[Postoperative endophthalmitis-a review of literature]

Susceptibility of Ocular Surface Bacteria to Various Antibiotic Agents in a Romanian Ophthalmology Clinic

Periodic assessment of bacterial contamination is necessary as it allows proper guidance in cases of eye infections through the use of appropriate antibiotics. Due to the extensive use of antibiotic treatment, many strains of the microbiota that cause infections are resistant to the usual ophthalmic antibiotics. The present study provides an updated assessment of the susceptibility of Gram-positive and Gram-negative bacteria found on the ocular surface to the most commonly used antibiotic agents in patients undergoing cataract surgery. A total of 993 patients were included in the study with ages between 44 and 98 years old. Conjunctival cultures were collected 7 days before cataract surgery. The response of Gram-positive and Gram-negative bacteria to various antibiotic classes, such as glycopeptides, cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, phenicols, tetracyclines, rifamycins, macrolides and penicillins, was assessed. From the tested antibiotics, vancomycin had 97.8% efficacy on Gram-positive bacteria. In the cephalosporin category, we observed a high level of resistance of the cefuroxime for both Gram-positive and negative bacteria. Antibiotics that have more than 90% efficacy on Gram-positive bacteria are meropenem, imipenem, netilmicin, amikacin and rifampicin. On Gram-negative bacteria, we found 100% efficacy of all tested fluoroquinolones, i.e., aminoglycosides (except for tobramycin), doxycycline, azithromycin, clarithromycin and chloramphenicol. The current study illustrates patterns of increased resistance in certain bacteria present on the ocular surface to some of the commonly used antibiotics in ophthalmological clinical practice. One such revealing example is cefuroxime, which has been highly used as an intracameral antibiotic for the prevention of bacterial endophthalmitis after cataract surgery.

[Functional results and complications in the long-term follow-up after 25-gauge vitrectomy of epiretinal membrane]

BACKGROUND

Idiopathic epiretinal membranes can lead, among other things, to visual impairment and metamorphopsia. The treatment of choice is a pars plana vitrectomy with removal of the membrane. The improvement of visual acuity and postoperative complications have already been described in several studies.

OBJECTIVE

The aim of this retrospective study is to evaluate the long-term outcome of at least 3 years.

MATERIAL AND METHODS

In the period from 2011 to 2016, a total of 667 eyes underwent 25-gauge pars plana vitrectomy, membranectomy and peeling of the ILM (Internal limiting membrane) because of epiretinal membrane by the same surgeon. This study included 51 eyes from 51 patients who had returned to our clinic after at least 3 years. For the follow-up, data were collected after 3 months and then annually, if available. The mean follow-up time was 57 months (37-104 months). In the postoperative follow-up visual acuity, intraocular pressure and complications were recorded.

RESULTS

Of the 51 eyes included 34 had a 25-gauge pars plana vitrectomy with phacoemulsification and artificial lens implantation, 8 eyes without phako and 9 eyes were already pseudophakic. The most common complication in the follow-up period was a persistent macular edema with 5.9% (3 eyes) and a recurrence of epiretinal membrane in 5.9% of cases. The best corrected logMar visual acuity was 0.4 (0.1-1.3; n = 51) preoperatively, at the last examination 0.23 (0-1.0; n = 51, p < 0.001). Three months postoperatively, the logMar visual acuity was 0.29 (n = 41), after 1 year 0.25 (n = 35), 2 years 0.23 (n = 29), after 3 years 0.26 (n = 29), after 4 years 0.27 (n = 27), after 5 years 0.24 (n = 17) and after 6 years 0.24 (n = 13).

CONCLUSION

The 25-gauge pars plana vitrectomy is a low complication procedure for the removal of epiretinal membranes. The clearest increase in visual acuity can be seen within the first 3 months postoperatively, but then stabilizes. In the long-term follow up a change in visual acuity can also be found after more than 3 years.

Delayed Bacterial Endotheliitis and Endophthalmitis 11 Years after Cataract Surgery

Infective endophthalmitis is an uncommon complication following intraocular surgery. Chronic endophthalmitis may present some time after intraocular surgery, making the diagnosis challenging. Cutibacterium acnes is a well-recognised causative agent of these chronic infections. Practitioners should be aware of the conditions required to culture this slow-growing organism. We report a case of delayed low-grade endophthalmitis presenting 11 years after cataract surgery. Cutibacterium acnes and Staphylococcus warneri were cultured from Descemet's membrane biopsy following three failed previous attempts at microbiological studies. Clinical features of the infection included discrete white granules on the iris, endothelium, and within the capsular bag of the patient's right eye. The patient presented with no signs of systemic infection and the left eye was normal on examination. Bullous keratopathy, secondary to endothelial dysfunction was a feature of this infection. This retrospective case report illustrates the prolonged periods for which Cutibacterium acnes can remain latent before causing clinical signs. While uncommon, endothelial involvement may occur and clinicians should consider low-grade infective endophthalmitis in cases with corneal oedema.

[Ophthalmopathologic Aspects of Endophthalmitis]

Endophthalmitis is one of the most severe ophthalmic emergencies. Most patients experience a permanent decrease in visual acuity after the event, but the eye can be preserved in most cases. However, when the eye is enucleated after endophthalmitis, ophthalmopathologic investigation of the globe with respect to the clinical history can provide valuable information regarding the ultimately frustrating course of the disease that can be helpful for the treatment of future patients. Often, valuable aspects also emerge with regard to the therapeutic approach. For example, in therapy-resistant fungal endophthalmitis the necessity of penetrating keratoplasty with a large graft diameter and possibly even removal of the lens including the capsular bag should be stressed. In the following, five enucleated eyes with a different spectrum of endophthalmitis, as well as different potential pathways of exogenous and endogenous endophthalmitis, are illustrated clinically and ophthalmopathologically. In summary, endophthalmitis requires urgent intervention; however, various differential diagnoses must be excluded. Histopathologic examination of enucleated eyes is helpful for understanding the course of the disease and may also have forensic significance.

[Treatment of postoperative endophthalmitis : Operate or only inject?]

BACKGROUND

Postoperative endophthalmitis is among the most feared complications encountered after intraocular surgery. A prompt diagnosis and initiation of treatment are crucial for the visual prognosis, which also depends on the causative microorganism. Despite advances in prevention and the availability of more epidemiological data, most of the evidence for treatment dates back to a single study, the early vitrectomy study (EVS) carried out in the early 1990s. The EVS showed that vitrectomy with intravitreal antibiotics was superior to intravitreal antibiotics alone, only when visual acuity was light perception or below. The addition of systemic antibiotics did not have any benefits. Over the last 30 years, however, surgical techniques have continued to evolve and the medicinal options have also been expanded. Moreover, the EVS examined only endophthalmitis after cataract surgery and strictly speaking the results cannot be transferred to endophthalmitis from other causes.

OBJECTIVE

This review discusses the current evidence for the different treatment modalities of the most important types of postoperative endophthalmitis.

CONCLUSION

The EVS provided important guidelines for the initial management of endophthalmitis and these guidelines remain relevant to this day; however, in view of the refinement of surgical techniques, novel treatment options, especially the nowadays continuously growing number of intravitreal injections and even some new antibiotics, it would be desirable if new controlled trials addressing the treatment of endophthalmitis would be performed.