Subconjunctival Antibiotics Research Articles

Aspergillus Endophthalmitis Secondary to Infectious Scleritis: Utility of Diagnostic PCR.

To describe a case of delayed-onset Aspergillus fumigatus endophthalmitis secondary to infectious fungal scleritis diagnosed with broad range polymerase chain reaction (PCR) from scleral nodular debridement and vitreous sampling during vitrectomy. Retrospective case report with slit lamp photography, optical coherence tomography, and fundus photography. A 76-year-old man presented with right eye worsening vision and pain concerning for progressive nodular scleritis and endophthalmitis eight months following a reportedly innocuous tree branch injury. Following the injury, he underwent an MRI, surgical exploration, subconjunctival antibiotic administration, and culturing due to persistent foreign body sensation. Cultures were negative, and the patient was started on oral NSAIDs, oral prednisone, and periocular triamcinolone injections following negative/normal infectious and rheumatologic workup for scleritis. The patient was referred for worsened scleritis with development of endophthalmitis. He underwent lamellar sclerectomy, debridement, and culture of purulent material from scleral nodules in coordination with diagnostic vitrectomy, vitreous sampling, and subconjunctival and intravitreal antibiotic and antifungal treatment. Broad range PCR was positive for Aspergillus fumigatus and targeted antifungal treatment initiated. The eye did not regain visual function and was enucleated for progressive pain six months following diagnosis. Fungal scleritis and endophthalmitis results in significant morbidity. Diagnostic vitrectomy and broad range PCR can aid in prompt diagnosis and targeted treatment, and may be useful in refractory cases.

Clinical Features of Patients with Penetrating Eye Injury and Foreign Body Complicated by Endophthalmitis

Purpose: to study the clinical features of patients with penetrating eye injury and foreign body, complicated by endophthalmitis.Methods. 68 patients (68 eyes) with penetrating injury and ocular foreign body were included in the retrospective study, including 91.2 % males and 8.8 % females. The mean age was 50.00 [32.00; 60.00] years. The patients were divided into 2 groups: with endophthalmitis — 24 patients, without inflammation — 44 patients. All patients underwent standard ophthalmologic methods of examination.Results. The age of patients with endophthalmitis was significantly greater compared to patients without inflammation — 51.50 [46.25; 63.25] years and 36.50 [31.25; 58.50] years, respectively (p = 0.0446). In the first day after injury, only 25 % of patients asked for medical care (p = 0.0071). In patients with endophthalmitis according to biomicroscopy data on admission the following were significantly more frequent: eyelid edema (p < 0.0001), purulent discharge (p < 0.0001), total hyphema (p = 0.029), hypopyon (p < 0.0001), iris edema (p < 0.0001), fibrin in vitreous body (p = 0.0014), as well as its destruction (p = 0.0005). 87.5 % of patients with endophthalmitis showed absence of fundus reflex (p = 0.0105), and 25 % of patients with inflammation showed increased intraocular pressure (p = 0.0019). In patients with endophthalmitis, surgical treatment was performed: cataract phacoemulsification in 91.7 % of patients (p < 0.0001), vitreoectomy in 87.5 % (p = 0.0098), enucleation of the eye in 12.5 % (p = 0.0165) and evisceration in 12.5 % (p = 0.0165). Bacterial culture in patients with endophthalmitis revealed Gram-positive microflora in 100 % of cases. There were also significant differences between the groups in the intravitreal, systemic and subconjunctival antibiotic therapy used.Conclusion. Patients with penetrating eye injury and foreign body, complicated by endophthalmitis, are characterized by more signs of inflammation, pronounced damage to the eye and its structures.

Antibiotic Protocols for Endophthalmitis Prophylaxis Following Open-Globe Repair: A Survey of U.S. Residency Programs.

Purpose To assess the various approaches to endophthalmitis prevention following traumatic open-globe injury (OGI) repair. Methods A research electronic data capture (REDCap) questionnaire evaluating the usage of antibiotics and steroids in patients with OGI was distributed to program directors of all U.S. ophthalmology residency programs using the Association of University Professors of Ophthalmology program directors' listserv. Completed questionnaires were analyzed for treatment patterns. Results The REDCap questionnaire was distributed to 111 programs, with 32 residency programs responding. Two responses were excluded. Ninety percent (27/30) of included programs used perioperative intravenous (IV) antibiotics, with 78% (21/27) of those giving one dose only. At the time of surgery, 27% (8/30) of programs gave intravitreal antibiotics and 60% (18/30) gave subconjunctival antibiotics. Postoperatively, 100% (30/30) gave topical antibiotics and 97% (29/30) gave topical steroids. Only 53% of responders discharged patients on oral antibiotics. Of the three programs who did not use IV antibiotics, all three gave intravitreal therapy and one also discharged patients on oral antibiotics. Conclusion There is a large variation in practice patterns for endophthalmitis prophylaxis among residency programs. Further investigation is needed to compare rates of endophthalmitis between these protocols and establish a safe and minimally burdensome standard of care.

Perceptions and practices of Australian cattle farmers for the treatment of pinkeye (infectious bovine keratoconjunctivitis)

Pinkeye or infectious bovine keratoconjunctivitis is a globally significant disease and occurs in every state of Australia. Economic loss due to pinkeye can be considerable and it is a major welfare concern, but not all cattle with the disease are treated by farmers. This study was conducted to understand the perceptions and practices of Australian farmers regarding the treatment of pinkeye: factors influencing when farmers treat pinkeye, treatments used and considered effective, and reasons for not treating. Data were gathered using a custom designed online questionnaire. Farmer responses suitable for assessment (n = 985) were analysed using descriptive analyses along with univariable and multivariable ordinal logistic regression models to evaluate the association of 15 explanatory variables with the outcome “when do you treat pinkeye?”. Results revealed three variables, farm size, times yarded and ranking of the pain caused by pinkeye, were significantly associated with the frequency of pinkeye treatment. Specifically, farmers with smaller farm sizes were more likely to treat their cattle for pinkeye more frequently. So too were those who yarded their cattle more, and those that rated pinkeye as highly painful. The most used treatments for pinkeye in Australia were pinkeye ointments (n = 861), followed by eye patches (n = 637), pinkeye spray (n = 623), fly control (n = 507), and pinkeye powder (n = 408). Over half of those who had used subconjunctival injection, pinkeye ointments, eye patches, injectable antibiotics and veterinarians rated them as highly effective treatments. Kerosene is still used by some farmers (n = 106). The most common reason for not treating pinkeye was that it was ‘too difficult to treat individuals’. These findings provide insight into the attitudes of Australian farmers to the treatment of pinkeye and should be used to improve pinkeye outcomes in cattle.

Subconjunctival antibiotics: an alternative to intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery

Background: There has been an increase in the use of routine intracameral antibiotics for endophthalmitis prophylaxis in cataract surgery. However, this can be associated with serious adverse events. Previously, subconjunctival antibiotics were the preferred route but there is minimal literature directly comparing the two. Hence, the safest and most efficacious route of prophylactic antibiotic administration remains controversial. Purpose: To evaluate the efficacy and safety of subconjunctival with intracameral antibiotics for postoperative endophthalmitis (POE) prophylaxis in patients undergoing uncomplicated cataract surgery. Methods: A literature review was conducted in Cochrane and PubMed for studies that compared the efficacy of prophylactic subconjunctival and intracameral antibiotics for post-cataract endophthalmitis. Searches were not limited to English or study design. Results: Three observational studies showed that subconjunctival and intracameral antibiotics both reduced POE rates. Intracameral antibiotics demonstrated a high efficacy (OR = 0.25, 95% CI 0.13-0.46, p < 0.0001) but was also associated with increased potential complications. All studies were conducted in a sequential nature during which cataract surgery techniques and instrumentation have improved in recent years. Conclusion: In institutions with a high incidence of endophthalmitis, routine intracameral antibiotic use would be more appropriate. However, in facilities with lower rates of POE, the subconjunctival route of delivery can be an alternative due to its better safety profile.

Risk Factors for Endophthalmitis Following Open Globe Injuries: A 17-Year Analysis.

Background/AimsTo determine the rate of endophthalmitis and assess risk factors for development of endophthalmitis following open globe injury (OGI).MethodsA retrospective chart review of all patients treated for OGI at the University of Michigan from January 2000 to July 2017 was conducted. Exclusion criteria included intravitreal injection or intraocular surgery in the 30 days prior to injury or less than 30 days of follow-up. A total of 586 out of 993 open globe injuries were included in the study. The main outcome measure was the rate of endophthalmitis.ResultsIn this study, 25/586 eyes (4.3%) had endophthalmitis. Of these, 12/25 eyes (48.0%) presented with endophthalmitis and 13/25 eyes (52.0%) developed endophthalmitis after globe closure. Multivariate analysis identified time to globe repair (OR 4.5, CI 1.9–10.7, p = 0.0008), zone I injury (OR 3.6, CI 1.1–11.0, p = 0.0282), and need for additional surgery (OR 5.5, CI 1.5–19.7, p = 0.0092) as factors associated with increased risk of developing endophthalmitis. Subconjunctival antibiotic injection at the time of globe closure (OR 0.3, CI 0.1–0.7, p = 0.0036) was associated with decreased risk of developing endophthalmitis.ConclusionPrompt globe closure and subconjunctival antibiotics may reduce the risk of endophthalmitis in OGI. Furthermore, our practice of a one-time dose of systemic prophylactic antibiotics, and intravitreal antibiotics if intraocular foreign body (IOFB) removal is delayed, was not found to increase the rate of endophthalmitis.

ENDOPHTHALMITIS AFTER TRANSCONJUNCTIVAL PARS PLANA VITRECTOMY: A 6-year Experience Without Prophylactic Intraoperative Subconjunctival Antibiotics.

This study aimed to investigate the incidence and risk factors of endophthalmitis after transconjunctival pars plana vitrectomy (PPV) without intraoperative subconjunctival antibiotics. Retrospective, consecutive case series at a single institution. Consecutive cases of transconjunctival 25-gauge PPV without intraoperative subconjunctival antibiotics performed by three retina surgeons at a single surgical site at the Dean McGee Eye Institute from 2012 to 2018 were reviewed. Of 4,263 cases of PPV without intraoperative subconjunctival antibiotics, five cases (0.117%, 5/4,263) of post-PPV endophthalmitis were identified. Of these five cases, four cases (80%, 4/5) received combined cataract extraction or secondary intraocular lens implantation at the time of PPV. The incidence of endophthalmitis in isolated PPV was 0.027% (1/3,606 cases), whereas the incidence in combined PPV with anterior segment procedures was 0.608% (4/657 cases). Risk factors for endophthalmitis included diabetes mellitus, which was present in 80% of patients with endophthalmitis (4/5 cases). Causative organisms were identified in four of the five cases (80%), including Staphylococcus epidermidis (N = 3) and Propionibacterium acnes (N = 1). Performing transconjunctival PPV alone with standard preparation using povidone-iodine and postoperative topical antibiotics for 1 week without intraoperative subconjunctival antibiotics did not lead to an increase in incidence of postoperative endophthalmitis (1 per 3,606 cases).

All India Ophthalmological Society members survey results: Cataract surgery antibiotic prophylaxis current practice pattern 2017.

Purpose:The purpose of this article is to document the current practice pattern of Indian ophthalmologists for antibiotic prophylaxis in cataract surgery to prevent endophthalmitis.Methods:Fifteen structured questions were sent online to all ophthalmologists registered with the All India Ophthalmological Society. The questionnaire was divided into three main categories of prophylaxis – preoperative, intraoperative, and postoperative. A web-based anonymous survey was conducted, and a unique response link allowed completing the survey only once. We compared the results with a similar 2014 survey among the members of the American Society of Cataract and Refractive Surgeons (ASCRS).Results:The response was received from 30.2% (n = 4292/14,170) ophthalmologists. The results were as follows: all respondents do not prepare the eye with 5% povidone-iodine (83% of them use povidone iodine), majority (90%) use topical antibiotic both pre- and post-operatively, 46% use subconjunctival antibiotic at the end of surgery, and 40% use intracameral antibiotic (46% of them in high-risk patients only). Moxifloxacin was the preferred antibiotic for topical and intracameral use. Comparison with the 2014 ASCRS survey results showed a similarity in decision for pre- and post-operative antibiotics and intracameral antibiotic but dissimilarity in the choice of intracameral antibiotic and decision for subconjunctival antibiotic.Conclusion:The antibiotic prophylaxis practice by the Indian ophthalmologists is not too dissimilar from the practice in North American Ophthalmologists (ASCRS) though all ophthalmologists in India must be nudged to preoperative preparation of the eye with povidone-iodine and discontinue the practice of postoperative subconjunctival and systemic antibiotic.

Antibiotic prophylaxis in cataract surgery: Understanding the trends of the day.

Postoperative endophthalmitis (POE) remains the most dreaded complication for any cataract surgeon worldwide. Although with more stringent peri-operative prophylactic measures in place, the rates of POE have dropped to <0.1% all over the world, the perfect formula which would provide the maximum protection against ocular infection remains the Holy Grail. It is interesting to see the preferred practice patterns of cataract surgeons all over the world, and these surveys have often formed the recommendations in the absence of a fixed set of guidelines on this topic. The 2006 ESCRS study[12] had first recommended the routine use of intracameral (IC) cefuroxime at the end of the cataract surgery as a safe and effective measure against POE. Eight years down the line, the 2014 ESCRS survey[3] showed that 74% of its members had routinely inculcated IC antibiotic usage into their practice. However, this also means that approximately one-fourth of the respondents had not inculcated this effective measure in their practice in 8 years since the publication. Similarly, the endophthalmitis prophylaxis surveys of ASCRS, 2007 and 2014,[45] showed a growing trend of IC antibiotic use from 30% to 50% among its respondents. This again also indicates that 50% of respondents in 2014 were not using IC antibiotic. In the Indian subcontinent, the practice patterns of cataract surgeons have been seen to vary widely. Some robust studies from larger institutes such as by Haripriya et al. concluded that IC moxifloxacin prophylaxis is effective with a 3.5-fold reduction in the overall rate of POE.[6] This study acknowledges that, while this does not constitute Level 1 evidence and that there is no consensus that IC antibiotic prophylaxis should be the standard of care, IC moxifloxacin prophylaxis should be considered for high-risk eyes experiencing posterior capsule rupture with vitreous loss. Kelkar et al. in their article “Antibiotics prophylaxis practice patterns for cataract surgery in India – Results from an Online Survey”[7] could elicit responses from a small number of participants – 1228 respondents (8.2%), which may not be truly representative of the prevalent practices among cataract surgeons in India; however, it does provide insights into POE prevention. In this study, preoperative povidone-iodine antisepsis was adopted by 94% of the respondents. Unfortunately, this figure needs to be made 100%. Nearly 38% of the respondents reported IC antibiotic usage routinely after cataract surgery, but 68% believed that it is important to have a commercially approved drug for IC use. Nearly 48% of the respondents were not using intraocular antibiotics since they were not convinced of the need. The AIOS member survey by Maharana et al.[8] is a commendable effort in bringing out some glaring shortcomings, and we can hope it will be the step toward formulation of a recommended set of guidelines which every anterior-segment surgeon practicing in the country will be expected to adhere to. In addition, following up with repeated surveys with the same cohort in the future would help to assess the changes which could be brought by these recommendations. However, only 30.2% of participation in the survey is still a small number, and it can be hoped that this participation can be increased in future surveys. The revelation from the study that only 83% use of povidone-iodine is an eye-opener showing that <100% of the respondents perform mandatory preoperative preparations. Use of postoperative subconjunctival antibiotics by 46% of the respondents is another revelation highlighting rigid barriers to the changing protocols of postoperative antibiotic regimen. Thus, we do understand that preferred practice patterns should not only give mandatory protocols on specific disease issues from time to time, but the ophthalmological community must also institute measures to execute the same in the large interest of our patients. There is a strong need to educate our ophthalmologists across the country of the changed protocols of antibiotic prophylaxis in the current scenario. These are the interesting facts which prove that there is a major challenge in convincing the respondents on the use of safety measures.

Endophthalmitis Following Pediatric Cataract Surgery: An International Pediatric Ophthalmology and Strabismus Council Global Perspective.

To compile international data on the risk factors, diagnosis, and treatment of endophthalmitis following pediatric cataract surgery. An e-mail containing a link to an online survey was sent to all members of the American Association for Pediatric Ophthalmology and Strabismus. The questionnaire examined the incidence, risk factors, treatment, outcomes, and prophylaxis of endophthalmitis following pediatric cataract surgery around the world. Two hundred thirty-seven ophthalmologists answered the questionnaire. Eight ophthalmologists (3.4%) encountered 22 cases of endophthalmitis following pediatric cataract surgery during their practice. Most patients with endophthalmitis following pediatric cataract surgery were 2 to 4 years of age (36.4%). An intraocular lens was implanted in 59.1% of cases, most of which were acrylic intraocular lenses (53.8%). The main presenting symptoms were photophobia (50%) and pain (40.9%). The most common signs were conjunctival injection (36.4%) and hypopyon (31.8%). The final visual acuity was counting fingers or worse in 86% of cases. The most common cultured organism was Staphylococcus aureus (31.8%). The most common management of endophthalmitis following pediatric cataract surgery was a combination of intravitreal, systemic, and topical antibiotics (36.4%). Most ophthalmologists (68.2%) administered prophylactic intracameral antibiotic treatment during surgery and 50% used vancomycin. Endophthalmitis following pediatric cataract surgery is an uncommon, multifactorial complication with poor visual prognosis. Efforts directed at minimizing its risk, such as treating potential predisposing systemic conditions, improving sterilization techniques, optimizing operative conditions to reduce complications and surgery duration, and using subconjunctival and intracameral antibiotics, decrease its incidence. Early postoperative evaluation, subsequent follow-up visits, and keeping a high index of suspicion should facilitate the recognition of endophthalmitis following pediatric cataract surgery to avoid delaying treatment. [J Pediatr Ophthalmol Strabismus. 2018;55(1):23-29.].

Endophthalmitis After Vitrectomy Surgery: A Case–Control Analysis

Purpose: To identify risk factors associated with endophthalmitis after pars plana vitrectomy (PPV) surgery. Methods: All eyes that presented with endophthalmitis after PPV from 2005 to 2015 in a community-based vitreoretinal subspecialty practice were evaluated using a retrospective nested case–control study. Exclusion criteria were presentation more than 6 weeks post-PPV, less than 3 months of follow-up, history of globe trauma, age less than 18, and history of trabeculectomy surgery. Controls were randomly selected among a population of patients who underwent PPV and did not develop endophthalmitis. Univariate and multivariate regression analyses were performed to evaluate the following perioperative risk factors: use of sclerotomy suture, use of subconjunctival antibiotics, use of endotamponade, presence of postoperative hypotony, and the use of small- versus large-gauge vitrectomy. Results: Thirty-two patients and 150 controls met inclusion criteria. The average time to presentation with endophthalmitis was 5 days after PPV. Endotamponade usage was the only variable that had significant impact on the risk of developing endophthalmitis in univariate and multivariate analyses. The odds ratio of disease in patients with endotamponade over patients without endotamponade was 0.15 (95% confidence interval: 0.06-40); thus, the odds of disease for patients with endotamponade were 85% lower than those without endotamponade. Median visual acuity significantly improved from 20 of 8000 at the time of diagnosis with endophthalmitis to 20 of 50 at 1-year follow-up ( P &lt; .001). Conclusion: The use of intraocular endotamponade may reduce the rate of endophthalmitis after PPV surgery.

A Review of Antibiotic Prophylaxis for Post-operative Endophthalmitis

The purpose of this review is to summarise all available evidence regarding antibiotic prophylaxis for post cataract surgery endophthalmitis as some prophylactic measures add significantly to the cost of surgery, are routinely used and yet their benefit to cataract patients has not been proven. Use of Povidone Iodine before starting the surgery is one of the most effective means of reducing the incidence of postoperative endophthalmitis. Intracameral cefuroxime is another important measure advocated by many studies. Intracameral moxifloxacin may be considered as an alternative to cefuroxime. Although pre and post-operative systemic or topical antibiotics, subconjunctival antibiotics and antibiotics in the irrigating solution have not been proven to decrease post-operative endophthalmitis, they have not been shown to be detrimental and hence surgeons may consider their use according to personal preferences and a costbenefit analysis of their healthcare system.

Methicillin-resistant Staphylococcus aureus buckle infection complicated by endophthalmitis and presumed choroidal abscess in a patient with ulcerative colitis

This patient presented with excessive pain, lid swelling, erythema, heat and limitations of extraocular movement (OD) nine days after a scleral buckle (SB) and pneumopexy surgery. Complicated buckle infection with endophthalmitis was impressed. Bacterial culture yielded methicillin-resistant Staphylococcus aureus. A choroidal abscess was identified 1 week after the episode. Complete visual recovery from hand motion to 20/30 (OD) was achieved with buckle removal, subconjunctival and intravitreal antibiotics. Endophthalmitis and choroidal abscess formation after SB surgery is extremely rare. Host factors including ulcerative colitis may play a role in causing the severe buckle infection of this patient.

Antibiotic Choice for the Prophylaxis of Post-Cataract Extraction Endophthalmitis

To determine the 8-year incidence of endophthalmitis after cataract surgery and to determine which surgical practices were associated with higher rates of endophthalmitis. Case-control study. A total of 75 318 eyes undergoing cataract extractions, performed by 26 different surgeons at 4public hospitals and 5 nonhospital surgical facilities. Cases of endophthalmitis were acquired using a detailed, prospectively designed demographic database. Controls were tabulated using volume data available from the provincial health care system. The primary outcome was the development of endophthalmitis. A total of 23 cases (13 with culture-positive results) of postoperative endophthalmitis occurred, yielding an overall 8-year incidence of 0.03%. The incidence of endophthalmitis varied between surgeons from 0% to 0.20%. Two surgeons had higher rates than the rest of the group: 1 high-volume surgeon (1059.4±231.9 mean cases per year) with an incidence of 0.08% (n= 7; P= 0.004) and 1 low-volume surgeon (123.5±44.8 mean cases per year) with an incidence of 0.20% (n= 2; P= 0.002). On univariate analysis, the rate of endophthalmitis was not influenced by the use of intracameral (0.898) or subconjunctival antibiotics (0.331), whereas the use of moxifloxacin was associated with a lower rate of endophthalmitis (P= 0.029). Surgery at 1 private facility (P= 0.046) and the use of timolol at the end of the procedure (P= 0.007) were associated with a higher rate of endophthalmitis. Multivariate analysis demonstrated that the odds of endophthalmitis was lower if a second-generation (P= 0.02) or fourth-generation (P= 0.008) fluoroquinolone antibiotic was used after surgery. In contrast, the odds of endophthalmitis occurring was higher if timolol (P= 0.0002) was used at the end of the procedure or if the surgery was performed at one of the private facilities (P= 0.009). The rate of endophthalmitis was lower if a fluoroquinolone was used after surgery. In contrast, endophthalmitis was more likely to occur if timolol was used at the end of the procedure or if surgery was performed at one of the private facilities.

Retained subretinal date palm tree thorn in a child

A 3-year-old boy presented with severe eye pain and nausea after colliding with a date palm tree branch. Examination under anesthesia revealed a self-sealed corneal laceration and traumatic cataract in his left eye. Cultures were taken and the patient received prophylactic subconjunctival, intravitreal, and systemic antibiotics because of the high risk of endophthalmitis. A thorn from the same tree grew Bacillus cereus. Examination after 2 weeks of the injury revealed a subretinal foreign body (a palm tree thorn), although there were no signs of endophthalmitis or retinal detachment. The patient underwent cataract extraction and laser demarcation of the subretinal foreign body, which was not removed. He was fitted for an aphakic contact lens. With alternate patching, his best-corrected visual acuity improved to 20/30.

A Novel Surgical Technique for the Treatment of Giant Fornix Syndrome

To describe a novel surgical treatment for patients with chronic relapsing conjunctivitis, corneal epitheliopathy, and ptosis secondary to giant fornix syndrome. A retrospective case series was performed looking at the presence or absence of preoperative symptoms of eye irritation, tearing, blurry vision, and discharge in 6 patients diagnosed with giant fornix syndrome. Their examination findings were noted, and all patients underwent an extensive conjunctivoplasty with resection of redundant forniceal conjunctiva with subconjunctival antibiotics. Final visual acuity, symptoms, and examination findings were noted with a minimum follow up of 9 months. Six patients were treated from November 2009 to November 2011. Duration of symptoms ranged from 3 to 40 months. Four patients were women while 2 were men, with age ranging from 61 to 85 years. Common symptoms were severe mucopurulent discharge, eye redness, tearing, and irritation with examination findings of severe conjunctival discharge and injection, corneal epitheliopathy, upper eyelid ptosis, and a deep upper and lower eyelid fornix. Most patients had undergone previous treatments with topical and/or oral antibiotics or steroids. All patients underwent surgical intervention using the surgical technique to be described with resolution of their symptoms, and even an improvement of 2 or more lines of best corrected visual acuity (3 of 5 patients). The authors' novel surgical technique helps restore the abnormal anatomy found in patients with giant fornix syndrome and thus, helps resolve chronic relapsing conjunctivitis and surface disease associated with this often underdiagnosed condition. Further studies are needed to evaluate the risk of entropion and dry eye syndrome due to the modification of the posterior lamella.

Role of topical, subconjunctival, intracameral, and irrigative antibiotics in cataract surgery

To summarize current understanding of antibiotic prophylaxis in cataract surgery, with particular emphasis on available evidence and change in practice patterns over the past decade. Povidone-iodine application prior to cataract surgery remains a universal practice, and is backed by good quality evidence. Subsequent to the results of the European multicenter trial documenting decreased risk of endophthalmitis with intracameral cefuroxime injection at the end of surgery, similar benefit with intracameral antibiotic use has been reported in studies with large sample sizes from multiple centers around the world. There has been a distinct change in practice patterns in many countries, with intracameral antibiotic use becoming part of routine protocol. In the USA, topical fluoroquinolone application remains the most popular mode of antibiotic prophylaxis. A promising approach is the development of novel drug delivery methods like polymeric devices designed for sustained antibiotic release. Based on current evidence, the recommended measures for endophthalmitis prophylaxis are preoperative topical instillation of povidone-iodine and intracameral antibiotic injection at the end of cataract surgery.

Collagen cross-linking for resistant corneal ulcer

Corneal ulcer is a devastating corneal disease which is potentially sight-threatening and conventionally is treated by topical antibiotics and in some cases with more invasive procedures such as keratoplasty. The aim of this study is to evaluate the efficacy of corneal collagen cross-linking in resistant corneal ulcers. Ten patients with resistant infectious corneal ulcers who had not responded properly to maximal treatment with topical and subconjunctival antibiotics were enrolled in the study and underwent classic corneal collagen cross-linking with riboflavin and UV-A under sterile conditions in the operating room and were followed up regularly. The result was healing and scar formation with improvement of vision in all patients except for two who underwent enucleation and tectonic penetrating keratoplasty. Corneal collagen cross-linking is a viable therapeutic option for treatment of corneal ulcers and can be used as an adjuvant for conventional treatment in resistant cases.

A case of suture-related bacterial keratitis and its treatment with topical imipenem

Risk factors for the development of corneal infection include loose or broken sutures, corticosteroid use, persistent epithelial defects, contact lens use, keratoconjunctivitis sicca, and a history of herpes simplex virus keratitis. Most of the data regarding suture-related keratitis come from literature on penetrating keratoplasty [1]. However, suture-related keratitis following cataract surgery appears to be a rare event [2]. The treatment of bacterial keratitis in patients with or without sutures is similar. In the treatment of serious suture-related corneal infections, topical fortified antibiotic combinations like vancomycin (50 mg/mL) and gentamicin (14 mg/mL) [3] or ceftazidime (50 mg/mL) and vancomycin (50 mg/mL) [3] have been used successfully. However, despite intensive topical, subconjunctival, and systemic antibiotics, corneal perforation can develop [2]. Therefore, selection of the appropriate agent and treatment planning are important for treatment of corneal infections. A beta-lactam antibiotic, imipenem, has often been used systemically and as an intravitreal therapy. However, no study has reported the topical use of imipenem as a monotherapy in the treatment of bacterial keratitis in patients with or without corneal sutures. This report presents the treatment of corneal infection with topical imipenem (50 mg/mL) as monotherapy in a patient who developed an infectious corneal complication due to a broken corneal suture after extracapsular cataract extraction with posterior chamber intraocular lens implantation.

Bleb-associated infections after intravitreal injection.

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