular foreign body but were culture negative. Age, gender, site of injury and presence of cataract did not significantly affect the culture positivity. Microbial contamination is a risk factor for the development for endophthalmitis. Despite the high frequency of microbial contamination, it develops only in few cases. Systemic antibiotics, virulence of the organism and host factors play a role in the manifestation of endophthalmitis. Prophylaxis with intraocular antibiotics should be strongly considered in cases with poor vision at presentation, larger corneoscleral laceration, delayed surgical intervention and uveal tissue or vitreous prolapse.

Intravitreal Moxifloxacin: Retinal Safety Study with Electroretinography and Histopathology in Animal Models

To determine whether moxifloxacin can be used safely as an intraocular antibiotic, retinal safety of intravitreal moxifloxacin was studied with electroretinography (ERG) and histopathology in animal models. Moxifloxacin was injected into mouse eyes at intravitreal concentrations of 5 to 500 microg/mL and into rabbit eyes at 150 microg/mL. As the control, the vehicle was injected into the fellow eyes of each animal. Four weeks after injection, ERG recordings were performed, and animal eyes were processed for histologic examination. ERG studies showed no significant difference between control and moxifloxacin-injected eyes at any dose in either the mouse or rabbit model. Histologic examination revealed no retinal abnormality in mice at 5 to 100 microg/mL or in rabbits at 150 microg/mL intravitreal moxifloxacin. In mice at 500 microg/mL, occasional focal retinal necroses were observed, suggesting isolated retinal toxicity at this concentration of moxifloxacin. Intravitreal moxifloxacin, up to 100 microg/mL in mice or 150 microg/mL in rabbits, caused no ERG or retinal histologic abnormality. These results indicate that moxifloxacin is a safe intravitreal antibiotic in mouse and rabbit animal models. If proven safe and efficacious by further study in humans, intravitreal injection of moxifloxacin could be considered as an alternative to currently used antibiotics in selected patients with resistance or allergy to the more traditional antibiotics.

PSEUDOMONAS AERUGINOSA ENDOGENOUS ENDOPHTHALMITIS WITH CHOROIDAL ABSCESS IN A PATIENT WITH CYSTIC FIBROSIS

To describe the clinical presentation, management, and outcome of a case of endogenous intraocular infection due to Pseudomonas aeruginosa in a patient with cystic fibrosis (CF). The authors describe a case of an adult patient with CF who developed an intraocular infection by P. aeruginosa. Diagnosis was confirmed by culture of purulent fluid obtained by transcleral incision and drainage. The infection persisted in spite of aggressive surgical intervention including extensive endoresection of the visibly affected retina and choroid and multiple administrations of appropriate intraocular, subconjunctival, and systemic antibiotics. Eventually, the eye became blind and painful and was enucleated. Endogenous intraocular infection by P. aeruginosa can occur in patients with CF who have not undergone lung transplantation. An infection of this type may be impossible to eradicate by aggressive surgical intervention and appropriate antibiotic therapy.

Destructive ophthalmic surgical procedures in Onitsha, Nigeria

to determine the incidence, trend and causes for surgical removal of the eyeball at the Guinness Eye Center Onitsha, Nigeria. Case files and theatre records of all patients who had eviscreration, enucleation or exenteration at the Guinness Eye Center Onitsha between 1995 and 2001 were reviewed. Information on age, sex, disease duration before hospital presentation, indication for surgery and the type of surgery were analysed. 56 eyes of 56 patients were surgically removed. Patients including some with penetrating eye injuries presented late for treatment; 37.5% and 53.5% had used traditional eye medicines (TEM) and eye drops possibly containing steroids, respectively, prior to hospital consultation. The indications for surgery were severe ocular infections, especially panophthalmitis; severe penetrating eye injuries and orbito-ocular tumours. The annual incidence ranged from 1.9 - 4.2% with an average of 3.4% . The downward trend observed in the later part of the study was associated with reduced incidence of ocular gunshot injuries, which in turn coincided with a reduction in violent crime in Onitsha and its environs. In spite of the observed downward trend in the rate of destructive eye surgery, the incidence of such procedures could be reduced further by timely intervention with modern microsurgical techniques; intraocular antibiotics and radiotherapy. The public should be educated on the harmful effects of TEM and abuse of eye drops. Those with eye problems should seek early hospital treatment.

Endophthalmitis caused by streptococcus pneumoniae

Purpose To investigate clinical settings, management strategies, antibiotic sensitivities, and visual acuity outcomes of endophthalmitis caused by Streptococcus pneumoniae. Design Retrospective, observational case series. Methods Records were reviewed of all patients with culture-positive endophthalmitis caused by Streptococcus pneumoniae treated at the Bascom Palmer Eye Institute between January 1, 1989 and December 31, 2003. MAIN OUTCOME MEASURES: Visual acuity and antibiotic sensitivities. Results Twenty-seven eyes of 27 patients met study inclusion criteria. The median follow-up was 7 months (range, 3 months to 10 years). Clinical settings included acute postoperative (10 eyes), corneal stitch abscess (5), corneal ulcer (3), bleb-associated (4), post-trauma (3), and endogenous (2). Eighteen cases (67%) were acute-onset (less than 3 weeks from event), with a median interval between event and presentation of endophthalmitis of 5 days (range, 1 day to 16 days). Nine cases (33%) were delayed-onset (median, 27 months; range, 3 to 121 months). Initial visual acuity was hand motions or better in 11 cases (41%). Initial therapeutic procedures included vitreous tap and injection of intravitreal antibiotics in 15 eyes (56%), pars plana vitrectomy and injection of intravitreal antibiotics in 10 eyes (37%), and evisceration in 2 eyes (7%). Seventeen (68%) of 25 eyes received intravitreal dexamethasone. Twelve patients (48%) received additional doses of intraocular antibiotics, and 11patients (44%) underwent secondary surgical intervention within one week of diagnosis. The Streptococcus pneumoniae isolates showed sensitivity patterns as follows: 27/27 vancomycin, 13/13 clindamycin, 6/6 cefazolin, 11/11 ciprofloxacin, 14/14 moxifloxacin, 24/26 (92%) ofloxacin, 12/14 (86%) levofloxacin, 13/14 (93%) gatifloxacin, and 1/13 (8%) gentamicin. The organism was sensitive to at least one antibiotic administered initially in all cases. Final visual acuity was 20/400 or better in 8/27 (30%) cases, but 10 eyes (37%) had a final vision of no light perception. Conclusion Despite prompt treatment with appropriate antibiotics, endophthalmitis caused by Streptococcus pneumoniae is associated with a poor visual prognosis.

Delayed-onset, bleb-associated endophthalmitis caused by lecythophora mutabilis

PurposeTo report delayed-onset, bleb-associated endophthalmitis caused by Lecythophora mutabilis. DesignInterventional case report. MethodsDescription of an otherwise healthy woman who developed delayed-onset fungal endophthalmitis associated with a preexisting filtering bleb. ResultsA 57-year-old woman who underwent trabeculectomy with Mitomycin C in her left eye 8 years earlier presented with a 10-day history of pain and decreased vision in her left eye. She underwent anterior chamber and vitreous taps and injection of intraocular antibiotics. Cultures grew the mold Lecythophora mutabilis. The patient underwent treatment with intraocular and systemic antifungal agents, three pars plana vitrectomies, partial iridectomy, and cryopexy to the bleb and angle structures. Four months after her last treatment, her left eye shows no residual infection, and vision corrects to 20/80. ConclusionBleb-associated endophthalmitis caused by L. mutabilis is resistant to amphotericin B but responsive to intravitreal and systemic voriconazole together with pars plana vitrectomy, iridectomy, and cryopexy to the bleb and angle structures.

Do we heed the Endophthalmitis Vitrectomy Study in Canada?

Background: The Endophthalmitis Vitrectomy Study (EVS) was a multicentre randomized clinical trial designed to guide the management of postoperative bacterial endophthalmitis. There is speculation that many physicians do not follow its recommendations, despite its intent. We surveyed Canadian vitreoretinal surgeons to determine whether surgeons are adopting the EVS recommendations in their management of bacterial endophthalmitis after cataract surgery.Methods: A survey was sent to 98 vitreoretinal surgeons across Canada who manage postoperative endophthalmitis following cataract surgery. The survey explored the management of patients presenting with a hypopyon or suspected endophthalmitis, or both, early (up to 2 weeks) after cataract surgery. For purposes of comparison with the EVS, the questions were divided into presenting visual acuity categories.Results: Of the 98 surgeons 30 (30.6%) responded to the survey. The preferred treatment for patients presenting with no light perception visual acuity was pars plana vitrectomy (23 respondents [76.7%]); 7 respondents (23.3%) preferred vitreous tap/biopsy. All but one of the respondents stated that they prefer pars plana vitrectomy for patients presenting with light perception vision; the remaining physician preferred either pars plana vitrectomy or vitreous tap/biopsy. For patients with hand motions visual acuity, 17 respondents (56.7%) would perform pars plana vitrectomy, II (36.7%) would perform vitreous tap/biopsy, and 2 (6.7%) would perform either procedure. Most of the respondents (20 [66.7%]) would perform vitreous tap/biopsy for patients with visual acuity of counting fingers, whereas 9 (30.0%) would perform pars plana vitrectomy, and I (3.3%) would perform either procedure. All the respondents indicated that they would use intraocular antibiotic therapy for initial treatment, 29 (96.7%) would use topical antibiotic therapy, 17 (56.7%) would inject antibiotics subconjunctivally, and I (3.3%) would use intravenous antibiotic therapy. Fourteen respondents (46.7%) would use intraocular steroid therapy.Interpretation: Most of the Canadian vitreoretinal surgeons who responded to this survey do not follow the recommendations of the EVS.

Endophthalmitis following cataract surgery in Sweden. The 1998 national prospective survey.

To investigate the morbidity of postoperative endophthalmitis (POE) following cataract surgery in Sweden in 1998. Clinically presumed cases of POE were reported in a prospective survey in which all Swedish ophthalmic surgical units except one had agreed to participate. Data on intraocular cultures and visual outcomes at 3 months after infection were supplied. Surgical cases that became infected were identified in the Swedish National Cataract Register, thereby enabling screening for various putative risk factors. The nationwide incidence of POE amounted to 58 cases out of 54 666 cataract operations, or 0.1% of surgical cases. The predominant aetiology was gram-positive bacteria, which comprised 57% of the material. Acrylic intraocular lenses were found to decrease the risk of POE significantly in comparison to hydrogel and polymethylmethacrylate lenses. The incidence of POE after cataract surgery in Sweden is similar to that currently reported elsewhere in the developed world. We hope that continued registration of cases of POE in Sweden will shed light on the possible influences of various prophylactic measures and different intraocular lens materials on the development of postoperative infection.

Treatment of Propionibacterium acnes endophthalmitis.

Propionibacterium acnes is a well-known cause of delayed endophthalmitis following cataract surgery. A white intracapsular plaque, keratic precipitates, and hypopyon may be present. Although there is no consensus on the treatment approach, recent studies have reviewed the outcomes of relatively large numbers of patients. Reasonable treatment options include pars plana vitrectomy and intra-ocular antibiotics with either partial or total capsulectomy/lens exchange. A good visual outcome is possible.

Vitrectomy in the management of uveitis

OBJECTIVE: To review the indications for vitrectomy in uveitis cases. PATIENTS AND METHODS: Charts of patients seen at the uveitis clinic of the Jules Gonin Eye Hospital from January 1993 to August 1998 and who had undergone vitrectomy were reviewed. Patients with infectious uveitis occurring within three months after intraocular cataract surgery were excluded. The types of uveitis were recorded and indications for vitrectomy were analyzed. RESULTS: A total of 630 patients were examined at the uveitis clinic. Fifty-one of these patients (51 eyes, 8.1%) were referred for vitrectomy and were included in this study. Vitrectomy was performed for three reasons: 1) to treat the complications of uveitis (90%), including vitreous opacification in 35 eyes (69%), retinal detachment in seven eyes (14%), epimacular membrane in seven eyes (14%), and dense opacification of the posterior capsule after cataract surgery in six eyes (12%)(the mean delay between uveitis and vitrectomy in this group was 8.4 years); 2) for diagnostic purposes in 19 eyes (37%); and 3) to remove confined infectious foci in 16 eyes (31%) and allow a thorough intraocular distribution of antibiotics. Visual acuity improved in 41 patients (80.4%), remained unchanged in three (5.8%), and decreased in seven (13.7%) because of secondary or persistent retinal detachment or cystoid macular edema. CONCLUSION: Vitrectomy was indicated to treat the complications of uveitis, to provide vitreous for diagnostic purposes, and to allow a better diffusion of intraocular antibiotics. Long-standing uveitis did not seem to be influenced by vitrectomy.