The Role of Systemic Antimicrobials in the Treatment of Endophthalmitis: A Review and an International Perspective

Are Treatment Patterns for Endophthalmitis After Cataract Surgery Following the EVS Trial Recommendations? An IRIS® Registry Analysis

OBJECTIVE

Evaluate whether treatment patterns for endophthalmitis after cataract surgery in American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) patients are in line with evidence-based guidelines established by the 1995 Endophthalmitis Vitrectomy Treatment Study (EVS), which showed that patients who present with light perception vision (LP) have better visual outcomes with immediate vitrectomy (VIT) compared with vitreous tap with antibiotic injection (TAP).

DESIGN

Retrospective cohort study SUBJECTS: IRIS Registry patients undergoing cataract surgery between 2014 and 2022 (identified by CPT codes), presenting with endophthalmitis (identified by ICD 10 codes) within 42 days post-cataract surgery, and having a record of being treated with VIT or TAP on the same or one day following endophthalmitis diagnosis were identified.

METHODS

Potential covariates of age, sex, race, ethnicity, geographic region, insurance status, and visual acuity on the day of endophthalmitis diagnosis were evaluated using multivariable logistic regression.

MAIN OUTCOME MEASURE

Treatment with VIT or TAP RESULTS: Of the 2425 patients who met the inclusion criteria, 14% (345) underwent VIT and 86% (2080) underwent TAP. 80% of patients (1946) presented with endophthalmitis within 14 days from cataract surgery (median = 6 days). Notably, 66% (173/263) of the patients presenting with LP vision underwent TAP instead of VIT. In a multivariable logistic regression model, receiving VIT instead of TAP was positively associated with poor vision at endophthalmitis presentation (LP - OR, 5.3 [CI: 2.9-10.5]; Counting Fingers, Hand Motion - OR 1.8 [CI: 1.0-3.6]) vs. [20/20-20/40] vision; Asian vs. White race (OR, 2.6 [CI: 1.2-5.1]); Hispanic vs. Non-Hispanic ethnicity (OR, 1.9 [CI, 1.0-3.2]); living in the West (OR, 1.5 [CI, 1.1-2.2]) and Midwest (OR- 1.4 [CI, 1.0-2.0]) (vs. South), but not with age, sex, and insurance coverage (P>0.05).

CONCLUSIONS

In the IRIS Registry, treatment patterns for post-cataract surgery endophthalmitis did not match evidence-based recommendations of the EVS, a randomized controlled clinical trial. More work is needed to evaluate whether the current treatment patterns are optimal for patients with post-cataract surgery endophthalmitis.

Antibiotic susceptibility in Endophthalmitis Management Study and intravitreal antibiotic practice trend in India-EMS Report #5

AIM

Analyze antibiotic susceptibility in the Endophthalmitis Management Study (EMS) and compare it with the current intravitreal antibiotic practice trend of members of the Vitreoretinal Society of India (VRSI) practicing in India.

METHODS

The microbiology work-up of undiluted vitreous included microscopy, culture-susceptibility, polymerase chain reaction (PCR), and next-generation sequencing (NGS). VRSI members were invited to the survey. The EMS conventional culture-susceptibility (PCR and NGS excluded) results were compared vis-a-vis gram-positive cocci (GPC), gram-negative bacilli (GNB), and less commonly used antibiotics with the current recommended intravitreal antibiotics. p < 0.05 was considered significant.

RESULTS

Culture and positivity (culture + PCR/NGS) positivity was 28.8% and 56.1%, respectively. GPC was most susceptible to cefazolin, linezolid, and vancomycin; GNB was most susceptible to amikacin, ceftazidime, colistin, and imipenem. There was no susceptibility difference between cefazolin and vancomycin (p = 0.999) and between ceftazidime and imipenem (p = 1.0). Colistin was superior to ceftazidime (p = 0.047) against GNB. The GNB resistant to amikacin (n = 14) were equally susceptible to ceftazidime and colistin; resistant to ceftazidime (n = 16) were susceptible to colistin; and resistant to colistin (n = 7) were susceptible to ceftazidime. The preference of VRSI members (n = 231) practicing in India was a vancomycin-ceftazidime combination (82%), vancomycin for GPC (94%), ceftazidime for GNB (61%), and voriconazole for fungi (74%).

CONCLUSION

In EMS, GPC had good susceptibility to vancomycin; GNB had good susceptibility to ceftazidime and colistin. Given the lower resistance of colistin, a vancomycin-colistin combination could be an alternative empiric treatment in post-cataract endophthalmitis in India.

Clinical Insights: Antimicrobial Therapy for Infectious Uveitis

Infectious uveitis is a major global cause of vision impairment. Despite the eye's immune privilege, afforded by the blood-ocular barrier that restricts microbial entry, several pathogens such as bacteria, viruses, fungi, and parasites can still infiltrate and cause ocular infections and complications. Clinicians often encounter significant challenges in treating infectious uveitis due to limited or ineffective treatment options. Modern molecular techniques and imaging can aid in diagnosing and assessing intraocular infections. Various antimicrobial therapies exist, spanning topical and systemic treatments, but these are constrained by issues like drug concentration, penetration, effective duration, toxicity, and side effects. Treatment approaches also differ based on the infection's etiology. This review provides recent updates on antimicrobial therapies from a clinical perspective, covering topical, systemic, and regional treatments for infectious uveitis.

New Approaches to Overcoming Antimicrobial Resistance in Endophthalmitis

Endophthalmitis is a rare but vision-threatening infection characterized by marked inflammation of intraocular fluids and tissues, uncommonly seen following surgery and intravitreal injection. Antimicrobials are used worldwide in the prophylaxis and treatment of bacterial and fungal infections of the eye and are standard treatment in the preoperative and postoperative care of surgical patients. However, antimicrobials are reported to be overprescribed in many parts of the world, which contributes to antimicrobial resistance (AMR). AMR complicates the prophylaxis and treatment of endophthalmitis. This article examines the prevalence and mechanisms of AMR in ocular microorganisms, emphasizing the importance of understanding AMR patterns for tailored treatments. It also explores prophylaxis and management strategies for endophthalmitis, with a discussion on the use of intracameral antibiotic administration. The use of prophylactic intracameral antibiotics during cataract surgery is common in many parts of the world but is still controversial in some locations, especially in the US. Finally, it highlights the role of stewardship in ophthalmology and its benefits in the treatment of endophthalmitis.

Next generation therapeutics for retinal neurodegenerative diseases

Neurodegenerative diseases affecting the visual system encompass glaucoma, macular degeneration, retinopathies, and inherited genetic disorders such as retinitis pigmentosa. These ocular pathologies pose a serious burden of visual impairment and blindness worldwide. Current treatment modalities include small molecule drugs, biologics, or gene therapies, most of which are administered topically as eye drops or as injectables. However, the topical route of administration faces challenges in effectively reaching the posterior segment and achieving desired concentrations at the target site, while injections and implants risk severe complications, such as retinal detachment and endophthalmitis. This necessitates the development of innovative therapeutic strategies that can prolong drug release, deliver effective concentrations to the back of the eye with minimal systemic exposure, and improve patient compliance and safety. In this review, we introduce retinal degenerative diseases, followed by a discussion of the existing clinical standard of care. We then delve into detail about drug and gene delivery systems currently in preclinical and clinical development, including formulation and delivery advantages/drawbacks, with a special emphasis on potential for clinical translation.

Characteristics and Risk Factors for Rhegmatogenous Retinal Detachment Related to Endophthalmitis

Purpose: To evaluate the risk factors for the development of concurrent or delayed-onset rhegmatogenous retinal detachment (RRD) related to endophthalmitis as well as the anatomic and visual outcomes with subsequent RRD repair. Methods: In this retrospective case study, a 2-tailed t test (continuous) and Fisher exact test were used to determine statistical significance of the observed findings. The relative risk (RR) and 95% CIs were calculated to assess statistical significance. Results: Of the 170 patients included, 22 were found to have a concurrent or subsequent RRD. Initial treatment with pars plana vitrectomy (PPV) (RR, 3.544; 95% CI, 1.650-7.614), aphakia (RR, 4.150; 95% CI, 1.434-12.011), endogenous endophthalmitis (RR, 2.684; 95% CI, 1.065-6.764), and posterior synechiae (RR, 3.026; 95% CI, 1.408-6.505) were statistically significant risk factors for RRD. Anatomically successful repair was achieved in 77.7% of patients. Conclusions: In addition to preexisting risk factors, the initial treatment of endophthalmitis may be a significant risk factor for RRD development, with a higher incidence of subsequent RRD in patients who have PPV as the initial treatment for endophthalmitis.

Literature- and Experience-Based Consensus for Acute Post-operative Endophthalmitis and Endogenous Endophthalmitis in Taiwan

Clinical practices on acute post-operative and endogenous endophthalmitis (EnE) are highly variable among clinicians due to a lack of up-to-date, high-quality evidential support. An expert consensus is thus much needed. A panel consisting of ten retinal specialists in Taiwan was organized. They evaluated relevant literature and developed key questions regarding acute post-operative and EnE that are cardinal for practice but yet to have conclusive evidence. The panel then attempted to reach consensus on all the key questions accordingly. There were eight key questions proposed and their respective consensus statements were summarized as follows: Gram staining and culture are still the standard procedures for the diagnosis of endophthalmitis. Vitrectomy is recommended to be performed earlier than the timing proposed by the Endophthalmitis Vitrectomy Study (EVS). Routine intracameral antibiotic injection for post-cataract surgery endophthalmitis prophylaxis is not recommended because of potential compounding error hazards and a lack of support from high-quality studies. Routine fundus examination is recommended for all patients with pyogenic liver abscess. In EnE, vitrectomy is recommended if diffused and dense vitritis is present, or if the disease progresses. These consensus statements may work as handy guidance or reference for clinical practices of acute post-operative and EnE.

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.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

Oral administration of S-nitroso-L-glutathione (GSNO) provides anti-inflammatory and cytoprotective effects during ocular bacterial infections

Bacterial endophthalmitis is a severe complication of eye surgeries that can lead to vision loss. Current treatment involves intravitreal antibiotic injections that control bacterial growth but not inflammation. To identify newer therapeutic targets to promote inflammation resolution in endophthalmitis, we recently employed an untargeted metabolomics approach. This led to the discovery that the levels of S-nitroso-L-glutathione (GSNO) were significantly reduced in an experimental murine Staphylococcus aureus (SA) endophthalmitis model. In this study, we tested the hypothesis whether GSNO supplementation via different routes (oral, intravitreal) provides protection during bacterial endophthalmitis. Our results show that prophylactic administration of GSNO via intravitreal injections ameliorated SA endophthalmitis. Therapeutically, oral administration of GSNO was found to be most effective in reducing intraocular inflammation and bacterial burden. Moreover, oral GSNO treatment synergized with intravitreal antibiotic injections in reducing the severity of endophthalmitis. Furthermore, in vitro experiments using cultured human retinal Muller glia and retinal pigment epithelial (RPE) cells showed that GSNO treatment reduced SA-induced inflammatory mediators and cell death. Notably, both in-vivo and ex-vivo data showed that GSNO strengthened the outer blood-retinal barrier during endophthalmitis. Collectively, our study demonstrates GSNO as a potential therapeutic agent for the treatment of intraocular infections due to its dual anti-inflammatory and cytoprotective properties.

Endogenous Endophthalmitis - A Major Review

Endogenous endophthalmitis (EE) is an uncommon but potentially devastating ocular infection involving the inner layers of the eye. The global incidence of EE is on the rise. Common ocular signs and symptoms associated with EE include conjunctival injection, ocular pain, and reduced visual acuity. On clinical examination, a history of prior or coexisting systemic infections, symptoms (e.g., fever, malaise), and localizing features may be noted. Clinical diagnosis is often challenging, resulting in critical delays that contribute to a poor prognosis. Blood cultures and ocular fluid samples can aid in conforming causative pathogen(s), after which empirical antibiotic therapy, both systemic and intravitreal, should be instated. The use of steroids to suppress inflammation remains controversial. Surgical options include pars plana vitrectomy. Overall prognosis varies depending on host and pathogen factors, and early diagnosis and initiation of appropriate treatment are crucial.

High risk and low prevalence diseases: Endophthalmitis

INTRODUCTION

Endophthalmitis is a serious, vision-threatening condition that carries with it a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of endophthalmitis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Endophthalmitis is a vision-threatening emergency associated with infection and inflammation of vitreous and aqueous humor. Risk factors include ocular trauma or surgery, immunocompromised state, diabetes mellitus, and injection drug use. History and examination include visual changes, ocular pain, and inflammatory findings (e.g., hypopyon). Fever may be present. Diagnosis should be based on the clinical evaluation, though aqueous or vitreous culture performed by the ophthalmology specialist is recommended. Imaging including computed tomography, magnetic resonance imaging, and ultrasound may suggest the disease but cannot exclude the diagnosis. Management includes emergent ophthalmology consultation and evaluation. Treatment for all types of endophthalmitis is injection of intravitreal antibiotics with consideration of vitrectomy in severe cases. Systemic antimicrobials are recommended in specific types of endophthalmitis. Prompt recognition and diagnosis are key to optimizing favorable visual outcomes.

CONCLUSIONS

An understanding of endophthalmitis can assist emergency clinicians in diagnosing and managing this serious disease.

Endogenous endophthalmitis due to Serratia marcescens secondary to late-onset empyema Post-Cardiac surgery in an End-Stage renal disease patient on peritoneal dialysis

Endogenous bacterial endophthalmitis results from bacterial seeding of the eye during bacteremia. A diagnosis of endogenous bacterial endophthalmitis requires clinical findings such as vitritis or hypopyon along with positive blood cultures. Serratia marcescens is the second most common pathogen causing hospital-acquired ocular infections. This report describes a case of endogenous bacterial endophthalmitis caused by S. marcescens in an older adult with end-stage renal disease (ESRD) on peritoneal dialysis, who had late-onset pleural empyema secondary to coronary artery bypass grafting (CABG). A 61-year-old gentleman presented with a two-day history of cloudy vision, black floaters, pain, swelling, and gradual vision loss in his right eye. There was no history of trauma, ocular surgeries, or previous similar episodes. He had myocardial infarction treated with CABG 3 months back. Examination showed a 3 mm hypopyon in the anterior chamber. He had classic signs of endophthalmitis with positive blood cultures for S. marcescens. He was treated with high-dose intravenous meropenem and intravitreal ceftazidime without vitrectomy. Endophthalmitis progressed to complete vision loss in his right eye, requiring evisceration. Endophthalmitis caused by S. marcescens is rare, but long-term outcomes can be severe, causing complete vision loss in about 60% of the patients. It is usually hospital-acquired, and the source can be late-onset empyema several months after cardiac surgery, in an immunocompromised patient. Systemic antibiotics should be supplemented with intravitreal agents with or without pars plana vitrectomy.

Endophthalmitis in children with open eye injury: epidemiology, risk factors, treatment

The article provides an overview of endophthalmitis cases in children with open eye injury — prevalence, causes and treatment results in Great Britain, USA, China, India, Vietnam, Saudi Arabia, and other countries with different healthcare facilities, lifestyle and traditions.

Clinical Practice Update: Management of Infectious Endophthalmitis After Intravitreal Anti-VEGF Injection

Although infectious endophthalmitis after intravitreal antivascular endothelial growth factor injections is rare, it is the most feared and potentially devastating complication of this procedure. There is no high-level evidence to provide definitive guidance on the management of endophthalmitis occurring after intravitreal injection (IVI). This clinical practice update reviews the published literature regarding post-IVI endophthalmitis and highlights areas in which further research is needed to better guide its management.

Prospective evaluation of the prevalence of conjunctival and intraocular bacteria in dogs undergoing phacoemulsification following a standardized aseptic preparation with 0.5% povidone iodine

PURPOSE

To evaluate bacterial contamination of conjunctiva and aqueous humor in dogs undergoing phacoemulsification following asepsis with 0.5% povidone iodine and determine the influence of intravenous antibiotics on outcome of contamination.

METHODS

Client-owned dogs were prospectively enrolled and randomly assigned to a control group, receiving 22 mg/kg intravenous cefazolin at induction prior to sampling, or experimental group receiving no antibiotic prior to sampling, masked to the surgeon. Dogs receiving antimicrobials in the pre-operative period were excluded. Asepsis was performed on all operated eyes using 0.5% iodine with minimum 3 min contact time at induction of anesthesia and repeated before surgery. A conjunctival swab and aqueous humor sample were collected prior to incision and following incision closure, respectively. Samples were submitted for aerobic and anaerobic bacterial culture and susceptibility.

RESULTS

Seventy-one eyes of 42 dogs were included. Median age was 9 years. Thirty-nine and 32/71 eyes received intravenous cefazolin and no antibiotic, respectively. Median procedure time was 40 min per eye. Conjunctival cultures were positive in 6 eyes (8.5%): Serratia marcescens (5 eyes) and Cutibacterium acnes (1 eye). Aqueous humor cultures were positive in 5 eyes (7.0%): S. marcescens (2 eyes), Pseudomonas aeruginosa (2 eyes), Staphylococcus pseudointermedius (1 eye). Prevalence of positive culture did not differ between groups (p = .74), order of eyes for bilateral procedures (p = .74) and diabetic status (p = 1).

CONCLUSIONS

Bacterial contamination of the conjunctiva and aqueous humor was present in 8.5% and 7.0% of dogs undergoing phacoemulsification after asepsis. Lack of IV cefazolin was not significantly associated with positive culture.

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.

Outcomes of evisceration or enucleation by resident trainees in patients with recalcitrant endophthalmitis or panophthalmitis

To evaluate the surgical outcomes and complications of evisceration or enucleation with primary implantation, performed by ophthalmology resident trainees, in regards to patients with recalcitrant endophthalmitis or panophthalmitis. We also compared the surgical outcomes and complications between resident trainees and experienced staff. In this retrospective analysis, the clinical records of all patients diagnosed with endophthalmitis or panophthalmitis who underwent enucleation or evisceration with primary implantation over a 13-year period were reviewed. The factors predicting implant exposure or extrusion in regards to patients who underwent eye removal by trainees were identified using multivariate analysis. The percentages of successful prosthesis fittings and complications were also reported. Sixty-six patient records, median age of 46.8 years, who underwent eye removal by resident trainees were reviewed. Thirty-six (55%) out of 66 patients were diagnosed with panophthalmitis. Four patients (6%) had implant exposure, and 4 patients (6%) had implant extrusion. Multivariate analysis demonstrated that Pseudomonas aeruginosa infection (P = .02, adjusted odd ratio [aOR] = 33.75) and not receiving intravitreal antimicrobial drugs before the eye removal procedure (P = .02, aOR = 30.11) were associated with implant exposure or extrusion. Patients with panophthalmitis who underwent evisceration had a higher rate of implant exposure or extrusion than those who underwent enucleation (P = .03, aOR 38.38). At the last visit, 65 patients had a successful prosthesis fitting. Furthermore, there were similar rates of complications and successful prosthesis fittings between experienced staff and resident trainees. This study suggests that evisceration or enucleation with primary implant placement in patients with recalcitrant endophthalmitis or panophthalmitis can be performed by resident trainees with acceptable surgical outcomes and a low rate of serious complications.

Aspergillus Endophthalmitis: Epidemiology, Pathobiology, and Current Treatments

Fungal endophthalmitis is one of the leading causes of vision loss worldwide. Post-operative and traumatic injuries are major contributing factors resulting in ocular fungal infections in healthy and, more importantly, immunocompromised individuals. Among the fungal pathogens, the Aspergillus species, Aspergillus fumigatus, continues to be more prevalent in fungal endophthalmitis patients. However, due to overlapping clinical symptoms with other endophthalmitis etiology, fungal endophthalmitis pose a challenge in its diagnosis and treatment. Hence, it is critical to understand its pathobiology to develop and deploy proper therapeutic interventions for combating Aspergillus infections. This review highlights the different modes of Aspergillus transmission and the host immune response during endophthalmitis. Additionally, we discuss recent advancements in the diagnosis of fungal endophthalmitis. Finally, we comprehensively summarize various antifungal regimens and surgical options for the treatment of Aspergillus endophthalmitis.

Endophthalmitis secondary to donor to host infection in posterior lamellar keratoplasties: A systematic review

Donor to host transmission of infectious agents is a well-recognized entity, more commonly related to Endothelial Keratoplasty (EK) than to Penetrating Keratoplasty (PK), that involves complications ranging from interface keratitis to endophthalmitis. A systematic review of the literature was conducted to identify the published articles until December 2020 reporting cases of endophthalmitis secondary to corneal graft contamination in posterior lamellar keratoplasties (DSAEK and DMEK) along with donor characteristics, microbiological profile, treatment and outcomes. Each identified article was assessed to meet donor to host infection criteria, defined as a post-procedural infection in which the same microbiological agent was identified in both the donor corneoscleral rim or preservation medium and receptor ocular tissue. From 23 research articles, eight reports of endophthalmitis in nine patients following DSAEK or DMEK secondary to donor to host infection fulfilled the inclusion criteria. The majority were male and the median age was 72.0 (45.0-81.0) years old. Indications of surgery were primarily pseudophakic bullous keratopathy and Fuchs dystrophy. A fungal pathogen was identified in eight of nine patients. All the cases underwent surgical management with lenticule removal or endothelial plaque aspiration. The final corrected distance visual acuity (CDVA) in all cases was 20/200 or better. Endophthalmitis after an EK procedure is a rare complication whose outcome depends on the aggressive and precocious treatment. Identification of early signs of interface keratitis and lenticule removal seems mandatory in patients undergoing DSAEK or DMEK to prevent further involvement of the globe.

The Diagnosis and Treatment of Fungal Endophthalmitis: An Update

In recent, large case series of fungal endophthalmitis (FE) that were published by Asian authors, the most frequent etiologic agents for all types of FE are molds (usually Aspergillus species, while Fusarium is the prevalent etiology in keratitis-related FE). Candida was the organism found in most cases of endogenous FE. However, we must keep in mind that prevalence of fungal species varies with the geographical area. Lately, polymerase chain reaction (PCR) was increasingly used for the diagnosis of FE, allowing for very high diagnostic sensitivity, while the costs become more affordable with time. The most important shortcoming of PCR—the limited number of pathogens that can be simultaneously searched for—may be overcome by newer techniques, such as next-generation sequencing. There are even hopes of searching for genetic sequences that codify resistance to antifungals. We must not forget the potential of simpler tests (such as galactomannan and β-d-glucan) in orienting towards a diagnosis of FE. There are few reports about the use of newer antifungals in FE. Echinocandins have low penetration in the vitreous cavity, and may be of use in cases of fungal chorioretinitis (without vitritis), or injected intravitreally as an off-label, salvage therapy.

Global Current Practice Patterns for the Management of Open Globe Injuries

PURPOSE

To determine global current practice patterns for the management of open globe injuries and identify areas of variation.

DESIGN

Cross-sectional survey.

METHODS

An online survey assessed global management paradigms for open globe injuries from August 2020 to January 2021. Responses were collected from experts at eye trauma centers and emergency departments worldwide who manage ≥1 open globe injury per month. The survey assessed the use/selection of antibiotics and steroids, procedural and imaging decisions, and admission practices for open globe injuries.

RESULTS

Responses were received from representatives of 36 of 42 institutions (85.7%), of which 33 (78.6%) had sufficient trauma volume to be included. Included responses were distributed across North America (n=12, 36.4%), Asia (n=12, 36.4%), South America (n=4, 12.1%), Africa (n=3, 9.1%), Europe (n=1, 3.0%), and Australia (n=1, 3.0%). Preoperative systemic antibiotics for open globe injuries were administered by 75.8% (n = 25/33) of institutions, while 30.3% (n = 10/33) administered preoperative topical antibiotics. Intraoperative ophthalmic antibiotics for open globe injuries were used by 54.5% (n = 18/33) of experts. Most institutions also administered postoperative systemic antibiotics (n = 23 [69.7%]) and topical steroids (n = 29 [87.9%]), although specific medication choices diverged. At 19 responding centers (61.3% of the 31 that had trainees), residents participated in surgical repairs. Many institutions discharged patients after repair, but 54.5% (n = 18/33) of locations routinely admitted them for observation.

CONCLUSIONS

Preferred management practices for open globe injuries vary widely. To ensure the highest standard of care for all patients, evidence-based international guidelines for the treatment of these injuries are needed.

Global Preferred Practice Patterns for the Management of Exogenous Endophthalmitis: A Survey by the American Society of Ophthalmic Trauma

OBJECTIVE

: To investigate the global practice patterns for the management of exogenous endophthalmitis.

METHODS

: This cross-sectional study was conducted to assess global practice patterns for the management of exogenous endophthalmitis. An online survey comprised of questions regarding the management of exogenous endophthalmitis was distributed to institutions who are members of International Globe and Adnexal Trauma Epidemiology Study Group (IGATES) or invited affiliates of the American Society of Ophthalmic Trauma and the Asia Pacific Ophthalmic Trauma Society. Responses were gathered from August 2020 to January 2021.

RESULTS

Of 42 institutions, 36 responses were received (86% response rate), of which 33 (79%) were included in the analysis. Included centers were from Asia (36%), North America (36%), South America (12%), Africa (9%), Europe (3%), and Australia (3%). Oral antibiotics were administered in 19 (58%) institutions, with moxifloxacin as the preferred agent (n=9, 27%). The preferred method for obtaining cultures was vitreous tap (n=25, 76%). Most institutions (n=26, 79%) routinely administered intravitreal vancomycin and ceftazidime, while intravitreal steroids were routinely administered at 11 centers (33%). Indications for performing vitrectomy included; decreased visual acuity (n=14, 39%); all cases of exogenous endophthalmitis (n=4, 12%); non-response to medical therapy (n=4, 12%); or no view of the fundus (n=4, 12%), indicating significant variation in surgical indications. More than half (n=17, 52%) of responding institutions routinely admitted patients with exogenous endophthalmitis to the hospital. Institutions in the United States were less likely to administer oral antibiotics (27% vs. 73%, P = 0.024) and to admit patients (9% vs. 73%, P < 0.001) compared to other countries.

CONCLUSIONS

: This study highlights the global variations in the management of exogenous endophthalmitis, especially as it pertains to surgical indications. Further establishment of evidence-based guidelines may be beneficial to provide more uniform guidance to optimize outcomes.

Rare case of endogenous Klebsiella endophthalmitis associated with emphysematous prostatitis in a patient with diabetes, cirrhosis and COVID-19

A 35-year-old Hispanic man presented with fever, chills, dysuria, diarrhoea, scleral icterus, tachycardia and tachypnea. He was found to be COVID-19 positive, CT of the pelvis revealed prostatic abscess, and urine culture grew Klebsiella pneumoniae Additionally, he was found to have diabetes and cirrhosis. During treatment, the patient developed vision loss, and was diagnosed with endogenous Klebsiella endophthalmitis. The patient was treated with intravenous antibiotics, pars plana vitrectomy, intravitreal antibiotics and cystoscopy/suprapubic catheter placement. On follow-up, the patient has had the suprapubic catheter removed, and successfully passed a voiding trial, but suffers permanent vision loss in both eyes.

[Microbiological and infectious disease aspects of postoperative endophthalmitis]

Infectious postoperative or postinjection endophthalmitis is a medical emergency. Gram-positive bacteria, such as staphylococci, streptococci and enterococci are the predominant causative agents, whereas Gram-negative pathogens (e.g. Klebsiella pneumoniae, Pseudomonas aeruginosa) and fungi account for a minority of cases. Using modern diagnostic tools, which include polymerase chain reaction-based assays in addition to Gram staining and agar culturing, a causal agent can be detected in the majority of cases, which enables a targeted treatment and estimation of the prognosis. Endophthalmitis is treated with intravitreal and often also intravenous administration of antibiotics, with the combination of vancomycin and ceftazidime being most commonly used. This article presents and summarizes recent developments in the microbiological etiology and diagnostics of endophthalmitis as well as treatment options and perioperative antibiotic prophylaxis in the light of emerging resistance patterns.