Clinical Features, Antibiotic Susceptibilities, and Treatment Outcomes of Endophthalmitis Caused by Staphylococcus epidermidis

PURPOSE

To report the clinical features, antibiotic susceptibilities, and visual acuity outcomes with endophthalmitis caused by methicillin-sensitive Staphylococcus epidermidis and methicillin-resistant S. epidermidis.

DESIGN

Retrospective case series.

PARTICIPANTS

All patients seeking treatment at a tertiary referral center between 2006 and 2016 with endophthalmitis caused by S. epidermidis.

METHODS

All records were reviewed for patients with a clinical diagnosis of endophthalmitis and positive vitreous culture results for S. epidermidis. Data were compared with the prior series at the same institution.

MAIN OUTCOME MEASURES

Clinical settings, antibiotic susceptibilities, and visual acuity.

RESULTS

Among 96 eyes of 96 patients, the most common postprocedural clinical settings were cataract surgery (47/96 [49%]), intravitreal injection (21/96 [22%]), trauma (8/96 [8%]), glaucoma surgery (7/96 [7%]), and penetrating keratoplasty (5/96 [5%]). The initial treatment included intravitreal vancomycin and ceftazidime in 89 of 96 eyes (93%) and intravitreal vancomycin and amikacin in 7 of 96 eyes (7%). A vitreous tap and injection with antibiotics was performed as the initial treatment in 83 of 96 eyes (86%) and pars plana vitrectomy was performed in 13 of 96 eyes (14%). All isolates were sensitive to vancomycin in both decades. In the most recent series, visual acuity at last follow-up was 5/200 or better in 68 of 96 eyes (71%) compared with 71 of 86 eyes (83%) in the prior study. In the current study, susceptibility to methicillin and moxifloxacin was present in 45 of 96 eyes (47%) and 29 of 85 eyes (34%), respectively, compared with 34 of 86 eyes (40%) and 27 of 39 eyes (69%) in the prior study. Final visual acuity was not significantly different between those eyes that were methicillin or fluoroquinolone sensitive and those that were resistant.

CONCLUSIONS

In the current and prior series, all S. epidermidis isolates were sensitive to vancomycin. Visual acuity outcomes were not dependent on methicillin or fluoroquinolone sensitivity.

Endophthalmitis and Concurrent or Delayed-Onset Rhegmatogenous Retinal Detachment Managed With Pars Plana Vitrectomy, Intravitreal Antibiotics, and Silicone Oil

BACKGROUND AND OBJECTIVE

The current study describes the treatment outcomes in patients with endophthalmitis and concurrent or delayed-onset retinal detachment managed with pars plana vitrectomy, intravitreal antibiotics, and silicone oil.

PATIENTS AND METHODS

In this noncomparative, retrospective case series, the medical records of patients diagnosed with endophthalmitis and retinal detachment from January 1991 through December 2014 at a tertiary eye care center in South India were reviewed. All patients received silicone oil for the management of retinal detachment either concurrently or during follow-up treatment.

RESULTS

A total of 93 patients were included in the current study. Retinal detachment was diagnosed at presentation in 20 of 93 patients (21.5%) (concurrent group: Group 1) and during follow-up in the remaining 73 of 93 patients (78.5%) (delayed-onset group: Group 2). In Group 1, the initial treatment consisted of vitrectomy, intravitreal antibiotics, and silicone oil injection in 19 of 20 patients. In Group 2, patients did not receive silicone oil during initial treatment but underwent silicone oil injection during subsequent surgery for repair of retinal detachment. Rates of complete retinal reattachment and visual acuity of 20/400 or better were 73.7% and 30.0%, respectively, in Group 1 and 98.5% and 39.7%, respectively, in Group 2. The median visual acuity at last follow-up in 44 eyes undergoing silicone oil removal was 20/100 (logMAR 0.7), whereas in the remaining 49 eyes that did not undergo silicone oil removal, median visual acuity was 20/2000 (logMAR 2.0).

CONCLUSION

In these patients with endophthalmitis with concurrent or delayed-onset retinal detachment, the use of silicone oil can be a useful adjunct. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:546-551.].

Comparison of Regional vs. General Anesthesia for Surgical Repair of Open-Globe Injuries at a University Referral Center

PURPOSE

This study compares the clinical features and physician selection of either Regional Anesthesia (peribulbar or retrobulbar block) with Monitored Anesthesia Care (RA-MAC) or General Anesthesia (GA) for open globe injury repair.

DESIGN

A non-randomized, comparative, retrospective case series at a University Referral Center.

PARTICIPANTS

All adult repairable open globe injuries receiving primary repair between January 1st, 2004 and December 31st, 2014 (11 years). Exclusion criteria were patients less than 18 years of age and those treated with primary enucleation.

METHODS

Data was gathered via retrospective chart review.

MAIN OUTCOME MEASURES

Data collected from each patient was age, gender, injury type, location, length of wound, presenting visual acuity, classification of anesthesia used, duration of the procedure performed, months of clinical follow-up, and final visual acuity.

RESULTS

During the 11 years study period, 448 patients were identified who had open globe injuries with documented information on zone of injury. Globe injury repair was performed using RA-MAC in 351/448 (78%) patients and general anesthesia in 97/448 (22%) patients. Zone 1, 2 and 3 injuries were recorded in 241, 135, and 72 patients respectively. The rates in specific zones, of RA-MAC versus GA were as follows: Zone 1 - 213/241 (88%) vs 28/241 (12%), Zone 2 - 104/135 (77%) vs 31/135 (23%) and Zone 3 - 34/72 (47%) vs 38/72 (53%). Open globe injuries repaired under RA-MAC had significantly shorter wound length (p<0.001), more anterior wound location (p<0.001) and shorter operative times (p<0.001). RA-MAC cases also had a better presenting and final visual acuity (p<0.001). Neither class of anesthesia conferred a greater visual acuity improvement (p=0.06). The use of GA did not cause any delay in the time elapsed from injury until surgical repair (p=0.74).

CONCLUSIONS

RA-MAC is a reasonable alternative to GA for the repair of open globe injuries in selected adult patients. RA-MAC was selected more often for Zone 1 and Zone 2 injuries. For eyes with Zone 3 injuries, there are equal selection ratio for RA-MAC and GA.

A novel clinical sign in intraocular tuberculosis: Active chorioretinitis within chorioretinal atrophy

Purpose

To report a novel clinical sign in patients with intraocular tuberculosis. The current study is an observational consecutive case series of patients diagnosed with intraocular tuberculosis managed at a tertiary eye care centre from June 1, 2012 to December 31, 2015.

Observations

The diagnosis of intraocular tuberculosis was made in 6 patients based on ocular features suggestive of tuberculosis along with a positive tuberculin skin testing and chest X-ray consistent with tuberculosis. All patients presented with decreased visual acuity ranging from 20/25 to 20/400, anterior chamber reaction, vitritis, multifocal choroiditis and vasculitis. All patients had an area of active chorioretinitis within the zone of pre-existing chorioretinal atrophy, apart from various other signs suggestive of intraocular inflammation. All patients were started on anti-tubercular therapy for a period of 9 months alone or in combination with oral corticosteroids tapered over 3–4 months. A prompt response to the treatment with resolution of chorioretinitis within the chorioretinal atrophy occurred in all patients. In addition, there was resolution of vitritis and improvement in the visual acuity ranging from 20/20 to 20/40 at last follow-up.

Conclusions and importance

and Importance: Active chorioretinitis within an area of chorioretinal atrophy is a novel clinical sign that may indicate intraocular tuberculosis.

Peptide Nucleic Acid-Fluorescence In Situ Hybridization for Detection of Staphylococci From Endophthalmitis Isolates: A Proof-of-Concept Study

Purpose

Rapid identification of pathogens causing endophthalmitis may improve treatment outcomes through early administration of species-specific medication. The current study reports a new molecular application of peptide nucleic acid–fluorescence in situ hybridization (PNA-FISH) with Staphylococcus-specific molecular PNA probes for the potential rapid detection of common pathogens causing endophthalmitis.

Methods

An experimental study was designed to evaluate the proof of concept at the microbiology laboratory of the Bascom Palmer Eye Institute. Stored culture-positive staphylococci endophthalmitis isolates obtained from prior vitreous samples (n = 15), along with broth as negative controls (n = 5) were used. Inoculum was prepared to a final concentration of 1 × 10⁵ colony-forming units/mL to ensure that the isolates were viable. Smears of samples were fixed and hybridized using QuickFISH protocol with probes for Staphylococcus.

Results

With PNA-FISH technique, Staphylococcus aureus was identified in 9 of 10 samples and coagulase-negative staphylococci were identified in 10 of 10 samples. Detection time was 20 minutes.

Conclusions

This study serves a proof of concept using a new microbial detection system with FISH probes, and may have the potential for clinical use in the rapid and accurate identification of isolates from patients with endophthalmitis.

Venous Air Embolism During Pars Plana Vitrectomy: A Case Report and Review of the Literature

Purpose:

Presumed venous air embolism (PVAE) is a rare and potentially fatal complication of pars plana vitrectomy that is poorly described and understood but requires improved awareness among ophthalmologists and vitreoretinal surgeons.

Methods:

A case report is presented along with a systematic review of published reports of PVAE during ocular surgery.

Results:

An otherwise healthy adult male undergoing retinal detachment repair under local anesthesia with monitored anesthesia care died from a PVAE. Literature search yielded 2 experimental models, 6 individual case reports, and several editorials. Review of existing reports reveals that PVAE can affect patients of any age or gender with no medical predilection and occurs in cases of trauma, endoresection, or retinal detachment repair. It is typically associated with a drop in end-tidal carbon dioxide during fluid–air exchange and can present similar to a hemorrhagic choroidal detachment. Analysis suggests that venous air embolism can be prevented by ensuring full engagement of the infusion cannula into the vitreous cavity prior to fluid–air exchange.

Conclusion:

Presumed venous air embolism is a potentially fatal complication of ocular surgery and in some cases may be recognized by ophthalmologists as a choroidal detachment during fluid–air exchange in pars plana vitrectomy. It is imperative to immediately stop the air infusion line if venous air embolism is suspected.

Endophthalmitis After Clear Corneal Cataract Surgery: Outcomes Over Two Decades

PURPOSE

To report the clinical features, causative organisms, and visual acuity (VA) outcomes associated with acute-onset endophthalmitis after clear corneal cataract surgery over the past 2 decades.

DESIGN

Retrospective case series.

METHODS

Clinical and microbiology records were reviewed for 63 eyes of 63 patients who presented to a tertiary referral center between 2006 and 2015 with culture-positive endophthalmitis occurring within 6 weeks of clear corneal cataract surgery.

RESULTS

The mean time between surgery and diagnosis of endophthalmitis was 8 days (median 6 days). The initial treatment included intravitreal vancomycin and ceftazidime in 59 of 63 (94%) eyes and intravitreal vancomycin and amikacin in 4 of 63 (6%) eyes. Intravitreal dexamethasone was used in 50 of 63 (79%) eyes. A vitreous tap and injection with antibiotics was performed as the initial treatment in 57 of 63 (90%) eyes and pars plana vitrectomy in 6 of 63 (10%) eyes. Coagulase-negative Staphylococcus was isolated in 39 of 63 (62%) eyes, Staphylococcus aureus in 7 of 63 (11%) eyes, and Streptococcus species in 7 of 63 (11%) eyes. A VA of ≥20/40 was achieved in 24 of 63 (38%) eyes. None of the gram-positive isolates were vancomycin resistant. Twenty-four of 49 isolates (49%) were sensitive to cephalothin, cefazolin, and cefuroxime. Sensitivity to fluoroquinolones included 22 of 52 (42%) to levofloxacin, 20 of 54 (37%) to ciprofloxacin, 16 of 47 (34%) to moxifloxacin, and 3 of 13 (23%) to gatifloxacin.

CONCLUSION

Causative organisms and visual outcomes are similar to those reported in the prior decade. In the current study, a number of isolates were resistant to cephalosporins and fluoroquinolones.

The Charles Schepens Lecture: Management Options for Vitreomacular Traction: Use an Individualized Approach

PURPOSE

To present the management options for vitreomacular traction (VMT) and to recommend an individualized approach to treatment selection.

DESIGN

Presented at the American Academy of Ophthalmology Annual Meeting, 2016, Chicago, October 15, 2016 (The Charles Schepens Lecture).

PARTICIPANTS

None.

METHODS

Review of published literature and clinical trials.

MAIN OUTCOME MEASURES

Visual and anatomic outcomes of various treatment options for VMT were reviewed.

RESULTS

The management options for VMT include pars plana vitrectomy, pneumatic vitreolysis, enzymatic vitreolysis, and observation. The surgical management using pars plana vitrectomy offers the most effective approach for VMT, but there are inherent risks and cost issues. Pneumatic vitreolysis is reported to be cost-effective and may be an anatomically successful nonsurgical option for management. Enzymatic vitreolysis with intravitreal ocriplasmin is another nonsurgical option, but both short- and long-term side effects may occur. Observation in selected patients can be associated with stable visual outcomes during long-term follow-up.

CONCLUSIONS

The final management decision should be individualized for specific patients depending on the patient's clinical findings, potential risks, probable benefits, and costs of each option.

Endophthalmitis caused by Gram-positive organisms with reduced vancomycin susceptibility: literature review and options for treatment

BACKGROUND

Endophthalmitis caused by Gram-positive organisms with reduced vancomycin susceptibility and/or resistance is an important clinical issue worldwide.

PURPOSE

To review the published literature on endophthalmitis caused by Gram-positive organisms with reduced vancomycin susceptibility and/or vancomycin resistance.

METHODS

The data were analysed from a PubMed search of endophthalmitis cases caused by Gram-positive organisms with reported reduced vancomycin susceptibility and/or vancomycin resistance from 1990 to 2015.

RESULTS

From 18 publications identified, a total of 27 endophthalmitis cases caused by Gram-positive organisms with reduced vancomycin susceptibility and/or vancomycin resistance were identified. The aetiologies of endophthalmitis were exogenous in 19/27 cases (11 post-cataract surgery, 2 post-penetrating keratoplasty, 1 post-glaucoma surgery, 4 post-open globe injury, 1 post-intravitreal injection of ranibizumab), and endogenous in 4/24 cases; no details were available about the four remaining patients. The causative organisms included Enterococcus species (7/27), coagulase-negative staphylococci (4/27), Staphylococcus aureus (4/27), Bacillus species (4/27), Streptococcus species (3/27), Leuconostoc species (3/27), Staphylococcus hominis (1/27), and unidentified Gram-positive cocci (1/27). Visual acuity of 20/400 or better at the final follow-up was recorded in 10/26 patients (38.5%; data were not available for one patient). Treatment options include fluoroquinolones, penicillin, cephalosporins, tetracyclines, and oxazolidinones.

CONCLUSIONS

In the current study, visual acuity outcomes were generally poor. Enterococcus and Staphylococcus species were the most common organisms reported and postoperative endophthalmitis after cataract surgery was the most common clinical setting.

High-hyperopia database, part I: clinical characterisation including morphometric (biometric) differentiation of posterior microphthalmos from nanophthalmos

PURPOSE To characterise and differentiate posterior microphthalmos (PM) and nanophthalmos (NO) using morphometric parameters.Patients and methodsConsecutive case database of patients with hyperopia >+7.00 D sphere was analysed retrospectively for clinical and biometric characterisation. Thirty-eight consecutive high-hyperopic subjects (75 eyes) with axial lengths <20.5 mm underwent uniform comprehensive ocular evaluation. Twenty-five subjects were diagnosed as PM and 13 as NO based on the horizontal corneal diameter. Parameters analysed included visual acuity, refraction, horizontal corneal diameter, anterior chamber depth, lens thickness, axial length, fundus changes, and associated ocular pathology.

PRIMARY OUTCOME MEASURES

ocular biometry difference between PM and NO.

SECONDARY OUTCOME MEASURES

differences in associated ocular pathologies between PM and NO.RESULTS Hyperopia ranged from +7 to +17 D and was similar in the two groups. Lens thickness was statistically more in NO than in PM group (4.53±0.75 mm vs 3.82±0.48 mm, P <0.001), whereas anterior chamber depth was more in the PM than in NO group (3.26±0.36 mm, vs 2.59±0.37 mm, P<0.001). NO had higher association with angle-closure glaucoma (66.7% vs 0%) and pigmentary retinopathy (38.5 vs 8.0%) but lesser association with macular folds (0% vs 24%) as compared with PM. NO was associated with poorer visual acuity.CONCLUSION PM and NO have significant differences in lens thickness, anterior chamber depth, prevalence of glaucoma, pigmentary retinopathy, macular pathology, and visual acuity while being similar in hyperopic refraction.

Clinical experience in treatment of diffuse unilateral subretinal neuroretinitis

Purpose

To describe the clinical features, management, and outcomes of patients with diffuse unilateral subacute neuroretinitis (DUSN).

Methods

A noncomparative, consecutive analysis of case series from two tertiary care campuses of LV Prasad Eye Institute, India, between January 2011 and April 2014 was performed. Medical records of the patients presenting with DUSN (early or late stage) were reviewed.

Results

The current study included 13 patients. The majority (10/13, 76.92%) of the patients were aged 20 years or less. All patients had unilateral eye involvement. Visual acuity at presentation was 20/200 or worse in 9/13 (69.23%) patients. A delay in diagnosis occurred in 6/13 patients, and initial diagnosis in these patients included retinitis pigmentosa (4 patients) and posterior uveitis (2 patients). Clinical features included early presentation (prominent vitritis, localized retinitis, and vasculitis) in 7/13 (53.85%) patients and late presentation (attenuation of vessels, retinal pigment epithelium atrophic changes, and optic atrophy) in 6/13 (46.15%) patients. Worm could not be identified in any of the cases. All the patients received laser photocoagulation of retina and oral albendazole treatment for a period of 30 days. With treatment, visual acuity improved in seven patients (six early stage, one late stage) and remained unchanged in six patients. Mean follow-up period was 8.69 months (range, 1–21 months). The mean central foveal thickness in the affected eye, done by optical coherence tomography, during the late stage of the disease was 188.20±40 µm (range, 111–242 µm), which was significantly thinner than the fellow eye, 238.70±36.90 µm (range, 186–319 µm), P=0.008.

Conclusion

DUSN is a serious vision threatening disease, which may progress to profound vision loss in the later stage of the disease. Visualization of subretinal worm is usually not possible. Treatment with high-dose albendazole therapy and laser photocoagulation may alter the blood–retinal barrier and may be useful in achieving visual recovery.

New Therapeutic Approaches in Diabetic Retinopathy

Diabetic retinopathy is a common microvascular complication of diabetes mellitus. It affects a substantial proportion of US adults over age 40. The condition is a leading cause of visual loss. Much attention has been given to expanding the role of current treatments along with investigating various novel therapies and drug delivery methods. In the treatment of diabetic macular edema (DME), intravitreal pharmacotherapies, especially anti-vascular endothelial growth factor (anti-VEGF) agents, have gained popularity. Currently, anti-VEGF agents are often used as first-line agents in center-involved DME, with recent data suggesting that among these agents, aflibercept leads to better visual outcomes in patients with worse baseline visual acuities. While photocoagulation remains the standard treatment for proliferative diabetic retinopathy (PDR), recent FDA approvals of ranibizumab and aflibercept in the management of diabetic retinopathy associated with DME may suggest a potential for pharmacologic treatments of PDR as well. Novel therapies, including small interfering RNAs, chemokines, kallikrein-kinin inhibitors, and various anti-angiogenic agents, are currently being evaluated for the management of diabetic retinopathy and DME. In addition to these strategies, novel drug delivery methods such as sustained-release implants and refillable reservoir implants are either under active evaluation or have recently gained FDA approval. This review provides an update on the novel developments in the treatment of diabetic retinopathy.

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

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.

Filamentous fungal endophthalmitis: results of combination therapy with intravitreal amphotericin B and voriconazole

Purpose

To report outcomes of exogenous fungal endophthalmitis treated with combination of intravitreal antifungal agents.

Design

Retrospective, non-randomized, interventional, consecutive case series.

Methods

Twelve eyes of twelve consecutive cases of filamentous fungal endophthalmitis were treated with a combination of intravitreal amphotericin-B and intravitreal voriconazole (AmB-Vo Regime) along with pars plana vitrectomy at a single center. Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed.

Results

Ten cases out of the twelve were postoperative endophthalmitis of which nine were part of a post cataract surgery cluster. The remaining included endophthalmitis following keratitis post pterygium excision (1) and following open globe injury (2). The most common fungus was Aspergillus terreus, which was isolated in 8/12, followed by A. flavus in 2/12 and Fusarium solani in 1/12. The presenting visual acuity ranged from light perception (LP) to counting fingers. The visual acuity at final follow-up was 20/400 or better in 7/12 eyes (58.33%) and 20/60 in 2/12 eyes (range 20/60 to LP). All eyes with corneal involvement had final visual acuity 20/400 or worse. Globe salvage was achieved in all cases.

Conclusion

Combining intravitreal amphotericin-B and voriconazole could be a novel treatment strategy in the management of endophthalmitis caused by filamentous fungus. Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

Bilateral endogenous endophthalmitis caused by vancomycin-resistant Staphylococcus epidermidis in a neonate

BACKGROUND

Neonatal bilateral endogenous endophthalmitis is rare and often results in devastating visual outcome.

FINDINGS

An 18-day-old neonate presented with whitening of the cornea in the left eye. The child was examined under anesthesia, and a diagnosis of bilateral endogenous endophthalmitis was made. Vitreous biopsy from the left eye showed no growth. Blood samples showed growth of Staphylococcus epidermidis which was multidrug resistant (including vancomycin) but sensitive to piperacillin-tazobactam. The patient was managed with bilateral intravitreal injections of piperacillin-tazobactam and systemic cefpodoxime. Systemic and topical antibiotics were given for 3 and 8 weeks, respectively, and infection was controlled. At 2-year follow-up, the right eye is fixing and following to light with clear view of the fundus and the left eye has a clear cornea with red glow of the fundus.

CONCLUSIONS

Vancomycin-resistant S. epidermidis may be a cause of endogenous endophthalmitis. Intravitreal piperacillin-tazobactam and systemic cefpodoxime were used to eliminate the infection in this neonate.

A case of vasculitis, retinitis and macular neurosensory detachment presenting post typhoid fever

Background

Ocular and extraocular immune-mediated phenomena are known to occur following febrile illness. Vasculitis, retinitis and neurosensory detachment are not well-recognized sequelae of typhoid fever.

Findings

We report a case of vasculitis, retinitis and macular neurosensory detachment presenting post typhoid fever. A 27-year-old female presented with decreased vision in right eye with history of typhoid fever (treated adequately 6 weeks prior). Her best corrected visual acuity in right eye was 20/125, N36. Fundus showed a patch of vasculitis and retinitis superior to the disc associated with macular neurosensory detachment and disc pallor. With oral steroids, the inflammation resolved and visual acuity improved to 20/20 at 6 weeks.

Conclusions

Immune-mediated vasculitis and retinitis following typhoid fever may respond well to systemic steroids.

Pharmacokinetics of intravitreal antibiotics in endophthalmitis

Intravitreal antibiotics are the mainstay of treatment in the management of infectious endophthalmitis. Basic knowledge of the commonly used intravitreal antibiotics, which includes their pharmacokinetics, half-life, duration of action and clearance, is essential for elimination of intraocular infection without any iatrogenic adverse effect to the ocular tissue. Various drugs have been studied over the past century to achieve this goal. We performed a comprehensive review of the antibiotics which have been used for intravitreal route and the pharmacokinetic factors influencing the drug delivery and safety profile of these antibiotics. Using online resources like PubMed and Google Scholar, articles were reviewed. The articles were confined to the English language only. We present a broad overview of pharmacokinetic concepts fundamental for use of intravitreal antibiotics in endophthalmitis along with a tabulated compendium of the intravitreal antibiotics using available literature. Recent advances for increasing bioavailability of antibiotics to the posterior segment with the development of controlled drug delivery devices are also described.

Vancomycin-resistant Gram-positive bacterial endophthalmitis: epidemiology, treatment options, and outcomes

Background

The purpose of this study is to evaluate the microbiological profile and treatment outcomes of vancomycin-resistant Gram-positive bacterial endophthalmitis. Medical records of all patients with Gram-positive bacterial endophthalmitis resistant to vancomycin presenting between 1 January 2005 and 31 December 2010 were reviewed in this noncomparative, consecutive, retrospective case series. Favorable outcome was defined as a best-corrected visual acuity of ≥20/200.

Results

Out of 682 culture-positive endophthalmitis isolates, 448/682 (65.6%) were associated with Gram-positive bacteria. In vitro resistance to vancomycin was noted in 7/448 (1.56%). Three cases were posttraumatic, three were postoperative, and one was endogenous in origin. Four Bacillus isolates, two Staphylococcus isolates, and an Enterococcus isolate were resistant. Isolates resistant to vancomycin were sensitive in vitro to ciprofloxacin in 6/7 (86%) patients. Presenting visual acuity was light perception in all seven cases. Favorable outcome was achieved in only 1/7 (14.3%) cases.

Conclusions

Vancomycin-resistant endophthalmitis is uncommon and usually associated with poor visual outcome. Bacillus sp. is the most frequent Gram-positive bacteria resistant to vancomycin. Fluoroquinolones like ciprofloxacin may be considered as a useful alternative in vancomycin-resistant endophthalmitis.