Intravitreal Antibiotic Injection Research Articles

A RARE CASE OF STERILE ENDOPHTHALMITIS FOLLOWING INTRAVITREAL TRIAMCINOLONE ACETONIDE INJECTION IN VITRECTOMIZED EYE

Introduction : Intravitreal Triamcinolone Acetonide (IVTA) has been widely used to treat Diabetic Macular Edema (DME). Sterile endophthalmitis is one of the major related complications after IVTA which occurs between 0.20% and 6.73% of the injections. We present a case of sterile endophthalmitis following IVTA injection in a patient with a vitrectomized eye and DME.
 Case Illustration : A 53?year?old female patient with a history of vitrectomy due to high-risk characteristic proliferative diabetic retinopathy on her right eye underwent IVTA for DME. One day after the injection, the visual acuity (VA) improved from 6/45 to 6/12 without any complication. Three days later, she complained of ocular discomfort and sudden diminution of vision. The VA had dropped to hand movement, with conjunctival injection, hypopyon, anterior chamber reaction, and an inaccessible fundus. The patient was treated with topical antibiotics, corticosteroids, and cycloplegic, followed by intravitreal antibiotics injection. Furthermore, vitrectomy and vitreous tap were performed. On one- week follow-up, the VA was improved to 6/60 with normal IOP. The anterior chamber and the vitreous cavity remained clear.
 Discussion : The etiology of sterile endophthalmitis following IVTA injection remains unclear. Compared to infectious endophthalmitis, the patient is usually in less pain, and the eye is less injected. Although it generally has a benign course, some studies have shown serious complications such as vitreous hemorrhage and retinal detachment. Therefore, caution should be taken to prevent such complications from developing.
 Conclusion : In presumed sterile endophthalmitis, a careful diagnosis and intervention must be reconsidered to avoid potential long-term visual loss due to its related complications.

A Case of Endophthalmitis with Atypical Anterior Symptom by Subconjunctival Dexamethasone Injection after Cataract Surgery

Purpose: To report a case of endophthalmitis with non-specific anterior segment symptom by subconjunctival dexamethasone injection and anterior chamber irrigation for the anterior chamber inflammation resulted in delayed diagnosis after cataract surgery.Case summary: A 74-year-old female patient with visual disturbance and anterior chamber inflammation had subconjunctival dexamethasone injection and anterior chamber irrigation after 5 days of cataract surgery. On the 7th day after surgery, the anterior chamber inflammation had decreased without visual acuity improvement and additional subconjunctival dexamethasone injection was done. The next day, she was referred to our hospital because there were no improvements in her visual symptom. When the patient visit our hospital, visual acuity was hand motion and cornea edema was shown. Because of corneal edema, anterior chamber cells were obscure, but it was assumed as 1+ grade. Severe vitreous opacity and increased vitreous cells were observed, so the fundus was barely visible. With diagnosis of endophthalmitis, vitrectomy and intravitreal antibiotic injection were performed. Seven weeks after surgery, best corrected visual acuity increased to 0.6, and there was no sign of recurrence.Conclusions: When the endophthalmitis after cataract surgery was misdiagnosed as toxic anterior chamber syndrome and subconjunctival dexamethasone injection and anterior chamber irrigation were performed, the diagnosis of endophthalmitis could be delayed because the symptoms of the anterior chamber could be non-specific. Therefore, it is important to take careful use of strong anti-inflammation medications after cataract surgery.

Oral administration of S-nitroso-L-glutathione (GSNO) provides anti-inflammatory and cytoprotective effects during ocular bacterial infections.

Bacterial endophthalmitis is a severe complication of eye surgeries that can lead to vision loss. Current treatment involves intravitreal antibiotic injections that control bacterial growth but not inflammation. To identify newer therapeutic targets to promote inflammation resolution in endophthalmitis, we recently employed an untargeted metabolomics approach. This led to the discovery that the levels of S-nitroso-L-glutathione (GSNO) were significantly reduced in an experimental murine Staphylococcus aureus (SA) endophthalmitis model. In this study, we tested the hypothesis whether GSNO supplementation via different routes (oral, intravitreal) provides protection during bacterial endophthalmitis. Our results show that prophylactic administration of GSNO via intravitreal injections ameliorated SA endophthalmitis. Therapeutically, oral administration of GSNO was found to be most effective in reducing intraocular inflammation and bacterial burden. Moreover, oral GSNO treatment synergized with intravitreal antibiotic injections in reducing the severity of endophthalmitis. Furthermore, in vitro experiments using cultured human retinal Muller glia and retinal pigment epithelial (RPE) cells showed that GSNO treatment reduced SA-induced inflammatory mediators and cell death. Notably, both in-vivo and ex-vivo data showed that GSNO strengthened the outer blood-retinal barrier during endophthalmitis. Collectively, our study demonstrates GSNO as a potential therapeutic agent for the treatment of intraocular infections due to its dual anti-inflammatory and cytoprotective properties.

Bacterial endophthalmitis following anti-VEGF intravitreal injections: a retrospective case series

BackgroundTo describe the incidence of endophthalmitis and the treatment outcomes of acute bacterial endophthalmitis following intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in a Brazilian hospital. The analysis was based on the timing of infection after intravitreal injection, culture results, visual acuity, and the presence of epiretinal membrane after a 1-year follow-up period, spanning nine years.MethodsThis retrospective case series, conducted over a 9-year period, aimed to evaluate the treatment outcomes of acute endophthalmitis following intravitreal Bevacizumab injections. The inclusion criteria involved a chart review of 25 patients who presented clinical signs of acute endophthalmitis out of a total of 12,441 injections administered between January 2011 and December 2019. Negative culture results of vitreous samples or incomplete data were excluded. Ultimately, 23 patients were enrolled in the study. Eight patients were treated with intravitreal antibiotic injections (IVAI) using vancomycin 1.0 mg/0.05mL and ceftazidime 2.25 mg/0.05mL, while 15 patients underwent pars plana vitrectomy (PPV) followed by intravitreal antibiotic injections at the end of surgery (IVAIES). The main outcome measures were the efficacy of controlling the infection with IVAI as a standalone therapy compared to early PPV followed by IVAIES. Data collected included pre-infection and one-year post-treatment best corrected visual acuity (BCVA), optical coherence tomography (OCT) abnormalities, and enucleation/evisceration rates. To compare groups, Mann-Whitney and ANOVA tests were employed for statistical analysis.ResultsThe incidence rate of bacterial endophthalmitis was 0.185% (1/541 anti-VEGF injections), with the highest infection rates observed in 2014 and 2017. Patients presented clinical symptoms between 2 and 7 days after injection. The most common isolated organisms were coagulase-negative Staphylococci and Streptococci spp. Treatment outcomes showed that both IVAI and PPV + IVAIES effectively controlled the infection and prevented globe atrophy. After one year, the PPV group with BCVA better than Light Perception had a significantly better BCVA compared to the IVAI group (p 0.003). However, PPV group had higher incidence of epiretinal membranes formation compared to the IVAI group. (P 0.035)ConclusionAnti-VEGF injections carry a risk of developing acute bacterial endophthalmitis. Isolated antibiotic therapy could be an effective treatment to control the infection, but performing PPV + IVAIES as a primary treatment showed promising results in terms of improving BCVA after one year, despite a higher rate of epiretinal membrane formation. Further studies are needed to confirm these findings.

PSEUDOMONAS AERUGINOSA-INDUCED ACUTE EXOGENOUS ENDOPHTHALMITIS POST-CATARACT SURGERY

Introduction: The Endophthalmitis Vitrectomy Study revealed that only a small percentage of endophthalmitis cases, specifically 4.1%, were caused by Gram-negative organisms, and the most frequent of these was Pseudomonas aeruginosa. Moreover, poor visual outcomes were consistently linked to this bacterium. Objective: To provide knowledge regarding Pseudomonas aeruginosa as a cause of exogenous endophthalmitis and its management. Case Illustration: A 65-year-old male was admitted to the Emergency Department due to pain and blurred vision in his left eye. After cataract surgery, three days prior, these symptoms had been present for four days. The patient had conjunctival redness, corneal edema, posterior synechia of the iris, and very low visual acuity in the affected eye. A B-mode ocular ultrasonography revealed a considerable vitreous opacity and an aberrant echo in the left eye, suggesting endophthalmitis in the patient. The patient underwent emergency surgery immediately, including Pars plana vitrectomy (PPV), Silicon oil, IOL extraction, and intravitreal antibiotics injection. Moreover, Pseudomonas aeruginosa was found in the vitreous by a smear test and culture process. On the first day after the surgery, the patient's vision improved to light perception but with incorrect projection. A Fundus exam showed an attached retina with silicon oil and no macular edema. After one month, the patient's visual acuity improved to 2/60. Conclusions: Identifying the causative organisms in infectious endophthalmitis is critical in determining treatment and visual results. Pars Plana Vitrectomy (PPV) followed by intravitreal injection of antibiotics as the "gold standard" treatment for acute postoperative endophthalmitis.

Delayed onset Cutibacterium (formerly Propionibecterium) acnes endophthalmitis triggered by intravitreal steroid injection.

We report a case of delayed onset Cutibacterium acnes (C. acnes, formerly Propionibacterium acnes or P. acnes) endophthalmitis with onset triggered by intravitreal steroid (triamcinolone acetonide; TA) injection in a pseudophakic patient, 7 years after cataract surgery.Methods/Patients: A 67 years old, male presented with gradual worsening of vision, eye redness and photosensitivity that started a month after intravitreal TA injection (Triescience, 4mg/0.1mL, Alcon Labs, Fort Worth, TX) for cystoid macular edema secondary to branch retinal vein occlusion in the right eye. Patient had undergone cataract surgery with intraocular lens (IOL) in that eye 7 years prior. Exam showed visual acuity of counting fingers at 3 feet, conjunctival injection, with 2+ anterior chamber cell and 2+ vitreous haze. Uveitis work up including Angiotensin converting enzyme (ACE), Quantiferon Gold, and syphilis IgG screen was negative. Diagnostic pars plana vitrectomy (PPV) with intravitreal injection of antibiotics was performed and vitreous sample was sent for detailed laboratory analysis. Vitreous fluid analysis was positive for C. acnes and negative for viral, fungal and malignant cells. Although the patient received intravitreal antibiotics injection twice, the intraocular infection and inflammation persisted which eventually required an IOL and capsular bag removal, followed by insertion of a secondary IOL later. Delayed onset C. acnes endophthalmitis may be triggered by an intravitreal steroid injection in pseudophakic patients.

Coagulase-negative staphylococcal endophthalmitis: clinical severity and outcomes based on speciation

ObjectiveTo identify characteristics and visual outcomes of coagulase-negative staphylococcal (CoNS) endophthalmitis in the era after the Endophthalmitis Vitrectomy Study. DesignSingle-centre retrospective analysis. ParticipantsForty-two samples from 40 patients with documented CoNS endophthalmitis. MethodsVisual acuity outcomes of CoNS endophthalmitis were assessed in relation to species and type of treatment instituted (i.e., pars plana vitrectomy [PPV] versus vitreous tap and injection of intravitreal antibiotics [T&I]) on 42 samples from 40 patients. ResultsStaphylococcus epidermidis was the most prevalent CoNS in our study. Cataract surgery and intravitreal injections were the most common sources for acute CoNS endophthalmitis. Eyes presenting with hand motion or better vision had similar mean final vision after either intravitreal antibiotics or PPV, whereas those with light perception or worse vision at onset had better outcomes after PPV only. Subanalysis showed that patients with S. epidermidis endophthalmitis (n = 39 eyes) had similar visual outcomes with either intravitreal injections or PPV regardless of visual acuity. Hypopyon and vitritis are not always present. ConclusionsPatients with S. epidermidis endophthalmitis may benefit similarly from either early vitrectomy or intravitreal antibiotic injections regardless of visual acuity. This finding may be a supplement to the complements the management standards set forth by the Endophthalmitis Vitrectomy Study.

Postoperative Exogenous Endophthalmitis Caused By Escherichia Coli: a Rare Case Report and Literature Review

We report a rare case of postoperative endophthalmitis caused by Escherichia coli. The diagnosis of postoperative endophthalmitis in our patient was established based on the clinical signs of hypopyon along with vitritis. The patient underwent pars plana vitrectomy, anterior chamber washout, intraocular lens removal, and intravitreal antibiotics (amikacin and vancomycin) injection. The culture of both the vitreous sample and the intraocular lens, revealed a heavy growth of Escherichia coli. Escherichia coli is an unusual microorganism to cause postoperative endophthalmitis. A major breach in the sterilization may explain this infection. Proper sterilization and prophylactic measures are crucial to avoid this disastrous complication.

Incidence and Clinical Course of Acute Endophthalmitis after Idiopathic Epiretinal Membrane Surgery with Microincision Vitrectomy

Purpose: To investigate the incidence and clinical course of acute endophthalmitis after idiopathic epiretinal membrane (iERM) surgery employing microincision vitrectomy (MIVS).Methods: We retrospectively reviewed the medical records of eyes with acute endophthalmitis developing after iERM surgery via 23- or 25-gauge MIVS from 2011 to 2021. The incidence, culture-positive rate (and responsible bacteria), final visual acuity (VA), and factors affecting poor visual outcomes were assessed.Results: Acute endophthalmitis developed in 20 of the 12,921 eyes (0.15%) after MIVS. Of these, 14 of 3,180 eyes treated via iERM (0.44%, one per 227 procedures) developed endophthalmitis; the incidence ratio (iERM versus non-iERM) was 7.1 (p < 0.001, 95% confidence interval [CI] = 2.6-22.7). At least one sclerotomy remained unsutured in all eyes after iERM surgery. Thirteen eyes (92.9%) were given intravitreal antibiotic injections after emergency vitrectomy, and one eye was treated with intravitreal antibiotic injection alone. Staphylococcus epidermidis was cultured from four eyes (28.6%); three strains were methicillin-resistant. All final VAs were not better than the initial VAs; the average VA decreased from 20/42 to 20/259 (p < 0.001). Six eyes (42.9%) attained legal blindness status (final VA < 20/200); Macular invasion was a unique risk factor for such blindness (p = 0.020, odds ratio = 35.0, 95% CI = 1.7-703.0).Conclusions: Acute endophthalmitis developing after iERM surgery with MIVS was more common than such endophthalmitis after other retinal surgery. Approximately 40% of the former patients became legally blind, and the risk was higher in eyes with macular involvement of endophthalmitis.

Cases of Orbital Cellulitis Revealing Neglected Intraocular Foreign Bodies

Background: Orbital cellulitis is defined as acute inflammatory orbital swelling of infectious origin. Most often secondary to sinusitis. Intraocular foreign bodies neglected because of their small size, or sometimes radio-transparent nature, can be difficult to diagnose even with radiology and be responsible for orbital cellulitis. We demonstrate the diagnostic and therapeutic difficulties.
 Patients and Methods: This is a retrospective descriptive study of patients with unilateral orbital cellulitis revealing neglected intraocular foreign bodies, conducted in the Department of Adult Ophthalmology, Hospital August 20, 1953, involving 58 patients, from January 2015 until December 2020.
 Results: The average age of the patients was 38.5 years. The most affected age group was between 21 and 30 years with a clear male predominance. A decrease in visual acuity was found in all patients (unilateral blindness 43%) and a cellulitis complicated by a purulent melt (43%). All patients received medical treatment, including intravitreal injections of antibiotics in 71% of cases, and surgical treatment consisting of extraction of the foreign body and immediate evisceration of the eyeball in 25% of cases.
 Conclusion: Orbital cellulitis, although mostly secondary to sinusitis, can reveal various etiologies such as intra-orbital foreign bodies that can go unnoticed and be life-threatening and functionally damaging, especially when the diagnosis is made late and management is inappropriate. The presence of an intraocular foreign body must be suspected in all cases of orbital trauma associated with a palpebral wound, even if it is minimal, or in the presence of a clinical aggravation. Any delay in diagnosis and/or treatment can lead to serious complications that can affect the functional and even vital prognosis. The surgical treatment consists of the extraction of the foreign body. The recourse to evisceration in our context unfortunately continues to persist at high rates; because of the delay of consultation and thus of the management.

Is the endophthalmitis vitrectomy study still relevant in 2022?

AbstractEndophthalmitis is a severe intraocular inflammatory response secondary to an infectious intraocular load. Postoperative endophthalmitis (POE) is the most common type. It is most often seen after cataract surgery and intravitreal injections (IVI) but can be seen after any intraocular procedures (e.g. glaucoma surgery or pars plana vitrectomy (PPV)). A definitive approach to treatment of endophthalmitis is not uniformly agreed upon by many vitreoretinal surgeons. The current standard treatment for acute POE remains the injection of intravitreal antibiotics with the addition of PPV for severe cases.In the 1990 s, a clinical trial (Endophthalmitis Vitrectomy Study, EVS) was conducted, comparing vitrectomy (VIT) versus intravitreal antibiotics in one arm and intravenous (IV) antibiotics yes or no in the other arm for the treatment of postoperative bacterial endophthalmitis. The suggestions regarding VIT was that it is of substantial benefit for patients with an initial VA of light perception (LP) while offering VIT should not be considered in patients with hand motion or better VA (Endophthalmitis Vitrectomy Study Group 1995).While the EVS has been widely used as the guideline for management of POE, even for indications other than after cataract surgery or placement of secondary intraocular lenses (IOL), the study has come under scrutiny. Some physicians recommend early PPV, or management based on clinical assessment other than visual acuity.But so many years after the results of EVS were published, remarkable progress in vitrectomy techniques have been achieved, including the introduction of transconjunctival surgery (23‐,25‐ and 27‐gauge instrumentation), higher cutting rates, wide‐angle visualization. Preoperative povidone‐iodine antisepsis, intravitreal antimicrobial injections, improved vitrectomy instrumentation, availability of silicone oil as adjunctive treatment and newer alternative antimicrobials contribute to better outcome for patients with endophthalmitis. Further advances in the microbiology diagnosis including polymerase chain reaction (PCR) and newer molecular application of peptide nucleic acid–fluorescence in situ hybridization (PNA‐FISH) are promising diagnostic tools.All those remarkable advances that took place in the decades after the EVS was published, leads us to the conclusion, that the results of the EVS are extremely important but some of the recommendations could be reconsidered. A new randomized prospective multicenter study should be organized to address management of endophthalmitis.

Early vitrectomy for exogenous endophthalmitis following surgery.

Endophthalmitis is a sight-threatening emergency that requires prompt diagnosis and treatment. The condition is characterised by purulent inflammation of the intraocular fluids caused by an infective agent. In exogenous endophthalmitis, the infective agent is foreign and typically introduced into the eye through intraocular surgery or open globe trauma. To assess the potential role of combined pars plana vitrectomy and intravitreal antibiotics in the acute management of exogenous endophthalmitis, versus the standard of care, defined as vitreous tap and intravitreal antibiotics. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5); Ovid MEDLINE; Ovid Embase; the International Standard Randomised Controlled Trial Number registry; ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. There were no restrictions to language or year of publication. The date of the search was 5 May 2022. We included randomised controlled trials (RCTs) that compared pars plana vitrectomy and intravitreal injection of antibiotics versus intravitreal injection of antibiotics alone, for the immediate management of exogenous endophthalmitis. We used standard methods expected by Cochrane. Two review authors independently screened search results and extracted data. We considered the following outcomes: visual acuity improvement and change in visual acuity at three and six months; additional surgical procedures, including vitrectomy and cataract surgery, at any time during follow-up; quality of life and adverse effects. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We identified a single RCT that met our inclusion criteria. The included RCT enrolled a total of 420 participants with clinical evidence of endophthalmitis, within six weeks of cataract surgery or secondary intraocular lens implantation. Participants were randomly assigned according to a 2 x 2 factorial design to either treatment with vitrectomy (VIT) or vitreous tap biopsy (TAP) and to treatment with or without systemic antibiotics. Twenty-four participants did not have a final follow-up: 12 died, five withdrew consent to be followed up, and seven were not willing to return for the visit. The study did not report visual acuity according to the review's predefined outcomes. At three months, 41% of all participants achieved 20/40 or better visual acuity and 69% had 20/100 or better acuity. The study authors reported that there was no statistically significant difference in visual acuity between treatment groups (very low-certainty evidence). There was low-certainty evidence of a similar requirement for additional surgical procedures (risk ratio RR 0.90, 95% confidence interval 0.66 to 1.21). Adverse effects included: VIT group: dislocated intraocular lens (n = 2), macular infarction (n = 1). TAP group: expulsive haemorrhage (n = 1). Quality of life and mean change in visual acuity were not reported. AUTHORS' CONCLUSIONS: We identified a single RCT (published 27 years ago) for the role of early vitrectomy in exogenous endophthalmitis, which suggests that there may be no difference between groups (VIT vs TAP) for visual acuity at three or nine months' follow-up. We are of the opinion that there is a clear need for more randomised studies comparing the role of primary vitrectomy in exogenous endophthalmitis. Moreover, since the original RCT study, there have been incremental changes in the surgical techniques with which vitrectomy is performed. Such advances are likely to influence the outcome of early vitrectomy in exogenous endophthalmitis.

Rapid treatment of endophthalmitis with intravitreal antibiotics is associated with better vision outcomes.

To discover whether the timing of intravitreal antibiotics, from the time of presentation to injection, affects the visual outcomes of patients with endophthalmitis from all causes. A retrospective study of consecutive patients managed at Auckland District Health Board between 1 January 2004 and 1 July 2021. The main outcome measure was final visual acuity at follow-up and the proportion of subjects with severe vision loss (≤6/60). Three hundred and seventy-four eyes were included in the study, with a median age of 69.7 years at presentation; 192 subjects (51.6%) were female. The median presenting visual acuity was hand movements and hypopyon was present in 194 subjects (51.9%). Cataract surgery was the most frequent aetiology in 115 subjects (30.7%), followed by intravitreal anti-vascular endothelial growth factor injections in 89 subjects (23.8%) and endogenous endophthalmitis in 54 subjects (14.4%). Median time to injection of intravitreal antibiotics was 3.5h (Interquartile range 2-6). On multivariate analysis, early treatment with intravitreal antibiotics was associated with better visual outcome, particularly for those treated within 2 h, while poor presenting visual acuity and culture-positive endophthalmitis were associated with worse outcomes. Rapid intravitreal antibiotic administration is associated with better final visual acuity outcomes, particularly for those receiving treatment within 2 h of presentation. Patients with severe vision loss on presentation, benefit the most with improved final visual acuity following expedited treatment.

Acute-onset postoperative endophthalmitis after cataract surgery performed by resident and attending physicians at a university teaching hospital.

To evaluate acute-onset postoperative endophthalmitis following cataract surgery and to compare rates between resident and attending physician-performed cohorts. Bascom Palmer Eye Institute, Miami, Florida. Retrospective chart review. Records of patients diagnosed with endophthalmitis within 6 weeks of surgery performed by attending and resident physicians between January 1, 2015, and December 31, 2020, were reviewed. Total cataract volume was obtained from institutional records, and resident case totals were obtained from case logs. Endophthalmitis cases were obtained from billing records and confirmed with chart review. There were 22 cases of endophthalmitis among 32 505 cases (0.068%). Endophthalmitis occurred in 6 of 6447 (0.093%) resident cases and 16 of 26 058 (0.061%) attending cases ( P = .55). The most common bacterial isolates were coagulase-negative Staphylococcus (8/22, 36.3%) and Streptococcus species (3/22, 13.6%), with negative cultures in 10 (10/22, 45.5%). Initial treatment with vitreous tap and injection of intravitreal antibiotics was performed in 21 eyes (21/22, 95.4%) and vitrectomy with intravitreal antibiotic injection in one (1/22, 4.5%). Vitrectomy was performed secondarily in 9 patients (9/22, 40.9%). Corrected distance visual acuity (CDVA) at last follow-up was ≥20/40 in 13 eyes (13/22, 59%) and ≤hand motions in 3 eyes (3/22, 13.6%). CDVA (logMAR mean ± SD) was 1.22 ± 1.16 in resident and 0.49 ± 0.79 in attending cases ( P = .11). In the current study, acute-onset postoperative endophthalmitis developed infrequently following cataract surgery. The rates and visual outcomes of endophthalmitis were similar in resident and attending cases.

Successful management of a rare case of endogenous endophthalmitis from soft tissue (gluteal) abscess

Endophthalmitis, an ophthalmic emergency carries poor visual prognosis without prompt diagnosis and treatment. Endophthalmitis is often exogenous and rarely endogenous. In this report, we describe a rare case of bacterial endogenous endophthalmitis in an immunocompetent 51-year-old patient due to methicillin-resistant staphylococcus aureus septicemia from a gluteal abscess. Ultrasonography confirmed endogenous endophthalmitis. The patient was treated with immediate intravitreal antibiotic injections, prolonged intravenous antibiotics in association with pars plana vitrectomy, retinal detachment repair and vitreous debris removal. Successful treatment was confirmed with negative blood cultures and a clear vitreous on b-scan ultrasound and fundus photography with improvement of his visual acuity. This case highlights the importance of consideration of rare infectious foci as etiology and prompts treatment for successful resolution of endogenous endophthalmitis.

Immediate Vitrectomy for Acute Endophthalmitis in Patients with a Visual Acuity of Hand Motion or Better.

PurposeTo determine the efficacy of immediate pars plana vitrectomy as the primary treatment for acute endophthalmitis in patients with a visual acuity (VA) of hand motion (HM) or better.MethodsA total of 149 patients who were referred to a single center for acute endophthalmitis after cataract surgery over the 13-year study period were retrospectively analyzed. Only patients presenting with a VA of at least HM were included. Patients were initially treated with either primary vitrectomy or intravitreal antibiotic injection alone, and their visual outcomes and reintervention rates after initial treatment were compared.ResultsThere was no significant difference in the proportion of good (final VA ≥20 / 40) and poor (VA ≤ counting finger) visual outcomes between the groups. However, subgroup analysis of patients with a VA of HM (92 eyes) showed that the incidence of reintervention (14 of 72 eyes [19.4%] vs. 9 of 20 eyes [45.0%]) and poor visual outcomes (10 of 72 eyes [13.9%] vs. 8 of 20 eyes [40.0%]) were lower after prompt vitrectomy than after intravitreal antibiotic injection alone (p = 0.019 and p = 0.022, respectively). For those with a VA of at least counting finger, no significant difference was observed between the groups.ConclusionsFor patients with endophthalmitis presenting with a VA of HM, performing a prompt vitrectomy reduced the incidence of reintervention and poor visual outcomes than the administration of intravitreal antibiotics alone. Our results suggest that primary vitrectomy for patients with endophthalmitis presenting with a VA of HM could be more beneficial than intravitreal antibiotic injection alone.

Endophthalmitis at a tertiary referral center: Characteristics and treatment outcomes over three decades.

Purpose: To explore the incidence, pathogens, treatment, and prognosis of endophthalmitis. Methods: Patients who were diagnosed with endophthalmitis from January 1990 to October 2020 at Peking Union Medical College Hospital were retrospectively reviewed and examined. Subgroup analysis was conducted regarding different initial treatment methods for eyes without concurrent retinal detachment (RD) at presentation. Results: A total of 249 eyes of 233 patients were included in this retrospective study. The most common clinical scenario was exogenous endophthalmitis (60.6%). The most frequent bacteria and fungi were coagulase-negative staphylococci (10.0%) and candida (6.8%), respectively. Retinal with/without choroid detachment was the most common complication after treatment. Patients with endogenous endophthalmitis were more likely to have binocular involvement; there were also more patients with diabetes mellitus or immunosuppressive diseases, and the prognosis of visual acuity (VA) was poorer. There were more eyes with concurrent RD at presentation that underwent serious complications after treatment (p < 0.05), and the visual outcome was worse than that without concurrent RD (p < 0.05). Subgroup analysis was conducted according to different initial treatments in eyes without concurrent RD. Group 1 received pars plana vitrectomy (PPV) with intravitreal injection of antibiotics (IVI) as initial treatment, Group 2 was initially treated with IVI only, and Group 3 was initially treated with nonsurgical treatment. More eyes that initially received IVI alone and nonsurgical treatment required additional treatments, especially additional PPV. VA in both Groups 1 and 2 significantly improved by the final VA. However, there was no significant difference in final VA between the two groups. There was an insignificant trend that serious posttreatment complications were more common in Group 1. In Group 1, 17 eyes received silicone oil or gas tamponade at the same time, whereas 62 did not. Eyes that were initially treated with PPV + IVI while without tamponade needed more additional treatments and additional IVI. Conclusion: Endophthalmitis is a devastating intraocular disease and requires early intervention. Endogenous endophthalmitis has a poorer visual prognosis than exogenous entity. PPV + IVI as an initial treatment may reduce additional therapy.

Comparison of Outcomes From Delayed-Onset Bleb-Related Endophthalmitis Treated With Pars Plana Vitrectomy Versus Vitreous Biopsy.

Bleb-related endophthalmitis (BRE) is a serious complication of glaucoma filtration surgery. The current study reports similar visual and intraocular pressure (IOP) outcomes in eyes treated with pars plana vitrectomy (PPV) compared with vitreous biopsy and injection of intravitreal antibiotics (TI). The purpose of this study was to investigate the isolated organisms, visual acuity (VA), and IOP outcomes associated with delayed-onset BRE in eyes treated with PPV versus TI. A retrospective chart review was conducted at the Bascom Palmer Eye Institute (Miami, Florida) and the University of Florida (Gainesville, FL) identifying patients treated for BRE with at least 1 month of follow-up from the inception of an electronic health record (2014 and 2011, respectively) through 2021. All patients had undergone bleb-forming glaucoma surgery at least 1 month before endophthalmitis diagnosis. Thirty-nine eyes from 39 patients (33 from Bascom Palmer, 6 from University of Florida) were included. Trabeculectomy was performed in 34 of 39 eyes (87.2%). Streptococcus species (9 eyes, 23.1%) and Staphylococcus species (8 eyes, 20.5%) were the most common isolated organisms and were similar in both treatment groups ( P =0.49). Baseline VA was worse in the PPV group (logarithm of the minimum angle of resolution: 2.51 vs. 2.16, P =0.04), but VA at last follow-up was similar ( P =0.48) in both groups. After recovery from BRE, the average IOP in the PPV group was 15.1 mm Hg on 0.9 IOP-lowering medications compared with 12.6 mm Hg on 1.2 medications in the TI group (IOP: P =0.56; medications: P =0.80). Additional glaucoma surgery was performed in 44.4% of the PPV eyes and 16.7% of the TI eyes ( P =0.09). In eyes with delayed-onset BRE, isolated organisms, visual outcomes, and IOP control were similar after initial PPV compared with TI.

Risk Factors Leading to Enucleation or Evisceration in Infectious Endophthalmitis.

Endophthalmitis treatment consists of intravitreal antibiotics injections and, in selected circumstances, pars plana vitrectomy. However, severe or refractory cases may require an enucleation or evisceration (ENEV). Our study seeks to identify risk factors leading to enucleation or evisceration in patients with infectious endophthalmitis. A retrospective chart review of subjects with a clinical diagnosis of infectious endophthalmitis was undertaken. The affected eyes were stratified into groups: those that underwent ENEV and those in which the eyeball was preserved (EP). The groups were compared using statistical analyses. In total, 69 eyes diagnosed with infectious endophthalmitis were included in the study. There was a higher frequency of exogenous infectious endophthalmitis in the ENEV group versus the EP group. Postsurgical infectious endophthalmitis was lower in the ENEV than in the EP group. A visual acuity of no light perception was more common in the ENEV compared to the EP group. Panophthalmitis was more frequent in the ENEV versus the EP group. Our findings suggest that eyes with endophthalmitis presenting with a visual acuity of no light perception, panophthalmitis, or exogenous etiology have a higher risk of requiring ENEV. In addition, eyes with a postsurgical etiology may be at a lower risk of requiring ENEV.

Subacute Methicillin-resistant Coagulase-Negative Staphylococcus hominis Endophthalmitis after Penetrating Keratoplasty Re-operation

Purpose: To report a case of subacute methicillin-resistant coagulase-negative Staphylococcus hominis endophthalmitis after re-operation for penetrating keratoplasty in a patient who had a penetrating keratoplasty rejection.Case summary: A 74-year-old man with underlying diabetes and hypertension who underwent bilateral penetrating keratoplasty at another hospital underwent penetrating keratoplasty reoperation due to corneal transplant rejection in the right eye. He had a history of end-stage glaucoma in the right eye and the visual acuity was finger counting at 30 cm. About 25 days postoperatively, the corneal epithelial defect was first found. Treatment based on suspicion of herpes simplex virus infection did not result in improvement and endophthalmitis was suspected in the right eye about 35 days after surgery. Anterior chamber irrigation, pars planar vitrectomy, and intravitreal antibiotic injection were performed. Culture revealed methicillin-resistant coagulase negative Staphylococcus hominis. After 2 months of treatment, the anterior chamber and vitreous inflammation decreased and best corrected visual acuity in the right eye recovered to 0.06.Conclusions: Subacute endophthalmitis caused by methicillin-resistant coagulase-negative Staphylococcus may occur after penetrating keratoplasty. Transplant failure due to infection can be avoided with vitrectomy and antibiotic treatment at the right time.