Effectiveness of immediate vitrectomy and intravitreal antibiotics for post-injection endophthalmitis

Evaluating the efficacy of pars plana vitrectomy in the management of endophthalmitis after following the endophthalmitis vitrectomy study: A systematic review and meta-analysis

Endophthalmitis is a devastating eye complication that requires prompt and effective treatment. A pivotal study in the field of endophthalmitis treatment is the endophthalmitis vitrectomy study (EVS), conducted over a decade ago. The primary objective of this study was to assess the effectiveness of pars plana vitrectomy (PPV) as a treatment option for endophthalmitis following the EVS study. We conducted a comprehensive search across three databases: PubMed, EBSCO host, and ProQuest. Reference lists of published articles were searched. Our study encompassed research conducted between January 2013 and January 2023 to ensure the most up-to-date findings. The best-corrected visual acuity (BCVA) in logMar, causative agents, and predicting factors for visual outcome were evaluated. Nine studies involving 351 eyes were included in the study; however, only eight were included in the meta-analysis. We observed a significant BCVA improvement compared to baseline at 1 month, >1-3 months, >3-6 months, and ≥12-month follow-up, with mean differences of 1.06 (P < 0.001), 1.25 (P < 0.001), 1.41 (P < 0.001), and 1.01 (P < 0.001), respectively. A causative organism was cultured in 61.4% of cases, and the majority of them were Coagulase-negative Streptococcus, Staphylococcus aureus, and Streptococcus sp. Factor associated with better visual acuity includes a younger age, lower intraocular pressure, and culture-negative endophthalmitis. Meanwhile, culture-positive endophthalmitis particularly Streptococcus sp., lower baseline vision, and presence of retinal detachment at initial presentation were identified as a prognostic for poorer visual outcome. PPV demonstrated a significant visual gain in patients with endophthalmitis in the 1st, 3rd, and 6th months. However, caution is warranted in drawing a definitive conclusion.

[Surgical therapy and pathogen detection in endogenous endophthalmitis : Analysis of data from five German eye hospitals]

BACKGROUND

Endogenous endophthalmitis results from hematogenous spread of bacterial or fungal infection in severely diseased patients. Specific systemic and intraocular therapy is required. The basis for this treatment is causal pathogen detection in blood culture or vitreous sample. However, functional results are limited.

OBJECTIVE

The current article provides practical hints for surgical therapy and pathogen detection in patients with endogenous endophthalmitis.

METHODS

A retrospective analysis of anonymous data of 68 male and female patients from 2018-2023 from five ophthalmology clinics in Germany was performed.

RESULTS

Mean age of affected patients was 71.4 years (31-96 years). Surgical therapy included pars plana vitrectomy (ppV) and intravitreal injection (IVOM). In 44 of 68 patients (65%), 1-3 surgeries were performed, 4-6 surgeries were required in 14/68 (21%) of patients, and 10 or more surgeries were required in 4/68 patients (6%). Pathogen detection was possible in 34% of vitreous specimens and in 11% of anterior chamber samples. Mean initial visual acuity was logMAR 1.5. After treatment and a mean follow-up of 2.5 months, mean visual acuity was logMAR 1.3. Preanalytical methods for specimen collection like the Freiburg endophthalmitis set to optimize pathogen detection are presented.

CONCLUSION

Severe inflammatory intraocular reactions in endogenous endophthalmitis necessitate a combination of ppV and repeated IVOM. In addition to providing a vitreous sample, ppV also serves to remove inflammatory fibrin membranes. Early pars plana vitrectomy with specific antibiotic or antifungal therapy should be sought in addition to the focus search and systemic therapy.

Visual outcome of 25 Gauge vitrectomy for acute post operative infectious endophthalmitis

BACKGROUND

The correlation between the change in foveal thickness measured using optical coherence tomography (OCT) following surgery for infectious endophthalmitis and preoperative and postoperative visual acuity is uncertain, and there are few pertinent studies on this topic.

OBJECTIVE

We explored the variations in macular thickness using OCT after emergency vitrectomy for post-cataract infectious endophthalmitis and the relationship between macular thickness with changes in visual function.

METHODS

We included 10 cases of post-cataract infectious endophthalmitis. Each patient underwent 25-G vitrectomy.

RESULTS

The infection in all 10 patients was under control and visual function improved. Postoperative vitreous humor culture was positive in 8 patients, including 7 cases of coagulase-negative Staphylococcus epidermidis and 1 case of Lactobacillus acidophilus. The average age of these 10 patients was 71.60 ± 8.71 years (P< 0.05, two-tailed). There was no significant correlation between time 2 (the time of onset after cataract surgery) and visual prognosis. The average time 1 (the time of the vitrification surgery caused by the onset of the disease) was 1.45 ± 0.76 days (P< 0.05, two-tailed). The postoperative 3dVA ranged from 0.20 to 3.00, with an average visual acuity of 1.87 ± 1.12, which was superior to the preoperative value (P< 0.01, two-tailed). The correlation between the post3dVA and post 1mVA was significant. The post 1mVA ranged from 0.05 to 2.20, with an average visual acuity of 0.94 ± 0.74 (P< 0.05, two-tailed). The correlation between post 1mVA and post3mVA was significant. Also, paired t-tests comparing preoperative and postoperative visual acuity revealed a significant correlation (P< 0.05, two-tailed). The post3mVA was 0-1.00 with an average visual acuity of 0.44 ± 0.41. The postoperative foveal thickness ranged from 176.00 to 514.00 μm, with an average thickness of 281.10 ± 113.12 μm.

CONCLUSION

Emergency 25-G minimally invasive vitrectomy can improve visual acuity and decrease the reoperation rate for patients who have acquired post-cataract infectious endophthalmitis. There were significant correlations between age, disease onset to operation time, preoperative and postoperative visual acuity, and postoperative macular thickness.

Management and Prognosis of Acute Post-Cataract Surgery Endophthalmitis: A 10-Year Retrospective Analysis in Eastern China

Acute post-cataract surgery endophthalmitis (APSE) is a serious vision-threatening complication of cataract surgery. Analysis of the management and prognosis in cases of APSE may provide better guidance for future treatment. Fifty-six patients (56 eyes) diagnosed with APSE between 2013 and 2022 were retrospectively reviewed. The incidence of APSE rate was 0.020% (95% CI: 0.011-0.029%). Intraocular cultures were positive in 18 (32.1%) cases, with 21 organisms isolated. Coagulase-negative staphylococci was the predominant isolate (12/21; 57.1%). The time from surgery to the onset of endophthalmitis was 7 days (interquartile range: 3-16) in patients with good best-corrected visual acuity (BCVA) (≥20/70) and 3 days (interquartile range: 1-8) in those with poor BCVA (<20/70). Multivariate linear regression analysis revealed that initial BCVA (logMAR) (p < 0.001), time from onset to initial intravitreal antibiotics (IVAs) (p < 0.001), and positive culture of highly virulent pathogens (p = 0.018) displayed significantly positive associations with the final BCVA (logMAR). Adjunctive use of intravitreal corticosteroids and systemic antibiotics were unrelated to a favorable final BCVA. In conclusion, the severity of the visual condition at baseline, as well as delayed treatment, are risk factors for poor visual outcomes in APSE.

Early Vitrectomy with Silicone Oil Tamponade in the Management of Postoperative Endophthalmitis

Background: Early vitrectomy for postsurgical endophthalmitis may improve visual acuity outcomes. Silicone oil as a tamponade has some potential benefits in the management of endophthalmitis. This study aims to evaluate the use of a silicone oil tamponade in the surgical management of endophthalmitis. Material and Methods: All patients with a pars plana vitrectomy with silicone oil tamponade for postsurgical endophthalmitis at the Department of Ophthalmology, University of Bonn, Germany, between 2017 and 2021 were retrospectively reviewed. We included all preoperative data, including BCVA at diagnosis, clinical findings, and symptoms. For every follow-up visit, we looked at BCVA and complications. Results: In total, 82 patients were included in this study. The mean follow-up was 13.1 months (range 1-58 months). An intravitreal injection was the cause in 42 patients (51.2%) and cataract surgery in 29 patients (35.4%). The mean interval between the causing event and the date of onset was 8.8 days (range, 1-59 days). The most prevalent pathogen was Staphylococcus epidermidis in 16 patients (19.5%). In 47 patients (57.3%), no pathogen was found. The initial best-corrected visual acuity was 2.1 logMAR and improved significantly to 1.0 logMAR after six months (p < 0.001) and 1.1 logMAR after 1 year (p < 0.001). In a multivariate analysis, a low BCVA at diagnosis (p = 0.041) was a significant predictor for poor visual acuity outcomes. A total of 17 patients (20.1%) developed postoperative complications. Five patients (6.1%) needed an anterior chamber washout with repeated injections of antibiotics. Two patients (2.4%) had persistent fibrin and were treated with YAG-laser treatment. Three patients (6.7%) developed a retinal detachment. Two patients (2.4%) had persistent corneal decompensation with endothelial cell loss and received perforating keratoplasty. We performed a matched-pair analysis (n = 30, each group n = 15) to compare a silicone oil tamponade with BSS at the end of surgery. The visual acuity outcome showed no significant differences (BCVA after one year: 1.17 logMAR in eyes with silicone oil and 0.90 logMAR in eyes with BSS; p = 0.684). Conclusions: In our study, a vitrectomy with silicone oil tamponade in the surgical management of postoperative endophthalmitis led to a significant improvement in visual acuity and had a low complication rate. Low BCVA at diagnosis was significantly associated with poor visual acuity outcomes. A comparison of silicone oil and BSS at the end of surgery showed similar results.

Preventive factors, diagnosis, and management of injection-related endophthalmitis: a literature review

BACKGROUND

Intravitreal medication injections represent the gold standard treatment for a variety of potentially blinding chorioretinal vascular diseases. Despite their excellent safety profile, they are associated with the feared complication of injection-related endophthalmitis (IRE). Though the overall incidence of IRE is low, due to the ever-increasing number of injections being performed, it is a complication that all retina specialists are likely to encounter. This article reviews various factors that could potentially influence the risk of IRE and discusses evidence-based strategies for management.

METHOD

PubMed was searched for keywords "intravitreal injection" and "endophthalmitis" from the period of 1995-2021. Relevant articles were reviewed and selected articles were analyzed with respect to the incidence, potential preventive factors, clinical presentation, microbial profile, management, and outcomes for IRE.

RESULTS

There is strong consensus supporting the use of povidone iodine topical antiseptic, eyelid retraction away from the injection site, and avoiding treatment of eyes with active surface or eyelid disease, but there is less agreement on the use of face masks versus "no-talking" policies and optimal anesthetic technique. Current evidence comparing tap and inject or early vitrectomy for treatment of IRE is inadequate to determine an optimal treatment strategy.

CONCLUSION

Intravitreal injections are sight saving, but even using established prophylactic measures there remains a small but real risk of infectious injection-related complications. Further investigations comparing tap and inject versus vitrectomy may help to establish optimal treatment, although the rarity of IRE makes designing adequately powered prospective trials a difficult task.