Management Of Endophthalmitis Research Articles

Antibiotic susceptibility in Endophthalmitis Management Study and intravitreal antibiotic practice trend in India-EMS Report #5.

Analyze antibiotic susceptibility in the Endophthalmitis Management Study (EMS) and compare it with the current intravitreal antibiotic practice trend of members of the Vitreoretinal Society of India (VRSI) practicing in India. The microbiology work-up of undiluted vitreous included microscopy, culture-susceptibility, polymerase chain reaction (PCR), and next-generation sequencing (NGS). VRSI members were invited to the survey. The EMS conventional culture-susceptibility (PCR and NGS excluded) results were compared vis-a-vis gram-positive cocci (GPC), gram-negative bacilli (GNB), and less commonly used antibiotics with the current recommended intravitreal antibiotics. p < 0.05 was considered significant. Culture and positivity (culture + PCR/NGS) positivity was 28.8% and 56.1%, respectively. GPC was most susceptible to cefazolin, linezolid, and vancomycin; GNB was most susceptible to amikacin, ceftazidime, colistin, and imipenem. There was no susceptibility difference between cefazolin and vancomycin (p = 0.999) and between ceftazidime and imipenem (p = 1.0). Colistin was superior to ceftazidime (p = 0.047) against GNB. The GNB resistant to amikacin (n = 14) were equally susceptible to ceftazidime and colistin; resistant to ceftazidime (n = 16) were susceptible to colistin; and resistant to colistin (n = 7) were susceptible to ceftazidime. The preference of VRSI members (n = 231) practicing in India was a vancomycin-ceftazidime combination (82%), vancomycin for GPC (94%), ceftazidime for GNB (61%), and voriconazole for fungi (74%). In EMS, GPC had good susceptibility to vancomycin; GNB had good susceptibility to ceftazidime and colistin. Given the lower resistance of colistin, a vancomycin-colistin combination could be an alternative empiric treatment in post-cataract endophthalmitis in India.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives.

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

Early Vitrectomy with Silicone Oil Tamponade in the Management of Postoperative Endophthalmitis.

Background: Early vitrectomy for postsurgical endophthalmitis may improve visual acuity outcomes. Silicone oil as a tamponade has some potential benefits in the management of endophthalmitis. This study aims to evaluate the use of a silicone oil tamponade in the surgical management of endophthalmitis. Material and Methods: All patients with a pars plana vitrectomy with silicone oil tamponade for postsurgical endophthalmitis at the Department of Ophthalmology, University of Bonn, Germany, between 2017 and 2021 were retrospectively reviewed. We included all preoperative data, including BCVA at diagnosis, clinical findings, and symptoms. For every follow-up visit, we looked at BCVA and complications. Results: In total, 82 patients were included in this study. The mean follow-up was 13.1 months (range 1-58 months). An intravitreal injection was the cause in 42 patients (51.2%) and cataract surgery in 29 patients (35.4%). The mean interval between the causing event and the date of onset was 8.8 days (range, 1-59 days). The most prevalent pathogen was Staphylococcus epidermidis in 16 patients (19.5%). In 47 patients (57.3%), no pathogen was found. The initial best-corrected visual acuity was 2.1 logMAR and improved significantly to 1.0 logMAR after six months (p < 0.001) and 1.1 logMAR after 1 year (p < 0.001). In a multivariate analysis, a low BCVA at diagnosis (p = 0.041) was a significant predictor for poor visual acuity outcomes. A total of 17 patients (20.1%) developed postoperative complications. Five patients (6.1%) needed an anterior chamber washout with repeated injections of antibiotics. Two patients (2.4%) had persistent fibrin and were treated with YAG-laser treatment. Three patients (6.7%) developed a retinal detachment. Two patients (2.4%) had persistent corneal decompensation with endothelial cell loss and received perforating keratoplasty. We performed a matched-pair analysis (n = 30, each group n = 15) to compare a silicone oil tamponade with BSS at the end of surgery. The visual acuity outcome showed no significant differences (BCVA after one year: 1.17 logMAR in eyes with silicone oil and 0.90 logMAR in eyes with BSS; p = 0.684). Conclusions: In our study, a vitrectomy with silicone oil tamponade in the surgical management of postoperative endophthalmitis led to a significant improvement in visual acuity and had a low complication rate. Low BCVA at diagnosis was significantly associated with poor visual acuity outcomes. A comparison of silicone oil and BSS at the end of surgery showed similar results.

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.

Novel options in diagnosis and treatment of endophthalmitis

AbstractEndophthalmitis remains the most vision‐threatening condition that in most severe cases can result in a loss of an eye and systemic spreading of the infection. It is defined as an acute inflammation of the inner tissues of the eyeball and is usually caused by intraocular contamination and colonization of infectious agents with exudation within intraocular space. The development of endophthalmitis as well as its clinical presentation and functional and anatomical outcomes is predefined by its type, kind of infection and therapy applied. There is a risk of progression of endophthalmitis to panophthalmitis, which could end up with evisceration or enucleation. The involvement of the general physician and other medical specialists into the treatment of the patients with endophthalmitis shall be always considered and should not be underestimated. As one of the most severe emergencies in ophthalmology, this condition requires urgent therapeutical or/and surgical intervention. Numerous studies compare the efficacy of the first line treatment for different types of endophthalmitis. Since decades the management of endophthalmitis is based on prompt recognition of infectious agents, immediate intraocular antimicrobial therapy and removal of the purulent exudate form the eye. Novel diagnostic options for endophthalmitis shall be considered in order to increase the precision of to treat patients with endophthalmitis. Improvement of the surgical techniques with the development of the new less traumatic instruments and he novel antimicrobial drugs can stablish a new standards of endophthalmitis care.

Update on Current Microbiological Techniques for Pathogen Identification in Infectious Endophthalmitis.

Infectious endophthalmitis is a vision-threatening medical emergency that requires prompt clinical diagnosis and the initiation of treatment. However, achieving precision in endophthalmitis management remains challenging. In this review, we provide an updated overview of recent studies that are representative of the current trends in clinical microbiological techniques for infectious endophthalmitis.

IN THE EYE OF THE STORM: HYPERVIRULENT KLEBSIELLA PNEUMONIAE

IN THE EYE OF THE STORM: HYPERVIRULENT KLEBSIELLA PNEUMONIAE

The Role of Silicone Oil in the Surgical Management of Endophthalmitis: A Systematic Review

(1) Background: We aimed to systematically review the current literature to evaluate if in patients with postoperative endophthalmitis treated with pars plana vitrectomy, silicone oil tamponade could provide a useful contribution to the control and eradication of infection and if it could influence anatomical recovery and functional outcome. (2) Randomized controlled trials, cross-sectional studies, case series, and case reports published in the English language in peer-reviewed journals were included. No restriction was placed based on the study location. We used medical subject headings (MeSH) and text words. We searched MEDLINE (OVID and PubMed), Google Scholar, ISI Web of Science (Thom-on-Reuters), and the Cochrane Library (Wiley) from January 1995 to the present. To ensure literature saturation, we scanned the reference lists of included studies or relevant reviews identified through the search. Risk of Bias was assessed using the Newcastle-Ottawa scale for longitudinal studies and Cochrane risk-of-bias tool for randomized trials. (3) Results: abstracts of 75 articles were selected for full-text reading; after full-text reading, 44 articles were taken into consideration in the systematic review. 5 out of 7 in vitro experimental studies demonstrated antimicrobial activity against different species of bacteria and fungi. The use of SO as endotamponade associated with PPV led to better visual acuity and a lower rate of retinal detachment and the need for additional surgery. (4) Conclusions: Silicone oil reduces the risk of postoperative retinal detachment, especially in case of undetected retinal breaks, produces compartmentalization of the eye, may lead to early visual recovery, allows laser photocoagulation, prevents severe postoperative hypotony and has antimicrobic activity due to an inhibitory effect for several species of pathogens. Concerns regarding possible toxic effects on the retina and optic disc, compartmentalization and impaired washout of pathogen toxins have been reported. It may also influence intravitreal antibiotic distribution and clearance.

Clinical Practice Update: Management of Infectious Endophthalmitis After Intravitreal Anti-VEGF Injection.

Although infectious endophthalmitis after intravitreal antivascular endothelial growth factor injections is rare, it is the most feared and potentially devastating complication of this procedure. There is no high-level evidence to provide definitive guidance on the management of endophthalmitis occurring after intravitreal injection (IVI). This clinical practice update reviews the published literature regarding post-IVI endophthalmitis and highlights areas in which further research is needed to better guide its management.

Adjunctive steroid therapy versus antibiotics alone for acute endophthalmitis after intraocular procedure.

Adjunctive steroid therapy versus antibiotics alone for acute endophthalmitis after intraocular procedure.

Mid-term safety and effectiveness of intravitreal dexamethasone implant to treat persistent cystoid macular edema in vitrectomized eyes for bacterial endophthalmitis.

To evaluate the mid-term safety and effectiveness of intravitreal dexamethasone implant (DEX-i) for treating unresponsive to medical therapy cystoid macular edema (CME) in vitrectomized eyes for endophthalmitis. Retrospective and interventional case series study conducted on vitrectomized eyes for endophthalmitis that developed a CME that did not adequately respond to medical therapy, who underwent 0.7-mg DEX-i. Main outcome measures were changes in central retinal thickness (CRT) and best corrected visual acuity (BCVA). Eleven eyes were included in the study. Microbiological findings of vitreous biopsies were 7 (63.6%) staphylococcus epidermidis; 3 (27.3%) Pseudomonas aeruginosa; and 1 (9.1%) Propionibacterium acnes. Median (interquartile range, IqR) duration of CME was 4.0 (3.0-4.0) months. Median (IqR) time between vitrectomy and DEX-i was 9.0 (9.0-11.0) months. Median CRT was significantly decreased from 548.0 (412.8-572.5) µm at baseline to 308.0 (281.3-365.5) µm at month 6 (p = 0.0009, Friedman test). Median BCVA significantly improved from 38.0 (30.5-44.8) letters at baseline to 50.0 (46.8-53.0) letters at month 6 (p < 0.0001, Friedman), with 9 (81.8%) eyes gaining ≥ 10 letters. Elevation of intraocular pressure was observed in one (9.1%) eye, which was successfully controlled with medical therapy. No recurrence of endophthalmitis or other complications was observed. Eight (72.7%) eyes required an additional DEX-i, while 3 (27.3%) were successfully controlled with only one DEX-i. CME recurrence occurred in 5 (62.5%) Gram-positive and 3 (100.0%) Gram-negative bacteria (p = 0.2357). In vitrectomized eyes for endophthalmitis affected by CME unresponsive to medical therapy, DEX-i had an acceptable safety profile and achieved favorable outcomes. The possibility of suppressing mechanisms for infection control should be taken into account, although correct management of endophthalmitis and long time without reactivation before DEX-i reduce the risk.

Commentary: Usage of intravitreal steroids in endophthalmitis: Horns of a dilemma

The usage of steroids intravitreally along with antimicrobials for endophthalmitis management has been marred with controversy for decades. To a large extent, management of endophthalmitis has been based on physician discretion and has a lot of variability between cases. The rationale behind steroids/anti-inflammatory agents is that endophthalmitis leads to severe inflammation and bystander damage to intraocular tissues, especially the neurosensory retina, resulting in irreversible functional changes. Suppressing this inflammation may help reduce the irreversible damage and shorten the overall disease course. It is not well understood whether the damage to the visual function is due to the infectious agent or the immune response developed by the host in response to it. There is no unanimous understanding regarding whether steroids have any definite role in visual improvement as demonstrated by this metanalysis, and previous reports as well.[1] The current article evaluated studies dealing with bacterial endophthalmitis alone. Considering fungal endophthalmitis, there is even lesser amount of evidence regarding the status of steroids, as steroids are believed to flare up intraocular pathogens. One way to approach this conundrum is to consider steroids once an initial dose of intravitreal antimicrobials has been given and/or vitrectomy has been done to reduce the microbial load. Then, if the patient is undergoing further intravitreal injections, intravitreal steroids can be considered. However, steroids may have a definite role in preserving the anatomical integrity during initial endophthalmitis management, preventing outcomes such as phthisis bulbi or requirement of evisceration.[2] The inconsistencies in management rationale, type of outcomes reported, and follow-up protocols in previous studies make a uniform consensus difficult—more so because quantifying resolution or a successful management of endophthalmitis is not standardized. Steroids may reduce tissue inflammation in the initial period, which in turn can reduce the chances of eyes requiring further vitrectomies or IOL explantation procedures. Another point to ponder is that the older evidence of intravitreal steroids is from days when an initial intravitreal regimen of antibiotics with or without steroids with additional injections would be considered followed by a period of observation. A decision of vitrectomy would be taken after noting the resolution pattern and based on physician discretion. However, with complete and early vitrectomy, as is becoming the norm gradually, after the organism load has been reduced, intravitreal steroids may also be considered in the retreatment regimens.[3] The biggest gray zone is for cases of fungal endophthalmitis, where no clear evidence is available due to extreme variability in clinical presentations. Authors have noted that visual outcomes may be better in fungal endophthalmitis with the usage of systemic or topical steroids under a cover of antifungal therapy.[4] However, the sensitivity of the fungi to the antifungal agent and the timing and dosage of steroids must be considered before starting the same. Currently, although we have an armamentarium of drugs and surgical modalities, the outcomes of endophthalmitis remain poor because of unknown host and organism related factors, which cannot be treated using conventional methods. Experimental studies in animals have shown that infectious endophthalmitis can induce the expression of cytokines, chemokines, and apoptotic factors. Recently, authors have also studied inflammatory changes in the vitreous taken from endophthalmitis patients and tried to identify factors that can predict the clinical outcomes of the disease.[5678] Apoptotic proteins such as Bax and Fas expression peaks at 48 h after initial endophthalmitis onset, and apoptotic rate peaks at 72 h under experimental conditions.[9] Many such host innate immune pathways are under research to try and target for endophthalmitis management in addition to antimicrobials. Reducing the concentrations of individual inflammatory mediators might limit the bystander damage to tissues while allowing a more favorable wound healing response along with neuroprotection. A TLR2 agonist, Pam3Cys, has been explored as a molecule which attenuates clinical inflammation, reduces bacterial load in retina, and preserves retinal architecture with electroretinogram in mice retina.[10] Anti-TNFa therapy may also have role in improving endophthalmitis outcomes.[11] Other possible drug targets in stage of development are anti IL6, anti IL1beta, anti IL8, etc., Scientists have also employed macrophage membrane-coated nanosponges as decoys to bind excess cytokines and chemokines in the vitreous to prevent cytotoxicity.[12] Further studies are needed to identify molecules that can help in reducing inflammation in severe and fulminating endophthalmitis cases and salvage such eyes toward both optimum anatomical and functional outcomes.

Short-term evaluation of clear corneal incision after phacoemulsification using anterior segment optical coherence tomography

Purpose The aim of this study was to investigate the ultrastructure of corneal incisions after phacoemulsification by anterior segment optical coherence tomography (AS-OCT). Patients and methods This is a prospective interventional study of 50 eyes of 50 patients with senile cataract attending the Outpatient Clinic of the Ophthalmology Department, Qena University Hospital, Qena, Egypt, for whom clear corneal-incision phacoemulsification was performed from July 2020 to July 2021. The patients had preoperative and postoperative AS-OCT, and were followed up at 1 week, 2 weeks, 1 month, and 3 months, postoperatively. The four AS-OCT features that were studied were corneal thickness at the site of the main incision, epithelial and endothelial changes at the wound, and Descemet’s membrane detachment. Results The mean age of the patients was 62.16±7.71 years. The mean corneal thickness was 768.06±102.03, 883.24±96.59, 841.98±100.70, 797.68±98.12, and 782.26±101.66 μm preoperatively, at 1 week, 2 weeks, 1 month, and 3 months postoperatively, respectively (P<0.001). Descemet’s membrane detachment was observed in nine (18%) and seven (14%) patients at 1 and 2 weeks postoperatively, respectively. Epithelial gaping was observed in five (10%) patients at 1 week and in two (4%) patients at 2 weeks. It was not observed after 1 month, postoperatively. Endothelial gaping was observed in 36 (72%) patients at 1 week, in 30 (60%) patients at 2 weeks, and in four (8%) patients at 1 month, and was not present after 3 months. Conclusion AS-OCT is an excellent tool to assess the integrity and structure of the corneal wound after phacoemulsification sensitively and quantitatively. So, it could play an important role in the early detection and management of endophthalmitis.

Spectrum of signs, symptoms, and treatment in amphotericin B-resistant Trichosporon endophthalmitis: A series of ten cases of post-cataract surgery cluster endophthalmitis.

The aim of this study was to present the signs, symptoms, management, and outcome of a series of cases of cluster endophthalmitis caused by a multi-drug resistant fungus, Trichosporon. This was a retrospective, non-randomized, consecutive interventional case series. Ten cases of postoperative endophthalmitis operated by a surgeon on three consecutive operation theater (OT) days presented 3-5 months after their surgery. All cases were microbiologically confirmed. The pathogen was found to be resistant to most antifungals, including amphotericin B. The cases had a latent period of around 45 days. Management of endophthalmitis included intravitreal injections, anterior chamber (AC) lavage, Pars Plana vitrectomy (PPV), posterior capsulotomy, IOL, and capsular bag removal. Multiple intravitreal injections were required due to recurrence of infections after initial improvement with voriconazole injections. Structural integrity was maintained and infection-free status was achieved in all the eyes. The presenting vision ranged from 6/60 to PL (perception of light). Seven out of 10 had improvement in their final vision over the presenting vision. Final outcome of four patients had vision of 6/24 or better, 4 patients had vision in the range of 2/60 to 6/36 and 2 patients had PL. Trichosporon can cause devasting infections even in the immunocompetent, especially in association with implants and catheters. Triazoles form the mainstay of treatment of Trichosporon infection due to the high susceptibility of the organism in vitro. A regimen including voriconazole and amphotericin B may prove to be the most effective. This is the first report of an outbreak of cluster endophthalmitis caused by Trichosporon.

Commentary: Dexamethasone and dilemma

Postoperative endophthalmitis has always been a nightmare for the patients and surgeons alike. Around 90% of patients having post trabeculectomy endophthalmitis and 40% of patients having postcataract surgery endophthalmitis would end up having final visual acuity worse than 20/200.[1] The economic burden of endophthalmitis is also significant as stated by Schmier et al.;[2] the average adjusted ophthalmic reimbursements were 156% greater for cases that developed endophthalmitis than for subjects having uncomplicated cataract surgery. The psychological impact on quality of life is also significant leading to poorer psychological well-being and ability to maintain a role in daily life.[3] Even after decades of publishing, the endophthalmitis vitrectomy study (EVS)[4] still holds key role in the endophthalmitis management algorithms. Ho et al.[5] in their study suggested that early vitrectomy may be beneficial for all cases and not just the ones with light perception or worse visual acuity as stated in EVS.[4] Few other studies also favor early vitrectomy.[67] The notable fact that EVS includes only postcataract surgery cases makes its significance diluted in cases post procedures other than cataract surgery specially in current era of variety of intravitreal injections, newer and more advanced surgical techniques, and newer drugs. Additionally, the postcataract endophthalmitis was proven to have better visual outcome than post trabeculectomy, postintravitreal injection, and endogenous endophthalmitis.[5] In treating endophthalmitis, antibiotics are the mainstay. Their augmentation with steroids remains controversial as ever. Many studies have reported that steroids do not add additional benefit to the final visual acuity of the patients.[8] The time of starting of steroids remains in the uncertainty. Concerns have been expressed regarding their safety and long-term outcomes. Shah et al.[9] reported worse visual outcome with the use of intravitreal steroids. In contrary to these reports, multiple studies have reported favorable outcomes with the use of intravitreal steroids and some reported that with the use of steroids even though the visual acuity did not have benefit, the intraocular inflammation and the overall morbidity related to the condition were helped.[101112] Albrecht et al.[11] in their study analyzed groups of “postcataract surgery,” “bleb related,” and “other” endophthalmitis, and they found a clinical trend of better visual acuity in the subgroup of postcataract surgery endophthalmitis patients who received steroids. Gan et al.[12] found out in their prospective placebo-controlled study that there was a trend toward better visual outcome in patients with suspected bacterial endophthalmitis when treatment with intravitreal antibiotics was combined with intravitreal dexamethasone. Multiple animal studies have also found out intraocular steroids to be beneficial in endophthalmitis.[81314] The authors in their practice have also noticed that during vitrectomy, immediate KOH mount assessment in a standard lab to rule out fungal infection and adjuvant intravitreal dexamethasone has helped their patients with faster recovery and less inflammation. The current metaanalysis does not show any clear visual benefit from use of adjuvant intravitreal dexamethasone in bacterial endophthalmitis.[15] Prospective randomized controlled trials for the treatment of postprocedure endophthalmitis with multicenter involvement are needed to clarify the gray areas around the usage of steroids and formulating preferred practice patterns for the new era.

Endophthalmitis: Changes in Presentation, Management and the Role of Early Vitrectomy.

Endophthalmitis is a sight-threatening condition, and its timely and appropriate management is essential in preventing permanent vision loss. Recent changes in clinical practice in endophthalmitis and advances in modern vitreoretinal surgery may limit the applicability of established randomised clinical trial evidence to current management. This review discusses the epidemiology, pathophysiology, changing patient presentation, diagnosis and advances in the management of endophthalmitis, presenting the existing literature on this topic and results from Sydney Eye Hospital.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-021-00406-6.

Topical ocular delivery of vancomycin loaded cationic lipid nanocarriers as a promising and non-invasive alternative approach to intravitreal injection for enhanced bacterial endophthalmitis management

Vancomycin (VCM) is a drug of choice for treating infections caused by Staphylococcus species, reported being the most causative agent of bacterial endophthalmitis. However, the ocular bioavailability of topically applied VCM is low due to its high molecular weight and hydrophilicity. The current study sought to explore whether the nanostructured lipid carriers (NLCs) fabricated via cold homogenization technique could improve ocular penetration and prolong the ophthalmic residence of VCM. A 23 full factorial design was adopted to evaluate the influence of different process and formulation variables on VCM-loaded NLC formulae. The optimized formula with the particle size of 96.4 ± 0.71 nm and narrow size distribution showed spherical morphology obtained by AFM and represented sustained drug release up to 67% in 48 h fitted to the Korsmeyer-Peppas model with probably non-Fickian diffusion kinetic. FTIR studies visualized the drug-carrier interactions in great detail. High encapsulation of VCM (74.8 ± 4.3% w/w) in NLC has been established in DSC and PXRD analysis. The optimal positively charged (+ 29.7 ± 0.47 mV) colloidal dispersion was also stable for 12 weeks at both 4 °C and 25 °C. According to in vivo studies, incorporation of VCM in NLC resulted in a nearly 3-fold increase in the intravitreal concentration of VCM after eye-drop instillation over control groups. Besides, microbiological evaluation admitted its therapeutic effect within five days is comparable to intravitreal injection of VCM. Further, the optimized formula was found to be nonirritant and safe for ophthalmic administration in RBC hemolytic assay. Also, fluorescent tracking of NLCs on rabbit's cornea showed an increase in corneal penetration of nanoparticles. Thus, it is possible to infer that the evolved NLCs are promising drug delivery systems with superior attainments for enhanced Vancomycin ophthalmic delivery to the eye's posterior segment and improved bacterial endophthalmitis management.

Better visual outcome associated with early vitrectomy in the management of endophthalmitis

AimsTo examine the role of early vitrectomy in the management of endophthalmitis from all causes.MethodsRetrospective study of 290 consecutive subjects diagnosed with endophthalmitis at Auckland District Health Board between 1...

Therapie der postoperativen Endophthalmitis

Postoperative endophthalmitis is among the most feared complications encountered after intraocular surgery. Aprompt diagnosis and initiation of treatment are crucial for the visual prognosis, which also depends on the causative microorganism. Despite advances in prevention and the availability of more epidemiological data, most of the evidence for treatment dates back to asingle study, the early vitrectomy study (EVS) carried out in the early 1990s. The EVS showed that vitrectomy with intravitreal antibiotics was superior to intravitreal antibiotics alone, only when visual acuity was light perception or below. The addition of systemic antibiotics did not have any benefits. Over the last 30years, however, surgical techniques have continued to evolve and the medicinal options have also been expanded. Moreover, the EVS examined only endophthalmitis after cataract surgery and strictly speaking the results cannot be transferred to endophthalmitis from other causes. This review discusses the current evidence for the different treatment modalities of the most important types of postoperative endophthalmitis. The EVS provided important guidelines for the initial management of endophthalmitis and these guidelines remain relevant to this day; however, in view of the refinement of surgical techniques, novel treatment options, especially the nowadays continuously growing number of intravitreal injections and even some new antibiotics, it would be desirable if new controlled trials addressing the treatment of endophthalmitis would be performed.

Immediate sequential bilateral cataract surgery and its relevance in COVID-19 era.

Immediately sequential bilateral cataract surgery (ISBCS) involves performing phacoemulsification with intraocular lens implantation in both the eyes of a patient, sequentially in the same operative sitting. There are well-documented advantages in terms of quicker visual rehabilitation and reduced costs. The risk of bilateral simultaneous endophthalmitis and bilateral blindness is now recognized to be minuscule with the advent of intracameral antibiotics and modern management of endophthalmitis. Refractive surprises are rare for normal eyes and with the use of optical biometry. As a result of the COVID-19 pandemic, all elective surgeries were stopped. This has resulted in a large backlog of deferred cataract surgeries. Now more than ever before, we should consider ISBCS as an excellent alternative to delayed sequential bilateral cataract surgery in the right hospital or surgical setting. In the age of COVID-19, it can help to decrease surgical scheduling and follow-up visits. The one change in practice that could have the most significant benefit in reducing infection exposure risk is ISBCS.