Endophthalmitis at the Bristol Eye Hospital: an 11-year review of 47 patients

Contamination of multi dose eyedrops in the intra and perioperative context

In this study, we examined the rate of contamination of multi-dose ophthalmic solutions in the operating theatre and the underlying risk for infection by examining the microbiological load on the tips of the dispenser bottles. A total of 245 samples of eye drop bottles were collected and analysed between June 2018 and January 2019. All were collected in the operating theatre of the University Eye Hospital Hamburg-Eppendorf. Contamination of the dropper tip occurred in 2% of the samples. Although the prevalence of contamination was low, the results of this study reveal the possibility of contamination of multi-dose eyedrops even when used by health care professionals in the controlled environment of an operating theatre. Following these results, we recommend the use of single-dose eyedrops in the pre- and intraoperative context.

Clinical analysis and predictive factors associated with improved visual acuity of infectious endophthalmitis

Background

To describe the clinical characteristics and analyze the predictive factors associated with improved visual acuity of 359 patients with infectious endophthalmitis.

Methods

This study retrospectively analyzed 359 eyes of 359 patients with infectious endophthalmitis from January 2014 to December 2018. The findings summarized some epidemiological characteristics of these patients, including age, sex, occupation, patient visit time, etiology, causative organisms, therapy, and best-corrected visual acuity. Multivariate logistic regression was performed to predict the relative factors of improved visual acuity (VA).

Results

Overall, 283 (78.83%) patients were male. The mean age was 48.0 ± 18.27 years. Ocular trauma, especially open globe injuries (246, 68.5%) was the most common etiology of infectious endophthalmitis in this study. The etiologies of infectious endophthalmitis were open globe injuries (68.5%), intraocular surgery (22.6%), and corneal ulcer-associated (6.7%) and endogenous causes (2.2%). In the etiology classification and visual acuity improvement group, had statistically significant differences in factors such as age, sex, patient visit time, pre-therapy visual acuity, etc. The average Logarithm of the Minimum Angle of Resolution (logMAR) best-corrected visual acuity on pre-therapy was 2.28 ± 0.60, and it had significantly improved to 1.67 ± 0.83 post-therapy (P < 0.05). Logistic regression analysis showed that visit time > 7 day (P = 0.034, OR = 0.522, 95% CI: 0.286–0.953), pre-therapy VA ≦logMAR 2.3 (P = 0.032, OR = 1.809, 95% CI: 1.052–3.110), post-surgical (vs. posttraumatic; P = 0.023, OR = 2.100, 95% CI: 1.109–3.974), and corneal ulcer-associated etiologies (vs. posttraumatic; P = 0.005, OR = 0.202, 95%CI: 0.066–0.621) were significantly associated with improved visual acuity after adjusting for possible confounding factors.

Conclusions

Among the patients with infectious endophthalmitis, middle-aged male, especially farmers and workers, accounted for a large proportion. Open globe injuries were the main cause and the gram-positive bacteria were the major causative organisms. The final visual outcomes seemed to vary according to the type of endophthalmitis, but early treatment and good initial visual acuity were important factors for visual acuity improvement.

Endogenous endophthalmitis in children and adolescents: Case series and literature review

Purpose:

To study the clinical and microbiological profile, treatment modalities, and anatomical and functional outcomes among children and adolescents with endogenous endophthalmitis (EE) at a tertiary eye care centre in India.

Methods:

Medical records of subjects <18 years, presenting with EE from 1997 to 2007 were reviewed. Cases where the causative organism was identified were included. Treatment regimen included systemic antibiotics, vitrectomy, intravitreal antibiotics, and enucleation. Systemic evaluation to identify the source of infection was done by an internist. Microbiological analysis of blood, urine, and ocular specimens was done. The favorable anatomical outcome was defined as the attached retina, with controlled intraocular pressure and clear media at the last follow up. The favorable functional outcome was defined as vision >3/60 on the final follow up. Univariate regression analysis was done to identify factors predicting functional outcome.

Results:

Thirty eyes of 30 subjects (23 (77%) males) were studied. The mean age at presentation was 6.8 years (range=1–16 years). Fever was evident in four (13%) and blood culture was negative in all cases. Gram-positive organisms were identified in 11 (37%) eyes, fungi in 3 (10%), and toxocara in 8 (27%) eyes. Twenty-three (77%) eyes underwent vitrectomy. Favorable functional and anatomical outcomes were achieved in 9 (30%) and 12 (40%) eyes, respectively. Eyes undergoing vitrectomy showed significant correlation with good functional outcome (P = 0.05).

Conclusion:

EE is under-reported and not well studied in children. The absence of systemic features may be evident in a developing country with over the counter availability of antibiotics. Gram-positive infections are common and vitrectomy is a beneficial modality of treatment.

Endophthalmitis following Suture Removal - Clinical Outcomes and Microbiological Profile

AIMS

To review the clinical profile and report the microbiology and treatment outcomes of endophthalmitis following suture removal.

METHODS

In this multi-center, retrospective interventional case series, 11 eyes of 11 patients who developed endophthalmitis following suture removal from January 2006 to December 2017 were reviewed.

RESULTS

Nine of the 11 patients developed a culture-proven, acute onset endophthalmitis [5.3 ± 3.1 days (range 2-10 days)]. Mean age was 15.8 ± 21.2 years (median 7; range, 1-66 years). Presenting visual acuity was extremely low ranging from light perception (PL) to counting fingers close to face (CFCF) at the time of diagnosis of endophthalmitis. Out of the 11 patients, 8 belonged to the pediatric age group; four out of those eight had loose sutures secondary to cataract surgery, two patients had loose sutures secondary to penetrating keratoplasty and 1 case each had loose sutures secondary to corneal tear repair and secondary IOL implantation, respectively. Streptococcus pneumoniae was the most common organism and was identified in seven cases and was susceptible to vancomycin in all these cases. Other bacterial isolates were Haemophilus influenzae and Achromobacter denitrificans. Three out of the 11 eyes had visual outcome of 20/200 or better. Six eyes were phthisical and one eye was eviscerated. Mean follow-up was 26.3 ± 31.2 weeks (range 2-92 weeks). Visual outcomes ranged from 20/40 to no light perception at the last follow-up.

CONCLUSIONS

Endophthalmitis following suture removal though rare, is observed most commonly in the pediatric population and has an acute and a fulminant course. Streptococcus pneumoniae was the most commonly isolated microorganism. Visual acuity outcomes were poor despite prompt recognition of endophthalmitis and appropriate antibiotic therapy.

Risk Factors for Post-Traumatic Endophthalmitis in Patients with Positive Intraocular Cultures

Purpose

To determine the risk factors for post-traumatic endophthalmitis in patients with positive intraocular culture.

Methods

An institutional-based prospective nonrandomized interventional study of patients older than 15 years who presented for primary repair of open globe injury between June 2003 and April 2005 was undertaken. The main outcomes measured were initial and final visual acuity, type of injury, presence of uveal and vitreous prolapse, time interval between injury and primary repair of the globe, length of wound, location of wound, and virulence of organism. Statistical analysis tests used were Student t-test, Fisher exact test, and chi-square test.

Results

Fifty patients were included in the study. They were divided into two groups: Group 1 (n=19) patients, who developed clinically significant endophthalmitis; and Group 2 (n=31) patients, who did not develop clinically significant endophthalmitis. Delay in primary repair more than 36 hours (p=0.042), length of wound more than 8 mm (p=0.050), and isolation of organisms like fungus (p=0.006, OR=14), Bacillus cereus (p=0.01, OR=11.25), and Pseudomonas aeruginosa (p=0.05–0.10, OR=11.3) significantly increased the risk of endophthalmitis. Mean initial and final visual acuity was better in Group 2 but was not statistically significant (p=0.21).

Conclusions

Final visual outcome in the presence of positive intraocular culture is poor. Isolation of virulent organisms, longer length of laceration, and delayed primary repair of open globe injuries have high risk of developing endophthalmitis. Prophylactic intraocular antibiotics should be considered in cases with longer length of wound and delayed primary closure.

Genome characterization of two bile-isolated Vibrio fluvialis strains: an insight into pathogenicity and bile salt adaption

Vibrio fluvialis is recognized as an emerging pathogen. However, not much is known about the mechanism of its pathogenesis, and its adaptation to a special niche such as the gall bladder. Here we describe two V. fluvialis strains that cause acute cholecystitis. It is noteworthy that both strains were susceptible to all antibiotics tested, which is in contrast to previous studies, suggesting substantial genetic diversity among V. fluvialis isolates. In agreement with their survival and growth in the gall bladder, the genomes of strains 12605 and 3663 contain a considerable number of genes that confer resistance to bile, including toxR, ompU, tolC, cmeABC, rlpB, yrbK, rpoS, damX and gltK. Furthermore, integrative and conjugative elements (ICEs), virulence factors and prophage regions were also detected in strains 12605 and 3663, reflecting their flexibility in recombination during the evolution of pathogenicity. Comparative analysis of nine available genomes of V. fluvialis revealed a core genome consisting of 3,147 genes. Our results highlight the association of V. fluvialis with a rare disease profile and shed light on the evolution of pathogenesis and niche adaptation of V. fluvialis.

The influence of needle gauge and infection source on vitreous aspirate cultures

BACKGROUND/AIMS

While the Endophthalmitis Vitrectomy Study (EVS) included only post-cataract surgery patients, the methods and data from that study are widely applied in the management of endophthalmitis of all types. We sought to examine how our experience with in-office vitreous aspiration differed from the EVS in two ways: first, by reviewing microbiological culture yields from vitreous aspirates obtained using 30-gauge needles versus 25-27-gauge needles and second, by reviewing culture yields in cases of endogenous versus non-endogenous endophthalmitis.

METHODS

Cases of endophthalmitis over a 14-year period were reviewed when vitreous tap was the initial diagnostic procedure. The data included infection source, needle size used to obtain a vitreous aspirate, organism cultured and rates of unsuccessful attempts at vitreous aspiration or dry taps.

RESULTS

10 cases were endogenous endophthalmitis, while 36 cases were a mix of postoperative, post-traumatic, post-intravitreal injection and miscellaneous patients. A positive microbiological culture was obtained in 11/36 (31%) of vitreous taps using a 25-27-gauge needle and in 8/10 (80%) taps using a 30-gauge needle (p<0.01). A positive vitreous culture was obtained in 18/36 (50%) of all non-endogenous cases, while a positive result was obtained in 0/10 (0%) cases of endogenous endophthalmitis (p<0.01).

CONCLUSIONS

The use of a smaller needle in obtaining vitreous samples in endophthalmitis did not lower the microbiological yield. A positive microbiological yield was significantly less likely in cases of endogenous endophthalmitis compared with non-endogenous cases. Vitreous tap as a method for identifying the causative organism in endogenous endophthalmitis was of limited utility.

Vibrio fluvialis: an emerging human pathogen

Vibrio fluvialis is a pathogen commonly found in coastal environs. Considering recent increase in numbers of diarrheal outbreaks and sporadic extraintestinal cases, V. fluvialis has been considered as an emerging pathogen. Though this pathogen can be easily isolated by existing culture methods, its identification is still a challenging problem due to close phenotypic resemblance either with Vibrio cholerae or Aeromonas spp. However, using molecular tools, it is easy to identify V. fluvialis from clinical and different environmental samples. Many putative virulence factors have been reported, but its mechanisms of pathogenesis and survival fitness in the environment are yet to be explored. This chapter covers some of the major discoveries that have been made to understand the importance of V. fluvialis.

Endogenous endophthalmitis: 10-year experience at a tertiary referral centre

PURPOSE

Endogenous endophthalmitis (EE) is a sight-threatening emergency and the aetiology is often multifactorial. Delayed diagnosis may exacerbate the poor visual prognosis. We describe the management and visual outcomes of EE presenting to a tertiary referral centre.

PATIENTS AND METHODS

A prospective consecutive case series of 64 patients presenting with presumed EE from 1997 to 2007 to the Royal Victorian Eye and Ear Hospital were included. All data were collected in a standardized manner. Outcome measures included: visual acuity, microbial profiles, and vitrectomy rate.

RESULTS

In total, 64 cases of EE were identified over the study period with a mean age of 57.5 years, and 53.5% were male. Presenting acuities ranged from Snellen 6/6 to no perception of light (NPL). Identifiable risk factors were present in 78.1%, with the majority related to intravenous drug abuse. A 64.1% culture positivity rate was recorded. A vitrectomy rate of 57, 56, and 21% was recorded in documented bacterial, fungal, and no growth cases, respectively. Final Snellen acuities ranged from 6/6 to NPL. A total of 5 out of 64 eyes were enucleated, of which 3 identified Klebsiella species. Better visual outcome was documented in fungal cases.

CONCLUSION

EE is a serious ocular condition and has a varied aetiology. Visual outcomes are often poor, irrespective of the method of management. Fungal aetiology often confers a better prognosis, and vitrectomy is advocated for bacterial proven cases.

Microbial cultures in open globe injuries in southern India

PURPOSE

To determine the risk factors leading to positive intraocular culture in patients with open globe injury.

METHODS

A prospective interventional study involving 110 eyes of 110 patients of more than 15 years of age, presenting with open globe injury, was undertaken. Emergency repair of the injured globe was done. Prolapsed intraocular tissue or aqueous humour was sent for microbial work up before repair. In endophthalmitis cases intravitreal antibiotics were given according to the antimicrobial sensitivity. Chi-square and logistic regression analysis were used to determine the risk factors.

RESULTS

Fifty-six patients showed microbial contamination. Bacteria were cultured in 42 patients and fungi in 14 patients. Nineteen patients developed endophthalmitis, of which 18 patients showed microbial growth initially. In univariate analysis, initial visual acuity (<6/360, P = 0.002), presence of uveal tissue prolapse (P < 0.001), vitreous prolapse (P < 0.001) and length of laceration (>8 mm, P < 0.001) were significantly associated with positive microbial culture, however, in the multivariate stepwise logistic regression delay in surgical intervention (>72 h, P < 0.001), uveal tissue prolapse (P = 0.004) and corneosclearal laceration (>8 mm, P = 0.013) were associated with increased risk of positive microbial culture. Six patients had intraocular foreign body but were culture negative. Age, gender, site of injury and presence of cataract did not significantly affect the culture positivity.

CONCLUSIONS

Microbial contamination is a risk factor for the development for endophthalmitis. Despite the high frequency of microbial contamination, it develops only in few cases. Systemic antibiotics, virulence of the organism and host factors play a role in the manifestation of endophthalmitis. Prophylaxis with intraocular antibiotics should be strongly considered in cases with poor vision at presentation, larger corneoscleral laceration, delayed surgical intervention and uveal tissue or vitreous prolapse.

RISKS OF INTRAVITREOUS INJECTION: A COMPREHENSIVE REVIEW

PURPOSE

To evaluate the prevalence of the most common serious adverse events associated with intravitreous (IVT) injection.

METHODS

A systematic search of the literature via PubMed from 1966 to March 1, 2004, was conducted to identify studies evaluating the safety of IVT injection. Data submitted in New Drug Applications to the U.S. Food and Drug Administration for drugs administered into the vitreous were included where available. Serious adverse events reported in each study were recorded, and risk per eye and risk per injection were calculated for the following serious adverse events: endophthalmitis, retinal detachment, iritis/uveitis, intraocular hemorrhage, ocular hypertension, cataract, and hypotony. Rare complications also were noted.

RESULTS

Data from 14,866 IVT injections in 4,382 eyes were analyzed. There were 38 cases of endophthalmitis (including those reported as pseudoendophthalmitis) for a prevalence of 0.3% per injection and 0.9% per eye. Excluding cases reported specifically as pseudoendophthalmitis, the prevalence of endophthalmitis was 0.2% per injection and 0.5% per eye. Retinal detachment, iritis/uveitis, ocular hypertension, cataract, intraocular hemorrhage, and hypotony were generally associated with IVT injection of specific compounds and were infrequently attributed by the investigators to the injection procedure itself. Retinal vascular occlusions were described rarely in patients after IVT injection, and it was unclear in most cases whether these represented true injection-related complications or chance associations.

CONCLUSION

The risk of serious adverse events reported after IVT injection is low. Nevertheless, careful attention to injection technique and appropriate postinjection monitoring are essential because uncommon injection-related complications may be associated with permanent vision loss.

Endophthalmitis caused by Pseudomonas aeruginosa

OBJECTIVE

To investigate the clinical settings and treatment outcomes for endophthalmitis caused by Pseudomonas aeruginosa.

DESIGN

Retrospective, noncomparative, consecutive case series.

METHODS

The medical records were reviewed of all patients treated for P. aeruginosa endophthalmitis at a single institution between January 1, 1987, and December 31, 2001.

MAIN OUTCOME MEASURES

Final visual acuity and rate of enucleation or evisceration.

RESULTS

The study included 28 eyes of 28 patients with a median age of 75 years (range, 5-93 years). The clinical setting of endophthalmitis included: cataract surgery (n = 9), corneal ulcer (n = 7), penetrating keratoplasty (n = 5), bleb associated (n = 2), glaucoma drainage implant (n = 2), pars plana vitrectomy (n = 1), iris cyst removal (n = 1), and trauma (n = 1). In acute-onset postoperative cases (n = 10), the median interval between surgery and presentation with endophthalmitis was 4 days (range, 1-26 days). The median duration of symptoms was 1 day, and all patients were treated on the day of diagnosis. Eleven patients (39%) had hand motions or better vision in the infected eye at the time of initial diagnosis. Because of no light perception visual acuity, necrosis of cornea and sclera, and intractable pain, 7 eyes (25%) underwent evisceration or enucleation as initial treatment; of the remaining 21 eyes, intravitreal antibiotics were administered in all cases and intravitreal dexamethasone was administered in 15 cases (71%). Pars plana vitrectomy was performed in 12 patients (43%). The organism was sensitive to the initial antibiotics administered in all but 2 cases. Final visual acuity was 5/200 or better in 2 of 28 eyes (7%). Nineteen patients (68%) had a final visual acuity outcome of no light perception, and no patient achieved a final visual acuity of better than 20/400. Overall, 18 of the 28 eyes (64%) were either eviscerated or enucleated.

CONCLUSIONS

Endophthalmitis caused by P. aeruginosa is associated with poor visual outcomes despite prompt treatment with intravitreal antibiotics to which the organisms were sensitive.

Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases

Endogenous bacterial endophthalmitis is a rare but serious condition that occurs when bacteria cross the blood-ocular barrier and multiply within the eye. We provide an overview of endogenous bacterial endophthalmitis by reviewing 267 reported cases and integrating this with our experience of an additional 19 cases. The majority of patients with endogenous bacterial endophthalmitis are initially misdiagnosed and many have an underlying disease known to predispose to infection. This condition is often previously undiagnosed. Blood cultures are the most frequent means of establishing the diagnosis. The most common Gram positive organisms are Staphylococcus aureus, group B streptococci, Streptococcus pneumoniae,and Listeria monocytogenes. The most common Gram negative organisms are Klebsiella spp., Escherichia coli, Pseudomonas aeruginosa, and Neisseria meningitidis. Gram negative organisms are responsible for the majority of cases reported from East Asian hospitals, but Gram positive organisms are more common in North America and Europe. The visual outcome is poor with most cases leading to blindness in the affected eye. Many patients have extraocular foci of infection, with an associated mortality rate of 5%. The outcome of endogenous bacterial endophthalmitis has not improved in 55 years and clinicians need to have a high level of awareness of this commonly misdiagnosed condition.

In vitro adhesion of Staphylococcus epidermidis to intraocular lenses

PURPOSE

To compare the in vitro adherence of slime-producing and non-slime-producing Staphylococcus epidermidis to different intraocular lenses (IOLs) to study the organism's contribution to postoperative endophthalmitis.

METHODS

Strains of slime-positive (ATCC 35984) and slime-negative (ATCC 12228) S epidermidis were used. The IOLs were made of poly(methyl methacrylate) (PMMA), PMMA with polypropylene haptics, silicone, hydrogel, acrylic, heparin-surface-modified (HSM) PMMA, and fluorine-surface-modified PMMA. The lenses were incubated overnight with bacteria, then sonicated and vortexed to separate the adhered bacteria. Quantitative cultures were performed and the results statistically analyzed.

RESULTS

Slime-negative strains of S epidermidis adhered to all IOLs but at a lower level than slime-positive strains. The most adherent lenses were acrylic with the positive strain and PMMA with the negative strain. The least adherent IOLs were PMMA with the positive strain and hydrogel with the negative strain. There were no significant differences between rigid and foldable lenses. Polypropylene was significantly more adherent than PMMA to the slime-positive strain. The acrylic and the HSM PMMA IOLs were significantly more adherent to the positive strain.

CONCLUSIONS

In vitro, there were significant differences in bacterial adhesion among IOL materials. Slime-positive strains of S epidermidis were more adherent than slime-negative ones.

Rapid detection and identification of Candida, Aspergillus, and Fusarium species in ocular samples using nested PCR

A protocol for the rapid detection of fungal DNA in ocular samples, derived from three species, Candida albicans, Aspergillus fumigatus, and Fusarium solani, has been developed. Two novel panfungal primers complementary to 18S rRNA sequences present in all three species were designed. Panfungal PCR was followed by three nested PCRs utilizing species-specific primers. PCR sensitivity ranged from 50 to 100 fg of free DNA and between one and two C. albicans organisms. In addition, we also developed a rapid and reliable DNA extraction protocol. This protocol minimized DNA loss during extraction, whilst removing compounds from vitreous and aqueous fluids that have previously been shown to have inhibitory effects on PCR. Preliminary results obtained after testing the protocol on three patient samples support culture results and medical history. However, one patient was PCR positive but culture negative, suggesting that the sensitivity of this protocol may exceed that of traditional culture techniques. This system, therefore, constitutes an additional protocol that may significantly aid patient management in cases where fungal endophthalmitis is suspected.

Vibrio ocular infections on the U.S. Gulf Coast

PURPOSE

To describe the epidemiology of Vibrio eye infections.

METHOD

We reviewed the records of a patient from our institution with V. vulnificus keratitis and conducted a literature search for other cases of ocular infections with Vibrio species.

RESULTS

A 39-year-old fisherman was struck in his left eye with an oyster shell fragment, developed suppurative V. vulnificus keratitis, and was successfully treated with combined cefazolin and gentamicin. Including our patient, 17 cases of eye infections with Vibrio spp. have been reported, and 11 (65%) involved exposure to seawater or shellfish. Of the seven cases due to V. vulnificus (six keratitis and one endophthalmitis), six had known exposure to shellfish or seawater along the U.S. coast of the Gulf of Mexico. Of five cases of V. alginolyticus conjunctivitis, three had been exposed to fish or shellfish. Three infections with V. parahaemolyticus (one keratitis and two endophthalmitis) were reported; two of these occurred in people exposed to brackish water on or near the Gulf Coast. Two cases of postsurgical endophthalmitis, one with V. albensis and one with V. fluvialis, also were reported.

CONCLUSIONS

In addition to septicemia, gastroenteritis, and wound infections, halophilic noncholera Vibrio species can cause sight-threatening ocular infections. Ocular trauma by shellfish from contaminated water is the most common risk factor for Vibrio conjunctivitis and keratitis. Nearly one half of reported Vibrio infections of the eye occurred along the U.S. coast of the Gulf of Mexico.

Endophthalmitis

Endophthalmitis is an inflammatory reaction of intraocular fluids or tissues. Infectious endophthalmitis is one of the most serious complications of ophthalmic surgery. Occasionally, infectious endophthalmitis is the presenting feature of an underlying systemic infection. Successful management of infectious endophthalmitis depends on timely diagnosis and institution of appropriate therapy. Recognition of the different clinical settings in which endophthalmitis occurs and awareness of the highly variable presentation it may have facilitate timely diagnosis. Biopsy of intraocular fluid/tissue is the only method that permits reliable diagnosis and treatment. The different presenting clinical settings, a rational approach to diagnosis (i.e., when, what, and how to biopsy), and the treatment of infectious endophthalmitis are reviewed.

Microorganisms cultured from the anterior chamber of ruptured globes at the time of repair

PURPOSE

We studied events leading to the development of posttraumatic endophthalmitis by examining the significance of 15 factors on microbial contamination of injured eyes.

METHODS

A prospective study was done of 30 ruptured globes in patients admitted to an urban medical center. Cultures were taken from the conjunctiva before and after preoperative disinfection and from the anterior chamber at the beginning and end of wound repair. Twenty-five of 30 patients received a three-day regimen of intravenous antibiotics that were begun before surgery.

RESULTS

Anterior chamber samples grew microorganisms in ten (33%) of 30 eyes, with positive cultures recovered from specimens taken at the beginning of wound repair in eight eyes and at the end of wound repair in six eyes. Contamination with indigenous flora may have occurred at the time of injury in one eye and during repair in another eye. Microbes recovered included Staphylococcus, Corynebacterium, and Aspergillus species. No patient developed endophthalmitis. Of the 15 factors studied, only intravenous antibiotics significantly decreased the incidence of positive anterior chamber cultures in eyes treated before wound repair compared with eyes not receiving such therapy (P = .002).

CONCLUSIONS

Despite the frequency of anterior chamber microbial contamination during injury or repair of the wound, with our treatment protocol and the presence of physiologic mechanisms to reduce intraocular microbes, no eyes developed clinical endophthalmitis. With our limited sample size only intravenous antibiotic therapy was found significantly to reduce anterior chamber microorganisms at the time of surgical repair, supporting their prophylactic use against the development of posttraumatic endophthalmitis.

Intraocular contamination during extracapsular cataract extraction with intraocular lens implantation

Ocular bacterial contamination has been studied in 45 eyes that underwent cataract surgery. The following samples were taken: (1) eyelid margin swab; (2) conjunctival swab; (3) aqueous humor after initial anterior chamber penetration; (4) anterior capsule fragment after capsulorrhexis or capsulotomy; (5) cortical lens material; (6) anterior chamber fluid after lens implantation. The percentages of contaminated samples were 15.5, 13.3, 0.0, 11.1, 13.3 and 6.6, respectively. There was a significant difference between the incidence of positive cultures in the aqueous humor at the time of incision and in subsequent intraocular samples. Positive cultures were found in 13 out of 45 eyes, only gram-positive organisms were recovered and coagulase-negative staphylococci were the most common (78.5% of the isolates). These results confirm previous reports on intraocular contamination during cataract surgery.

Endophthalmitis as presenting symptom of group G streptococcal endocarditis

Group G streptococci can cause serious infections in patients with predisposing factors. Involvement of the eye has rarely been reported in patients without ocular history. Two cases of group G streptococcal endocarditis which presented with an endogenous endophthalmitis are reported. Topical and systemic antimicrobial therapy resulted in recovery, but visual outcome was poor.