Acanthamoeba endophthalmitis following penetrating keratoplasty for Acanthamoeba keratitis

The incidence of severe complications in acanthamoeba keratitis: Qualitative and quantitative systematic assessment

Acanthamoeba keratitis (AK) is a rare, sight-threating corneal infection. The disease is challenging to diagnose and treat, and the amoeba can rapidly encyst, persisting in the tissue and causing recurrences. Medical therapy is conventionally considered the first line treatment, but advanced cases could require more invasive treatments like a "chaud" corneal transplant. We review the incidence of severe complications in patients affected by AK. Of 439 reports screened, 158 met our inclusion criteria. Incidence of severe complications was low, with 2.21 % patients developing perforation, 1 % requiring evisceration/enucleation and less than 1 % developing endophthalmitis. Corneal transplantation was required in 16.68 % of the cases. According to our results, and considering the reported incidences of these complications in other infectious keratitis, AK patients have an overall low risk of developing perforation, endophthalmitis, and enucleation/evisceration. Nevertheless, data available in the literature remain poor, and further randomized control trials are needed to confirm our findings.

Therapeutic keratoplasty for severe Acanthamoeba keratitis: risk factors, clinical features, and outcomes of postoperative recurrence

PURPOSE

To investigate the effect of therapeutic keratoplasty (TKP) in patients with severe Acanthamoeba keratitis (AK) and to analyse the clinical features and risk factors for recurrence.

METHODS

Clinical data of patients with severe AK treated with lamellar keratoplasty (LK) or penetrating keratoplasty (PK) due to ineffective drug therapy were analysed in this retrospective study. The effects of keratoplasty, clinical features, and risk factors for recurrence were analysed.

RESULTS

The cohort comprised of 58 patients (59 eyes). Of these, 36 eyes were treated with PK and 23 were treated with LK. The probabilities of successful globe salvage were 91.7% and 91.3%, respectively. The final visual acuity (VA) was ≥ 20/60 in 14 eyes (38.9%) that underwent PK and 15 eyes (65.2%) that underwent LK. Postoperative recurrence of Acanthamoeba infection was detected in 10 eyes; 6 eyes (16.7%) showed recurrence after PK, and 4 eyes (17.4%) showed recurrence after LK. Recurrence occurred between 3 and 80 days (median, 14.5 days) after the operation. The risk factors for recurrence after LK were topical corticosteroid use before diagnosis (p = 0.040) and hypopyon (p = 0.009), while those after PK were topical corticosteroid use before diagnosis (p = 0.045). Clinical manifestations of postoperative recurrence include greyish-white infiltration of the recipient bed, anterior chamber inflammation, graft oedema, and keratic precipitate.

CONCLUSION

TKP is a treatment option for severe AK that responds poorly to antiamoebic therapy (AAT), although Acanthamoeba infection may relapse, and the visual prognosis is guarded. Topical corticosteroid use before AAT and hypopyon is the two risk factors for recurrence.

Risk factors and microbiological characteristics: from bacterial keratitis with hypopyon to keratitis-related endophthalmitis

PURPOSE

To compare the clinical and microbiological characteristics in patients with bacterial keratitis with hypopyon (BKH), bacterial keratitis-related endophthalmitis (BKE), and bacterial endophthalmitis without keratitis (BE).

METHODS

Data from all inpatients who were clinically diagnosed with BKH, BKE, and BE from 2018 to 2020 were collected retrospectively. The demographics, predisposing risk factors, clinical characteristics, microbiological profiles, and antibiotic susceptibility of the patients were evaluated.

RESULTS

Approximately 9.46% (28/296) of eyes with BKH progressed to endophthalmitis. The hypopyon (OR = 5.35, 95% CI: 2.17-7.08) and corneal perforation (OR = 2.47, 95% CI: 1.04-4.86) were significantly related to the development of BKE. The odds ratios for hypopyon of less than 1 mm, 1-3 mm, and greater than 3 mm were 1, 2.09 (95% CI: 1.17-3.15), and 4.12 (95% CI:2.59-5.68), respectively. The predominant causative pathogen was Staphylococcus epidermidis (36.43%, 38.89%), followed by Streptococci (14.73%, 16.67%), Staphylococcus aureus (8.53%, 7.79%), and Pseudomonas aeruginosa (9.30%, 7.14%) in eyes with BKH and BE. However, the main pathogens were Pseudomonas aeruginosa (37.50%) and Staphylococcus aureus (31.25%) in eyes with BKE. In the BKH, BKE, and BE groups, almost 100% of Staphylococcus aureus isolates were sensitive to vancomycin (97.70%, 100%, 95.56%), about a half were sensitive to fluoroquinolones (51.85%, 39.90%, 62.34%), and approximately 30% were sensitive to trimethoprim/sulfa (27.77%, 21.56%, 33.56%) and cefazolin (41.47%, 20.31%, 38.81%). The susceptibility of Pseudomonas aeruginosa to fluoroquinolones antibiotics was 55.75%, 66.67%, and 62.58%, respectively, in the three groups.

CONCLUSIONS

The height of hypopyon and corneal perforation are risk factors for progression to endophthalmitis in eyes with bacterial keratitis. When Staphylococcus aureus and Pseudomonas aeruginosa are identified, vigilance is required for advanced endophthalmitis.

Risk factors, management, and outcomes of Acanthamoeba keratitis: A retrospective analysis of 110 cases

Purpose

To evaluate the risk factors, medical and surgical management, and visual outcomes of patients affected by Acanthamoeba keratitis (AK) over a 16-year period.

Observations

Records were reviewed retrospectively for all AK patients treated at University of Iowa between 2002 and 2017. Main outcomes measured were risk factors, time to diagnosis, coinfection types, initial and final visual acuities, and treatment outcomes, with failure of medical therapy defined as need for therapeutic keratoplasty (TK). Effects of steroid use on these outcomes were determined. Among all AK cases occurring during the study period (N = 110), the median age of the AK cohort was 31 years (range 8–80 years), and 49.1% were men. Contact lens wear was the primary risk factor for AK (95/100, 86.4%), and the median time to diagnosis was 0.70 (0.23–1.23) months. Forty-four AK patients (40%) failed medical therapy. Vision outcomes were better for AK patients with successful medical therapy compared to those requiring TK (LogMAR 0.00 v. 0.30; p < 0.0001). Corticosteroid use was associated with increased time to diagnosis (1.00 v. 0.50 months; p = 0.002), decreased final vision (LogMAR 0.10 v. 0.00; p < 0.05) and increased need for TK (40/77 v. 4/33; p < 0.001).

Conclusions and importance

Acanthamoeba keratitis cases have increased over the past two decades at our institution. In this large retrospective study, AK was commonly misdiagnosed with delayed diagnosis and high rates of failed medical therapy. Corticosteroid use before AK diagnosis led to poorer outcomes. Our findings underscore the need for ophthalmologists to suspect Acanthamoeba in the setting of contact lens-associated keratitis before topical steroids are initiated.

Surgical management of acanthamoeba chorioretinitis

Purpose

Acanthamoeba chorioretinitis is a rare manifestation of the parasitic infection, and reported cases often result in enucleation. Surgical removal of Acanthamoeba chorioretinitis has not been previously described. We report a surgical case of Acanthamoeba chorioretinitis spread from keratitis that ultimately resulted in a disease-free outcome.

Observations

A healthy 80-year-old male with a history of keratoconus requiring a penetrating keratoplasty in the fellow eye presented with a severe corneal ulcer clinically consistent with Acanthamoeba keratitis. He ultimately required a penetrating keratoplasty and improved clinically until he developed vitritis on post-operative month 1 and was diagnosed with endophthalmitis. B-scan ultrasound demonstrated vitreous opacities and a large retinal mass that reduced in size following serial intravitreal injections of antibiotics, oral antibiotics, and a limited pars plana vitrectomy. He underwent a repeat pars plana vitrectomy 6 weeks later and a retinal mass in the mid-periphery with an associated tractional retinal detachment was noted. A localized retinectomy was performed around the lesion which was excised entirely, and silicone oil was instilled. Pathology of the lesion showed acute and chronic granulomatous necrotizing inflammation with the presence of several definitive amoebic organisms and numerous cells suspicious for amoebae. The patient was maintained on oral antibiotics by the Infectious Disease Service and was disease-free 1-year post-infection.

Conclusions and importance

Acanthamoeba chorioretinitis is a rare, devastating disease and often leads to enucleation. We present a surgical case showing control of the infection utilizing a surgical retinectomy. Aggressive local therapy and a multidisciplinary approach with the Infectious Disease Service may lead to a successful outcome.

Epidemiology of keratitis/scleritis-related endophthalmitis in a university hospital in Thailand

To demonstrate the demographics, associated factors, clinical presentations, microbiology, management, visual outcome and complications of keratitis/scleritis-related endophthalmitis (KSE). A retrospective chart of all endophthalmitis patients diagnosed between September 2001 and August 2011 was reviewed. Only endophthalmitis cases with previous corneal or scleral infection were included in the study. The patients were followed until losing vision or eyeball, becoming phthisis, or the end of 2018. Eighty-seven patients with KSE were identified, all unilateral. The mean age was 56.4 ± 21.4 years. There was a slight male predilection (55 patients, 63.2%). The mean follow-up time was 50 ± 149 weeks. The causative pathogens were identified in 35 patients (40.2%), with the highest frequency being bacteria. The most common bacterium was Pseudomonas aeruginosa (n = 13), and the most common fungus was Aspergillus sp. (n = 5). Fifteen patients achieved (17.2%) final visual acuity (VA) of hand motion or better after treatment. Eyeball removal was performed in 61 (70.1%) patients. From multivariate analysis, the only prognostic factor for poor final VA (worse than hand motion, HM) was poor VA (worse than HM) at the initial visit (relative risk 1.97, 95% confidence interval 1.15–3.36, p = 0.013). KSE is uncommon but has a devastating outcome. We found that the patient’s initial VA was the only predictor for their final vision. P. aeruginosa was the most common identifiable organism in this study. However, several fungal infections were recognised. These findings should raise awareness for treatment of KSE in the tropics.

Cluster of Post-Operative Endophthalmitis Caused by Acanthamoeba T10 Genotype - A First Report

PURPOSE

To report a cluster of postoperative Acanthamoeba endophthalmitis after routine cataract surgeries.

METHODS

A brief summary of sentinel events leading to the referral of 4 patients of postoperative endophthalmitis to our hospital is followed by clinical descriptions and the various diagnostic approaches and interventions used. Genotyping and phylogenetic analysis are also discussed.

RESULTS

Four cases of postoperative cluster endophthalmitis, presumed to be bacterial and treated as such, were referred to our hospital. The presence of an atypical ring infiltrate in the first case facilitated the diagnosis of Acanthamoeba endophthalmitis. All patients had vitritis, corneal involvement, and scleral inflammation. Multiple diagnostic methods, such as corneal scrapings, confocal microscopy, aqueous and vitreous taps, scleral abscess drainage, histopathological studies, polymerase chain reaction, and genotyping and phylogenetic analyses of isolated Acanthamoeba, were used to confirm the diagnosis of endophthalmitis and to establish the extent of ocular involvement. Various medical and therapeutic interventions used to control the infections were also documented. The isolated Acanthamoeba were confirmed as belonging to the T10 genotype, an environmentally and clinically rare variety.

CONCLUSIONS

This is the first report of a cluster of postoperative T10 genotype Acanthamoeba endophthalmitis, occurring after routine cataract surgery in immunocompetent individuals. Contrary to current perceptions, a rapidly evolving infection can occur with Acanthamoeba.

Bilateral Acanthamoeba Panophthalmitis: A rare and unique case

Purpose

To describe a unique case of bilateral Acanthamoeba panophthalmitis in a 65-year-old male resulting in bilateral enucleation.

Observation

A 65-year-old man presented with a 10-year history of bilateral uveitis and scleritis, complicated by cataracts. He had undergone phacoemulsification with posterior chamber intraocular lens implantation in both eyes, left corneal transplant and pars plana vitrectomy, all without improvement in his vision and pain. Due to complete loss of vision and severe pain in his both eyes, the patient underwent bilateral enucleation. Pathologic examination of both eyes revealed severe acute, chronic, and granulomatous inflammation with abundant scar formation. Multiple large pre-retinal, choroidal, and vitreal cavitary lesions in both eyes were filled with necrotic debris, containing both Acanthamoeba trophozoites and cysts. These findings were consistent with a well-developed, bilateral Acanthamoeba panophthalmitis.

Conclusions and importance

This unique case represents the first ever reported bilateral Acanthamoeba panophthalmitis and illustrates the extreme complication of ocular Acanthamoeba infection.

Fulminant Acanthamoeba Endophthalmitis After Cataract Surgery-A Case Report

PURPOSE

To report a case of Acanthamoeba endophthalmitis after an uneventful cataract surgery.

METHODS

Description, management, and outcomes of a biopsy-proven case of Acanthamoeba endophthalmitis.

RESULTS

Two days after a routine cataract surgery elsewhere, the patient presented with acute endophthalmitis diagnosed as a bacterial infection based on timing and severity. When conventional methods of management failed, the patient was referred to us. Only the presence of an atypical ring infiltrate suggested Acanthamoeba as a probable cause. Subsequent diagnostic evaluations confirmed the initial suspicion. Management with topical antiamoebics and intracameral and intravitreal voriconazole was attempted. Systemic voriconazole and metronidazole were also administered. However, because of relentless disease progression, the eye had to be eviscerated. The cornea, aqueous, vitreous, and sclera were positive by culture and/or polymerase chain reaction and histopathology.

CONCLUSIONS

Acanthamoeba usually causes a chronic smoldering keratitis and, very rarely, scleritis. This report, which is the first of its kind, emphasizes the fact that fulminant endophthalmitis with associated scleritis can occur after ocular surgery in an immunocompetent individual, with no significant ophthalmic history.

Outcome of therapeutic deep anterior lamellar keratoplasty in advanced Acanthamoeba keratitis

Purpose

To report and analyze the outcomes of therapeutic deep anterior lamellar keratoplasty (DALK) in patients with advanced Acanthamoeba keratitis (AK).

Methods

Medical records of microbiologically confirmed AK, underwent DALK from 2004 to 2017, were reviewed and the data related to early and late outcome including complications were retrieved. Outcome of cases with largest diameter of infiltrate ≥8 mm at the time of surgery (advanced keratitis) were analyzed and compared with those with less severe keratitis (infiltrate size less than 8 mm).

Results

Out of 23 patients of AK in whom DALK was performed, ten (43.4%) patients had advanced keratitis. Mean age of these patients was 38.7 ± 8.6 years (range, 25 to 56). Median visual acuity at presentation was 2.78 (IQR, 1.79-3.0) that improved to 1.79 (IQR, 0.70-2.78) postoperatively. Early complications included recurrence of AK in 2 (20%), Descemet's membrane detachment in 5 (50%), and persistent epithelial defect in 3 (30%) cases. Overall, 6 (60%) grafts failed, whereas 4 (40%) patients had clear graft at their last follow-up. Median follow-up of these cases was 5 months (IQR, 1.4-11.4). One graft developed stromal rejection, which resolved with increased dose of corticosteroids. In comparison, DALK performed for less severe keratitis (N = 13) had 1 (7.6%) recurrence and 2 (15.8%) grafts failure (OR, 8.25). The probability of one-year graft survival and eradication of infection was 32% and 74.1%, respectively, in advanced cases compared to 91.6% and 83.9% in less severe cases.

Conclusion

Outcome of DALK in advanced Acanthamoeba keratitis is less favorable compared to those carried out for less severe keratitis cases.

High fluence PACK-CXL as adjuvant treatment for advanced Acanthamoeba keratitis

Purpose

To describe the outcome of adjuvant high fluence photoactivated chromophore for infectious keratitis cross-linking (PACK-CXL) used to treat an advanced form of refractory Acanthamoeba keratitis (AK) diagnosed several months after initial presentation.

Observations

An otherwise healthy 24-year old female presented with a severe unilateral keratitis. The diagnosis eluded clinicians for several months and when finally confirmed as AK, anti-amoebic therapy was instated and only appeared to be effective after addition of high fluence PACK-CXL.

Conclusion and importance

In this case of advanced AK, high fluence PACK-CXL treatment given adjuvant to pharmacologic anti-amoebic therapy resulted in lasting pain relief, re-epithelization and eradication of the Acanthamoeba parasite. Given adjuvant to anti-amoebic pharmacotherapy, high fluence PACK-CXL might be a useful method for treating typically refractory advanced AK.

Acanthamoeba endophthalmitis during treatment for cutaneous disease in a renal transplant patient

Acanthamoeba infections are difficult to diagnose and treat. We present a renal transplant patient who developed Acanthamoeba endophthalmitis on therapy with posaconazole and miltefosine for cutaneous acanthamobiasis. The patient was maintained on intracameral voriconazole injections, and oral azithromycin, fluconazole, and flucytosine. This case highlights novel presentations and treatments for acanthamoebic infection.

Orbital implant exposure after Acanthamoeba panophthalmitis

Purpose

Acanthamoeba is a protozoa that can lead to severe ocular disease and sequelae. Although intraocular Acanthamoeba infection is rare, the following case demonstrates an unusual presentation of recurrent Acanthamoeba infection in a 30 year old contact lens wearing male.

Observations

After presenting with recurrent Acanthamoeba keratitis and undergoing various treatments, the patient developed nodular scleritis, which evolved into panophthalmitis, and ultimately, required enucleation. Eight months post-operatively, the patient developed orbital implant exposure secondary to persistent Acanthamoeba infection and underwent removal of the implant and aggressive, systemic treatment involving a multispecialty care team. He then underwent placement of a dermis fat graft and had no signs of persistent infection at the time of last follow-up, which was 24 months after placement of the dermis fat graft.

Conclusions

and Importance: To the authors' knowledge, this is the first known case of Acanthamoeba infection causing orbital implant exposure. Persistent infection should be considered in Acanthamoeba patients who have undergone enucleation and have orbital implant exposure. Better knowledge regarding the pathogenesis and extracorneal complications of this challenging disease may improve patient care and outcomes.

Associated factors, diagnosis and management of Acanthamoeba keratitis in a referral Center in Southern China

BACKGROUND

To analyse the associated factors, diagnosis, clinical manifestations and therapeutic effects of Acanthamoeba keratitis at a tertiary ophthalmic centre in Southern China.

METHODS

A retrospective clinical study was performed in fifteen patients who were admitted to Zhongshan Ophthalmic Centre (ZOC) from January 2004 to December 2014. The patients' pathogenesis-associated factors were analysed, and preoperative diagnoses were determined using corneal scraping cultures and/or confocal microscopy followed. All diagnoses were confirmed by postoperative pathological examinations. At follow-up, best-corrected visual acuity (BCVA), the recurrence rate and graft transparency were evaluated to assess therapeutic effects.

RESULTS

The main pathogenic factors observed in the fifteen patients were a history of injury or a foreign body entering the eyes (12 cases). In all, Acanthamoeba keratitis was preoperatively diagnosed in 5 cases using corneal scraping cultures or confocal microscopy. Ocular symptoms included redness, photophobia, tearing, and blurred vision. Penetrating keratoplasty was performed in thirteen patients, and postoperative pathological examinations were performed to confirm these diagnoses. The logarithm of the minimum angle of resolution (logMAR) of visual acuity was significantly improved after keratoplasty (p < 0.01). No recurrence was observed, and approximately 90% of the corneal grafts were found to be transparent during the follow-up period.

CONCLUSIONS

Corneal trauma may be the main pathogenic factor that causes Acanthamoeba keratitis in southern China. Corneal scraping combined with confocal microscopy was helpful for achieving a correct diagnosis. Early keratoplasty combined with amoebicidal therapy is an effective treatment strategy in Acanthamoeba keratitis.

ACANTHAMOEBA ENDOPHTHALMITIS AFTER RECURRENT KERATITIS AND NODULAR SCLERITIS

PURPOSE

To describe the clinical course of a patient with Acanthamoeba keratitis, who despite prompt treatment progressed to histopathology-confirmed Acanthamoeba retinitis and endophthalmitis.

METHODS

Case report.

RESULTS

A healthy 30-year-old male wearing soft contact lens was diagnosed with Acanthamoeba keratitis and treated medically and surgically over the course of 1 year with presumed resolution of the infection. Yet, his infection recurred with documented spread to sclerokeratitis, and overwhelming endophthalmitis. Concerns about extra-ocular spread prompted a therapeutic enucleation with histopathologic evidence of Acanthamoeba organisms throughout the globe.

CONCLUSION

This is a case of a severe recurrent Acanthamoeba infection presenting initially as keratitis, followed by sclerokeratitis and histolopathology-confirmed endophthalmitis. This case demonstrates that despite persistent medical and surgical intervention, eradication of organisms may not be possible.

Risk factors for endophthalmitis requiring evisceration or enucleation

Endophthalmitis has devastating sequelae resulting in blindness and even loss of eyeball. Although the prognosis of endophthalmitis has much improved with the advances of antibiotics and vitreoretinal surgery, of the number of patients that required evisceration or enucleation is still significant. We retrospectively reviewed the charts of 210 eyes of 210 patients with endophthalmitis andcompared the group that required evisceration or enucleation with those that received salvaging therapies. Regression analysis was used to identify the risk factors for evisceration or enucleation. Thirty eyes (14.3%) underwent enucleation or evisceration. The group of eviscerated or enucleated eyes were older (58.7 vs. 42.2 years, p < 0.001), had more women (56.7% vs. 22.2%, p = 0.003), had poorer initial visual acuity (2.79 vs. 2.10 LogMAR, p < 0.001), and had longer duration before intervention (18.03 vs. 5.74 days, p = 0.031). The most common primary indications for endophthalmitis were infections from corneal ulcer (50.0% vs. 4.4%, p < 0.001) andfrom endogenous source (23.3% vs. 5.6%, p < 0.001). Less common indications were trauma (26.7% vs. 67.8%, p < 0.001) and postoperative (6.7% vs. 22.2%, p = 0.049) endophthalmitis. After adjusting for confounding factors, corneal ulcer-related endophthalmitis, endogenous endophthalmitis and initial visual acuity were the independent risk factors for evisceration or enucleation.

Infectious keratitis progressing to endophthalmitis: a 15-year study of microbiology, associated factors, and clinical outcomes

PURPOSE

To describe the incidence, microbiology, associated factors, and clinical outcomes of patients with infectious keratitis progressing to endophthalmitis.

DESIGN

Nonrandomized, retrospective, consecutive case series.

PARTICIPANTS

All patients treated for culture-proven keratitis and endophthalmitis between January 1, 1995 and December 31, 2009, at the Bascom Palmer Eye Institute.

METHODS

Ocular microbiology and medical records were reviewed on all patients with positive corneal and intraocular cultures over the period of the study. Univariate analysis was performed to obtain P values described in the study.

MAIN OUTCOME MEASURES

Microbial isolates, treatment strategies, and visual acuity (VA) outcomes.

RESULTS

A total of 9934 corneal cultures were performed for suspected infectious keratitis. Only 49 eyes (0.5%) progressed to culture-proven endophthalmitis. Fungi (n = 26) were the most common responsible organism followed by gram-positive bacteria (n = 13) and gram-negative bacteria (n = 10). Topical steroid use (37/49 [76%]) was the most common associated factor identified in the current study, followed by previous surgery (30/49 [61%]), corneal perforation (17/49 [35%]), dry eye (15/49 [31%]), relative immune compromise (10/49 [20%]), organic matter trauma (9/49 [18%]), and contact lens wear (3/49 [6%]). There were 27 patients in whom a primary infectious keratitis developed into endophthalmitis, and 22 patients in whom an infectious keratitis adjacent to a previous surgical wound progressed into endophthalmitis. Patients in the primary keratitis group were more likely to be male (22/27 [81%] vs 8/22 [36%]; P = 0.001), have history of organic matter trauma (8/27 [30%] vs 1/22 [5%]); P = 0.030), and have fungal etiology (21/27 [78%] vs 5/22 [23%]; P<0.001). Patients in the surgical wound-associated group were more likely to use topical steroids (20/22 [91%] vs 17/27 [63%]; P = 0.024). A VA of ≥ 20/50 was achieved in 7 of 49 patients (14%), but was <5/200 in 34 of 49 (69%) at last follow-up. Enucleation or evisceration was performed in 15 of 49 patients (31%).

CONCLUSIONS

Progression of infectious keratitis to endophthalmitis is relatively uncommon. The current study suggests that patients at higher risk for progression to endophthalmitis include patients using topical corticosteroids, patients with fungal keratitis, patients with corneal perforation, and patients with infectious keratitis developing adjacent to a previous surgical wound. Patients with sequential keratitis and endophthalmitis have generally poor visual outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Endophthalmitis: A review of recent trends

Endophthalmitis is a feared complication of trauma, surgical procedures and septicemia. Although uncommon, its potential for significant visual loss is well recognized. Especially over the past decade, complicated surgeries and medical techniques have increased and seriously ill patients are being sustained in ever increasing numbers. New pathogens are being recognized and known ones reclassified thanks to advances in molecular analysis. Continuously evolving PCR methodologies also add a new dimension to the diagnosis of infectious endophthalmitis. As well, medical literature is now truly international, encompassing studies from around the world that expand our understanding of ocular infectious disease. This report reviews some of these changes as they relate to endophthalmitis and particularly to the spectrum of organisms involved.