Exogenous fungal endophthalmitis: microbiology and clinical outcomes

Comparison of voriconazole concentration in the aqueous humor and vitreous between non-scraped and scraped corneal epithelium groups after topical 1% voriconazole application

PURPOSE

To investigate the penetration of topical 1% voriconazole through the cornea into the aqueous humor in New Zealand white rabbits and to determine the effect of mechanical scraping of the corneal epithelium.

MATERIALS AND METHODS

The right eyes of 29 New Zealand white rabbits were maintained with the epithelium intact, and the left eyes underwent mechanical epithelium debridement of the central 7.5 mm of the cornea. A loading dose consisted of a drop of 1% voriconazole applied every 5 min for the initial half hour and followed by a maintenance dose consisting of a drop every 20 min, which was applied for about 2 hr. Then, the first sample was obtained 5 min after the first seven doses (loading dose) were given, and then four more samples were taken 5 min after four more subsequent drops (maintenance dose). The samples were analyzed by high performance liquid chromatography.

RESULTS

The mean aqueous concentration of voriconazole was 33.44 +/- 5.77 microg/mL 5 min after the loading dose in the non-scraped group and 57.67 +/- 6.77 microg/mL in the scraped group, respectively. The mean aqueous concentration of voriconazole was maintained in a range from 19.97 to 23.70 microg/mL 5 min after the maintenance doses in the non-scraped group and from 44.44 to 49.02 microg/ mL in the scraped group. The mean vitreous concentration of voriconazole ranged from 0.38 to 0.49 microg/mL in the non-scraped group and ranged from 0.72 to 0.94 microg/mL in the scraped group. These levels were statistically significant (P < 0.05) between the scraped and non-scraped groups.

CONCLUSIONS

Topically administered voriconazole achieved minimum inhibitory concentrations in the aqueous for all the organisms most commonly involved in fungal endophthalmitis and achieved minimum inhibitory concentrations in the vitreous for some pathogenic fungi. The concentrations of voriconazole were higher in the scraped group than in the non-scraped group.

Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002-2009)

PURPOSE

To evaluate acute-onset postoperative endophthalmitis occurring at an academic medical center and to compare rates over the last 25 years at a single institution.

DESIGN

Retrospective, consecutive case series.

METHODS

Medical records were reviewed for all patients diagnosed with acute-onset postoperative nosocomial endophthalmitis from 2002 through 2009 associated with surgery at Bascom Palmer Eye Institute.

RESULTS

The 8-year frequency of acute-onset postoperative endophthalmitis was 0.025% (14 of 56 672 intraocular surgeries). The rate was 0.028% (8/28 568) for cataract surgery and 0.011% (2/18 492) for pars plana vitrectomy (PPV). Both PPV endophthalmitis cases followed 20-gauge surgery and no cases followed small-gauge, transconjunctival PPV (n = 2262). Three cases occurred following penetrating keratoplasty (3/2788, 0.108%). The most common bacterial isolate was Staphylococcus (n = 7, 50%). Initial treatment involved ocular paracentesis (n = 8, 57%) or vitrectomy (n = 5, 36%), in combination with injection of intraocular antibiotics (n = 14, 100%). Vancomycin and ceftazidime were used in 13 eyes (93%) and intraocular steroids were given initially to 9 eyes (64%). Final visual acuity was > or =20/200 in 9 eyes (64%) and 2 eyes (14%) were no light perception. At this institution since 1984, there has been a statistically significant trend for a decreasing rate of acute-onset postoperative endophthalmitis (1984-1994: 0.09%; 1995-2001: 0.05%; 2002-2009: 0.025%; P < .001).

CONCLUSION

At a university teaching hospital involving resident, fellow, and faculty surgeons, the frequency of acute-onset postoperative nosocomial endophthalmitis is low, has not increased in the era of sutureless clear corneal cataract surgery, and has steadily decreased when compared to prior time periods from the same institution.

Evaluating exaggerated, prolonged, or delayed postoperative intraocular inflammation

PURPOSE

To provide a diagnostic approach for the evaluation of patients with exaggerated, prolonged, or delayed postoperative intraocular inflammation.

DESIGN

Perspective.

METHODS

Selected articles on normal and abnormal postoperative intraocular inflammation were reviewed and interpreted in the context of the authors' clinical and research experience.

RESULTS

In addition to infectious endophthalmitis, a number of noninfectious conditions characterized by exaggerated, prolonged, or delayed postoperative inflammation have been described. Heuristically, increased postsurgical inflammation may be categorized by time from surgery to first recognition using the following general guidelines: as immediate and occurring within 2 days after surgery; as early and occurring after 2 days, but within the first 2 weeks, after surgery; and as delayed and occurring more than 2 weeks after surgery.

CONCLUSIONS

Although infectious endophthalmitis always must be excluded as a cause of increased postoperative intraocular inflammation, potential noninfectious causes also exist. We review both infectious and noninfectious causes of increased postoperative inflammation and provide a diagnostic framework for evaluating such patients.

Postoperative mycotic endophthalmitis

We report a series of 4 patients who experienced a low-grade mycotic endophthalmitis 3 to 7 months after uneventful cataract surgery. In all patients, the capsular bag was irrigated several times and amphotericin B was instilled intraocularly as well as systemically. In the fourth patient, a pars plans vitrectomy was been performed. Microbiological examination of aqueous humor samples revealed Candida parapsilosis in 3 patients and Candida albicans in 1 patient as causative microorganisms. At follow-up examinations performed up to 12 months after the lavage, visual acuities were 0.2, 0.1, 0.1, and hand motion in the 4 patients, respectively. The main reason for the remaining reduction in visual acuity was retinal and optic nerve atrophy. The findings show that a mycotic etiology of postoperative low-grade infectious endophthalmitis should be considered.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives

Endophthalmitis is a rare but sight-threatening complication that can occur after ocular surgery or trauma or as a consequence of systemic infection. To optimize visual outcome, early diagnosis and treatment are essential. Over recent decades, advances in hygienic standards, improved microbiologic and surgical techniques, development of powerful antimicrobial drugs, and the introduction of intravitreal antibiotic therapy have led to a decreased incidence and improved management of endophthalmitis. However, endophthalmitis still represents a serious clinical problem. This review focuses on current principles and techniques for evaluation and treatment of endophthalmitis. In addition, it addresses recent developments regarding antimicrobial treatment and prophylaxis of infectious endophthalmitis.

Chronic intraocular copper foreign body and candida: a unique combination

PURPOSE

To describe a case of unilateral intermediate uveitis, retained copper intraocular foreign body (IOFB) and fungus.

METHODS

Interventional case report.

RESULTS

Brown-orange discoloration of the iris, lens and opacified vitreous was observed. Computed tomography revealed a retained IOFB, which was composed of copper. IOFB was removed during vitrectomy and cataract surgery. Copper deposition was demonstrated on the anterior capsule. Incidentally, dimorphic fungus were found in the vitreous.

CONCLUSIONS

The presence of intraocular copper might have reduced the virulence of the fungus preventing endophthalmitis.