Management of endophthalmitis while preserving the uninvolved crystalline lens

The purpose of this work is to report on the management of endophthalmitis in phakic eyes in which the crystalline lens was preserved. The current study is a noncomparative consecutive case series of patients who developed culture-proven endophthalmitis and were treated between January 1995 and June 2009. The study included only phakic patients whose infection was managed without removal of the crystalline lens. Using a computerized search of Microbiology Department records, patients were identified with phakic lens status and clinically diagnosed endophthalmitis. A total of 12 phakic eyes from 11 patients met the study criteria. The etiology of infection was endogenous (n = 6), postoperative (n = 5), and post-traumatic (n = 1). Pars plana vitrectomy and injection of intravitreal antimicrobials was performed in seven eyes (58%), and vitreous tap and injection of antimicrobials was performed in five eyes (42%). All eyes showed progression of lens opacification after treatment. Overall, nine (75%) achieved visual acuity outcomes ≥20/80, including five of seven (71%) eyes treated with vitrectomy and four of five eyes (80%) treated with injection of antibiotics alone. One of seven eyes (14%) treated with vitrectomy had a poor visual outcome (defined as <20/400) compared with one of five (20%) eyes treated with intravitreal antimicrobials alone. During follow-up, all 12 eyes had progression of lens opacification and five of 12 (42%) eyes underwent cataract surgery with posterior chamber intraocular lens placement. In phakic patients, successful treatment of endophthalmitis can be achieved while preserving the uninvolved crystalline lens. Future cataract surgery with posterior chamber intraocular lens placement can be accomplished in many of these patients

An outbreak of Ralstonia pickettii endophthalmitis following intravitreal methotrexate injection

PURPOSE: To report an outbreak of endophthalmitis in three eyes of two patients following intravitreal methotrexate, caused by Ralstonia pickettii. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: Medical records and microbiology results of two patients who presented with acute endophthalmitis following intravitreal methotrexate injection in November 2013 were reviewed. RESULTS: Following intravitreal injections, the patients experienced pain and decrease in vision in the affected eye within 24 hours of receiving intravitreal methotrexate injection. The presenting visual acuity in case 1 was 20/50 in the left eye. The presenting visual acuity in case 2 was hand motions in the right eye and counting fingers at 1 m in the left eye. Both the patients received methotrexate prepared in the same manufacturing facility. Both the patients underwent vitreous biopsy and intravitreal injection of vancomycin 1 mg/0.1 mL, amikacin 400 µg/0.1 mL, and dexamethasone 400 µg/0.1 mL. Microbiology cultures from vitreous, and used and unused vials of methotrexate from the same batch grew R. pickettii. After 8 months of follow-up, both the patients had visual acuity 20/60 or better. CONCLUSION: R. pickettii can be rarely associated with outbreak of endophthalmitis. Timely intervention can be associated with good visual outcome in such patients

Intravitreal Dexamethasone in the Management of Delayed-Onset Bleb-Associated Endophthalmitis

Purpose. To report the visual acuity (VA) outcomes and culture results of delayed-onset bleb-associated endophthalmitis (BAE) with and without intravitreal dexamethasone (IVD). Methods. Retrospective nonrandomized comparative case series of BAE at Bascom Palmer Eye Institute between January 1, 1996 and December 31, 2009. Clinical data were compared using the 2-sided Student's t-test for patients who received IVD and patients who did not receive IVD. Results. 70/83 (84%) received IVD, and 13/83 (16%) did not receive IVD. Mean baseline VA was 20/90 in the IVD group and 20/70 in the group that did not receive IVD (P = 0.57). Mean presenting VA was 0.9/200 in the IVD group and 1.7/200 in the group that did not receive IVD (P = 0.23). Repeat cultures were positive in 2/70 (3%) IVD cases and 1/13 (8%) cases that did not receive IVD (P = 0.57). Mean VA at 1 month was 5/200 in the IVD group and 1.8/200 in the group that did not receive IVD, logMARΔ of 0.85 and 1.56, respectively (P = 0.02). Mean VA at 3 months was 7/200 in the IVD group and 3/200 in the group that did not receive IVD, logMARΔ of 0.74 and 1.33, respectively (P = 0.14). Conclusion. In the current study of BAE, IVD was associated with improved short-term VA outcomes without an increased rate of persistent infection

Risk Factors for Endophthalmitis and Retinal Detachment with Retained Intraocular Foreign Bodies

Purpose. To analyze risk factors for endophthalmitis and retinal detachment (RD) in patients with retained intraocular foreign bodies (IOFBs). Design. A retrospective, interventional, consecutive case series. Participants. All patients treated at Bascom Palmer Eye Institute for traumatic IOFBs between 1999 and 2008. Methods. Analysis of visual outcome, mechanism of injury, management, and postoperative course. Results. 108 eyes with IOFBs were identified. Endophthalmitis occurred in 7 eyes (6.4%) at presentation, and risk was higher with vegetable matter exposure (P = 0.003). All eyes with posterior segment IOFBs received intravitreal antibiotics and there were no cases of endophthalmitis after initial management. RD was identified in 6 of 108 eyes (5.5%) at presentation. Risk factors were entry more than 5 mm behind the limbus (P < 0.001) and posterior segment IOFB (P = 0.028). Postoperative RD occurred in 11 of 102 eyes (10.7%). Risk factors for postoperative RD were preoperative endophthalmitis (P = 0.001), posterior segment IOFB (P = 0.008), and retinal impact sites (P = 0.028). Conclusions. Risk factors for endophthalmitis included vegetable matter exposure and delay to initial management. Risk factors for RD were posterior entry site, posterior segment IOFB, endophthalmitis, and retinal impact sites. No eyes developed endophthalmitis after presentation

Coexisting choroidal neovascularization and active retinochoroiditis—an uncommon presentation of ocular toxoplasmosis

Abstract Background Choroidal neovascularization during the active stage of Toxoplasma retinochoroiditis is an uncommon clinical presentation. The authors retrospectively reviewed medical charts of patients with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. Findings Three patients presented with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. All lesions had adjacent subretinal hemorrhage. The diagnosis was confirmed based on clinical presentation, fundus fluorescein angiography (FFA), and optical coherence tomography (OCT) findings. The patients were managed with a combination of treatments including intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), oral anti-Toxoplasma treatment, and oral corticosteroids. In all patients, the retinitis lesion resolved in 6 weeks and the coexisting choroidal neovascular membrane resolved over 6 to 12 weeks. Conclusions Recurrences in Toxoplasma retinochoroiditis are common as satellite lesions adjacent to an old atrophic scar. Coexisting choroidal neovascularization with active Toxoplasma retinochoroiditis is an important presentation and should be suspected in the presence subretinal hemorrhage and managed with a combination of anti-Toxoplasma treatment and intravitreal anti-VEGF. </jats:sec

High-resolution genotyping of Pseudomonas aeruginosa strains linked to acute post cataract surgery endophthalmitis outbreaks in India

BACKGROUND: Investigation of two independent outbreaks of post cataract surgery endophthalmitis identified the reservoir of epidemic strains of P. aeruginosa. METHODS: Patient isolates cultured from vitreous fluid of all the nine cases and from the peripheral devices of phacoemulsification machine were subjected to high-resolution Fluorescent Amplified Fragment Length Polymorphism (FAFLP) analysis. RESULTS: FAFLP based genotyping of the isolates confirmed nosocomial transmission. Although biochemical characterization and antibiotic susceptibility profiles grouped all the isolates together, FAFLP based genotyping revealed that, all the outbreak isolates were derived from 2 different strains, with independent origins. One group of isolates was traced to phacoprobe and the second one to the internal tubing system of the phacoemulsification machine used in cataract surgery. In silico analysis indicated possible evolution in both the clusters of P. aeruginosa isolates due to genetic polymorphisms. The polymorphisms were mapped to gene products (cell envelope, outer membrane proteins) possibly having significant role in pathogenesis. CONCLUSION: The present study is probably the first one to apply FAFLP typing successfully to investigate outbreaks of postoperative endophthalmitis (POE) in an ophthalmic setting, which was able to identify the source, and helped to make rational decisions on sterilization procedures that halted more cases of infection in these hospitals

Fluorescent amplified fragment length polymorphism (FAFLP) genotyping demonstrates the role of biofilm-producing methicillin-resistant periocular Staphylococcus epidermidis strains in postoperative endophthalmitis

BACKGROUND: An observational case series was used to study the virulence characteristics and genotypes of paired Staphylococcus epidermidis isolates cultured from intraocular samples and from periocular environment of patients with postcataract surgery endophthalmitis. METHODS: Eight S. epidermidis isolates were obtained from three patients (2 from patients #1 and 2 and 4 from patient #3) whose vitreous and/or anterior chamber (AC) specimens and preoperative lid/conjunctiva samples were culture positive. Cultures were identified by API-Staph phenotypic identification system and genotypically characterized by Fluorescent Amplified Fragment Length Polymorphism (FAFLP) and checked for their antimicrobial susceptibility. The isolates were tested for biofilm-production and methicillin-resistance (MR) by PCR amplification of icaAB and mecA gene respectively. RESULTS: Four out of eight S. epidermidis strains showed multiple drug resistance (MDR). All the eight strains were PCR positive for mecA gene whereas seven out of eight strains were positive for icaAB genes. In all three patients FAFLP typing established vitreous isolates of S. epidermidis strains to be indistinguishable from the strains isolated from the patient's conjunctival swabs. However, from patient number three there was one isolate (1030b from lid swab), which appeared to be nonpathogenic and ancestral having minor but significant differences from other three strains from the same patient. This strain also lacked icaAB gene. In silico analysis indicated possible evolution of other strains from this strain in the patient. CONCLUSION: Methicillin-resistant biofilm positive S. epidermidis strains colonizing the conjunctiva and eyelid were responsible for postoperative endophthalmitis (POE)