Post-traumatic Infectious Endophthalmitis

FUNGAL ENDOPHTHALMITIS MASQUERADING AS SYMPATHETIC OPHTHALMIA

PURPOSE

To describe the ocular pathology of a patient with fungal endophthalmitis with features mimicking sympathetic ophthalmia.

METHODS

Review of medical records and histopathology of a single patient.

RESULTS

A 72-year-old man who sustained penetrating injury to the left eye with an agave plant presented to our clinic 16 months after the initial injury. Before presentation, the patient had developed endophthalmitis and had undergone anterior chamber washout, vitrectomy, and intravitreal steroids, antibiotics, antifungals, and anti-vascular endothelial growth factor therapy. At presentation, the patient had a blind, painful eye and subsequently underwent enucleation. Histopathology demonstrated granulomatous inflammation with multinucleated giant cells in the iris and Dalen-Fuchs nodules with CD68-positive epithelioid histiocytes associated with the retinal pigment epithelium sparing the choriocapillaris. These findings were initially attributed to sympathetic ophthalmia. The fellow eye did not have any signs of inflammation, and Grocott methenamine silver stain was positive for filamentous fungal elements, leading to a diagnosis of fungal endophthalmitis.

CONCLUSIONS

Fungal endophthalmitis may develop histopathologic features that are similar to those observed in sympathetic ophthalmia. Recognition of the overlap between the histopathologic features of these diseases may reduce the possibility of misdiagnosis and unnecessary treatment of the fellow eye.

Presenting Characteristics, Treatment, and Visual Outcomes in Streptococcal Compared to Non-Streptococcal Endophthalmitis

PURPOSE

Report the clinical findings, risk factors, treatment, and visual outcomes associated with Streptococcus endophthalmitis in comparison to culture-positive endophthalmitis associated with non-Streptococcus species.

METHODS

A retrospective chart review of adults between 18 and 89 years of age diagnosed with exogenous culture-positive endophthalmitis between January 1, 2009, and January 1, 2018, at the Duke Eye Center (Durham, North Carolina) with at least six months of follow-up from time of initial diagnosis was conducted. Clinical data including patient demographics, ocular history, baseline corrected visual acuity (VA) prior to presentation, time to presentation, presenting exam findings, VA at presentation, presumed etiology of endophthalmitis, medical and surgical management, and VA at the six-month follow-up was extracted and statistically analyzed.

RESULTS

Fifty-six eyes from 56 patients with culture-positive endophthalmitis were identified. Eyes with Streptococcus (n=18) had elevated intraocular pressure (IOP) at presentation (p=0.002), worse mean VA (Snellen) at presentation (20/14159 vs. 20/3098, p<0.001), and worse mean VA (Snellen) at six months (20/3475 vs. 20/235, p<0.001) compared to non-Streptococcus cases (n=38). Time to presentation (days) (median, IQR) was longer in eyes that underwent glaucoma surgery for both Streptococcus (2241 (836, 3709) vs. 3 (2, 31), p=0.003) and non-Streptococcus endophthalmitis (1236 (125, 3582) vs. 6 (4, 25), p<0.0001). There was no difference in VA at six months between Streptococcus and non-Streptococcus eyes based on treatment.  Conclusions: Streptococci are rare but important causes of exogenous endophthalmitis, and in our study, they were associated with worse visual outcomes than non-Streptococci. A history of any glaucoma surgery, even procedures performed years earlier, should be elicited when evaluating patients with ocular symptoms.

Clinical Findings Predicting Posttraumatic Endophthalmitis after Repair of Open Globe Injuries

BACKGROUND

To evaluate risk factors for developing endophthalmitis after repair of open globe injuries.

METHODS

Retrospective chart analysis of 1303 patients from May 1996 till December 2019.

RESULTS

All patients received prophylactic intravenous broad-spectrum antibiotics for 5-7 days. Endophthalmitis was clinically suspected in 37 (2.8%) eyes and was culture proven in 14 of these eyes (1.1%). Univariate analysis identified poor initial visual acuity at presentation, rural setting of injury, contaminated wound and lens injury as significant predictors for the development of clinically suspected endophthalmitis. Intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics decreased risk of developing endophthalmitis (OR: 2.28;95% CI,1.07-4.86; p = .033).

CONCLUSIONS

Poor initial visual acuity, rural setting of injury, contaminated wound, and lens injury increased risk of suspected posttraumatic endophthalmitis. Prophylactic intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics reduced the risk of posttraumatic endophthalmitis.

Endophthalmitis: a bibliometric study and visualization analysis from 1993 to 2023

Aims

This study is designed to generalize and depict the research hotspots of endophthalmitis through bibliometric methods and software and analyze the evolutive tendency of the work on this severe disease over the past 30 years.

Methods

This study employed a rigorous bibliometric approach. We identified all endophthalmitis-related literature by conducting a comprehensive search of the Science Citation Index Expanded database under the Web of Science Core Collection. The data was then analyzed and visualized using CiteSpace and VOSviewer, two widely recognized software tools in the field of bibliometrics. CiteSpace was used to analyze the country distributions, dual map overlay of journals, keyword bursts, and co-cited references. VOSviewer was employed to describe the authors and co-cited authors, the journals, the co-cited journals, and the keywords co-occurrence network. This robust methodology ensures the reliability and validity of the study's findings.

Results

A total of 2960 publications, including 2695 articles and 265 reviews, were included in this bibliometric study. There has been no shortage of endophthalmitis-related publications since 1993, with an apparent upward trend during recent years. Possible correlations with the COVID-19 pandemic are also analyzed. These studies were finished by 11,048 authors from 75 countries worldwide, with the United States in the lead. In the keyword co-occurrence network, except for the endophthalmitis term, cataract surgery becomes the keyword with the highest frequency. Different categories of endophthalmitis, including postoperative, post-injection, post-traumatic, and endogenous endophthalmitis, and antibacterial and anti-inflammatory therapies of infectious endophthalmitis, are discussed by categories. From the perspective of the timeline, postoperative and post-injection endophthalmitis were the dominant forms before and after the year 2000, respectively. Co-citation analyses reveal that the Endophthalmitis Vitrectomy Study (EVS) conducted in 1995 provides pivotal guidance for later research. Diverse pathogenic bacteria (e.g., Coagulase-negative Staphylococci, Propionibacterium acnes, Viridians Streptococci, and Bacillus cereus) or fungi (e.g., Candida, Aspergillus, and Fusarium) contribute to varying treatment principles and clinical prognosis, which should be taken seriously. In addition, intravitreal and intracameral antibiotics are the mainstay for treating and preventing infectious endophthalmitis, respectively.

Conclusion

Our bibliometric analysis provides an overview of dynamic evolution and structural relationships in the research field of endophthalmitis. The displayed hotspots and developmental directions have reference values for future investigation.

Clinical characteristics and management outcome of acute infectious endophthalmitis

PURPOSE

This study aimed to investigate the demographics, clinical characteristics, and management outcomes of patients with acute infectious endophthalmitis (AIE).

METHODS

This retrospective chart review was conducted on all patients admitted with the clinical diagnosis of infectious endophthalmitis from 2017 to 2022. Demographic data, patients' clinical characteristics, the type of acute infectious endophthalmitis (post-operative, post-traumatic, bleb-associated, and endogenous endophthalmitis), the type of surgical procedure in the post-operative cases, the microbiologic analysis results of vitreous samples, therapeutic measures, and visual outcomes of patients were recorded.

RESULTS

In this study, 182 participants, including 122 male (67%) and 60 (33%) female, were involved. The mean age of patients was 54.56 ± 21 years, with a range of 1-88 years old. The most prevalent type of AIE was post-operative (59.9%), followed by endogenous (19.2%), post-traumatic (17%), and bleb-associated (3.8%). The most common type of intraocular surgery in the post-operative subgroups of AIE patients was phacoemulsification (57.8%). The median (interquartile range) of the primary and final BCVA of patients was 1.5 (1.35, 1.85) and 0.65 (0.35, 1.35), respectively. Vitreous haziness grade (OR, 2.89; 95% CI, 1.11-5.74; p = 0.009) and the primary VA (OR, 60.34; 95% CI, 2.87-126.8; p = 0.008) revealed statistical significance for final vision loss.

CONCLUSION

AIE is a devastating condition with poor visual outcomes, which presents with acute inflammatory signs and symptoms regardless of its type. However, prompt and appropriate treatment leads to visual recovery to a functional level in many patients.

Clinical and pathogenic characteristics of infectious endophthalmitis in children: A retrospective analysis

Infective endophthalmitis is an ophthalmic infection that in severe cases can cause complete loss of vision. In children, the defense against infection is low and eye tissue is not fully developed, leading to increased vulnerability to endophthalmitis. Children may be unable to understand the symptoms; thus, developing a method for prevention and treatment of this disease in children is important. Therefore, we analyzed the clinical and pathogenic characteristics of infectious endophthalmitis in children and provided evidence for clinical treatment. The clinical data of 78 children (78 eyes) with infectious endophthalmitis were retrospectively analyzed. The clinical characteristics, pathogen distribution, drug sensitivity, clinical medication, and treatments were summarized and analyzed. In total, 74 (94.87%) had ocular infections caused by trauma and 75 (96.15%) were from rural townships. A total of 108 sterile specimens were examined, with a positive detection rate of 37.04%. The sensitivity rates of Gram-positive cocci and bacilli to vancomycin were 100%. The sensitivity rates of Gram-negative bacilli to ceftazidime, piperacillin/tazobactam, amikacin, gentamicin, ciprofloxacin, and levofloxacin were 100%. Of the 78 patients, 53 (67.95%) received intravitreal injection and 54 (69.23%) underwent vitrectomy. Trauma is the main factor leading to infectious endophthalmitis in children, wherein Gram-positive bacteria are the most common pathogens. Thus, a timely understanding of the pathogen and drug sensitivity is needed. Intravitreal injection and vitrectomy are effective treatments.

Fungal Diseases Caused by Serious Contamination of Pharmaceuticals and Medical Devices, and Rapid Fungal Detection Using Nano-Diagnostic Tools: A Critical Review

Fungal-contaminated compounded pharmaceuticals and medical devices pose a public health problem. This review aimed to provide an organized overview of the literature on that critical issue. Firstly, it was found that compounding pharmacies can produce drugs that are contaminated with fungi, leading to outbreaks of severe fungal diseases. Secondly, inadequate sterile compounding techniques or storage conditions, or exceeding the limit of a fungal count, can result in fungal contamination. Lastly, nanotools can be used to rapidly detect fungi, thus improving fungal diagnostic procedures. To achieve this goal, we have reviewed the published data on PubMed, the CDC, and FDA Web sites, and a literature search was undertaken to identify severe fungal infections associated with compounding pharmacies outside of hospitals, limited by the dates 2003 to 2021. The "Preferred Reporting Items for Critical Reviews" were followed in searching, including, and excluding papers. Fungal outbreaks have been documented due to contaminated pharmaceuticals and medical devices. In 2013, 55 people died from fungal meningitis caused by contaminated steroid injections containing methylprednisolone acetate. Additionally, in 2021, Aspergillus penicillioides contamination was reported in ChloraPrep drugs, which was attributed to the storage conditions that were conducive to the growth of this fungus. These incidents have resulted in severe infectious diseases, such as invasive mycoses, cornea infections, Endophthalmitis, and intestinal and gastric mycosis. By implementing preventive measures and policies, it is possible to avoid these outbreaks. Creating Nano-diagnostics presents a major challenge, where promptly diagnosing fungal infections is required to determine the proper corrective and preventive measures.

Simultaneous Bilateral Open-Globe Repair and Vitreoretinal Surgery for Explosive-Related Ocular Injury

Purpose: To report an approach to explosive injuries with simultaneous, co-surgeon bilateral ruptured globe repair and pars plana vitrectomy for bilateral intraocular foreign bodies (IOFBs). Methods: A case and its findings were analyzed. Results: A 31-year-old man had bilateral vision loss after an air compressor malfunction that caused a high-pressure explosion to his face. An examination showed bilateral open-globe injuries and IOFBs, necessitating urgent repair. Given the risk for endophthalmitis and the need for expeditious repair, open-globe repair surgery was performed in both eyes simultaneously by co-surgeons followed by pars plana lensectomy, vitrectomy with IOFB removal, and silicone oil placement. The final visual acuity after bilateral scleral-fixated intraocular lens implantation was 20/20 OD and 20/25 OS. Conclusions: This case of bilateral open-globe injuries and IOFBs required expeditious repair with bilateral, simultaneous surgery that ultimately resulted in excellent visual outcomes. Simultaneous surgery may be an option for bilateral ocular trauma.

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.

Ocular Bacterial Infections: A Ten-Year Survey and Review of Causative Organisms Based on the Oklahoma Experience

Ocular infections can be medical emergencies that result in permanent visual impairment or blindness and loss of quality of life. Bacteria are a major cause of ocular infections. Effective treatment of ocular infections requires knowledge of which bacteria are the likely cause of the infection. This survey of ocular bacterial isolates and review of ocular pathogens is based on a survey of a collection of isolates banked over a ten-year span at the Dean McGee Eye Institute in Oklahoma. These findings illustrate the diversity of bacteria isolated from the eye, ranging from common species to rare and unique species. At all sampled sites, staphylococci were the predominant bacteria isolated. Pseudomonads were the most common Gram-negative bacterial isolate, except in vitreous, where Serratia was the most common Gram-negative bacterial isolate. Here, we discuss the range of ocular infections that these species have been documented to cause and treatment options for these infections. Although a highly diverse spectrum of species has been isolated from the eye, the majority of infections are caused by Gram-positive species, and in most infections, empiric treatments are effective.

Visual Outcomes and Prognostic Factors of Traumatic Endophthalmitis Treated by Pars Plana Vitrectomy: 11 Years Retrospective Analysis

Aim: To evaluate the visual outcome of traumatic endophthalmitis and describe the risk factors associated with poor visual acuity and retinal detachment (RD) development over an 11-year period. Methods: Medical records of 34 patients with traumatic endophthalmitis who underwent PPV over a period of 11 years (1 January 2010−31 December 2020) were reviewed. We extracted details regarding demographic data, initial and final best corrected visual acuity (BCVA) using a standard Snellen chart, wound and IOFB characteristics, ocular associated lesions, and treatment. The outcome was evaluated according to the final BCVA which was defined as poor < 0.1 or good ≥ 0.1 Results: Endophthalmitis rate was 29.8% in open globe injuries. The mean age was 43.6 ± 16.5 years and the majority of patients were males (32 out of 34, 94.1%). All patients received systemic (moxifloxacin) and intravitreal antibiotherapy. We performed pars plana vitrectomy (PPV) in all cases. Poor visual outcome was associated with wound size ≥ 3 mm (p = 0.02), the association of IOFB (p = 0.016), and the development of RD (p = 0.00). The presence of IOFB (p = 0.01) and wound size ≥ 3 mm (p = 0.01) were statistically associated with RD development. After treatment, 47.05% of patients achieved final BCVA ≥ 0.1. Conclusion: Wound size ≥ 3 mm, IOFB and RD were risk factors for poor visual outcomes in traumatic endophthalmitis.

Antibiotic Protocols for Endophthalmitis Prophylaxis Following Open-Globe Repair: A Survey of U.S. Residency Programs

Purpose  To assess the various approaches to endophthalmitis prevention following traumatic open-globe injury (OGI) repair. Methods  A research electronic data capture (REDCap) questionnaire evaluating the usage of antibiotics and steroids in patients with OGI was distributed to program directors of all U.S. ophthalmology residency programs using the Association of University Professors of Ophthalmology program directors' listserv. Completed questionnaires were analyzed for treatment patterns. Results  The REDCap questionnaire was distributed to 111 programs, with 32 residency programs responding. Two responses were excluded. Ninety percent (27/30) of included programs used perioperative intravenous (IV) antibiotics, with 78% (21/27) of those giving one dose only. At the time of surgery, 27% (8/30) of programs gave intravitreal antibiotics and 60% (18/30) gave subconjunctival antibiotics. Postoperatively, 100% (30/30) gave topical antibiotics and 97% (29/30) gave topical steroids. Only 53% of responders discharged patients on oral antibiotics. Of the three programs who did not use IV antibiotics, all three gave intravitreal therapy and one also discharged patients on oral antibiotics. Conclusion  There is a large variation in practice patterns for endophthalmitis prophylaxis among residency programs. Further investigation is needed to compare rates of endophthalmitis between these protocols and establish a safe and minimally burdensome standard of care.

The Impact of Frailty Syndrome on Endogenous Endophthalmitis Development and Outcomes: A Population-Level Analysis

PURPOSE

Characterize the impact of frailty on endogenous endophthalmitis (EE) development and clinical outcomes among septicemic patients.

DESIGN

Population-level, retrospective cohort study.

PARTICIPANTS

Adult inpatients within the National Inpatient Sample (years 2002-2014) diagnosed with bacterial septicemia.

METHODS

Septicemic patients were classified as frail or nonfrail using the previously validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, and diagnosis of EE was abstracted from International Classification of Diseases 9 codes. We used multivariable logistic regression to generate odds ratios (ORs) for rates of EE development and in-hospital mortality based on frailty status. We also examined the association between frailty and blood culture-proven organism class, inpatient length of stay, and total charges billed to insurance.

MAIN OUTCOME MEASURES

Incidence of EE among septicemic patients; rates of EE development among frail and nonfrail patients; blood culture-proven microbe type, length of stay, and total charges billed to insurance.

RESULTS

9294 of 18 470 658 (0.05%) inpatients with bacteremia developed EE, 2102 (22.6%) of whom had at least 1 frailty-defining feature (predominantly malnutrition [68%]). Odds of developing EE were 16.7% higher for frail patients (OR, 1.167; 95% confidence interval, 1.108-1.229) when controlling for age, sex, race, concomitant human immunodeficiency virus/AIDS, pyogenic liver abscess, infectious endocarditis, cirrhosis, and diabetes with chronic complications. Frail EE patients had a 27.9% increased odds of in-hospital death, independent of age, sex, race, and Elixhauser comorbidity score (OR, 1.279; 95% confidence interval, 1.056-1.549). Higher rates of methicillin-resistant Staphylococcus aureus bacteremia (14.3% vs. 10.9%, P = 0.000016), gram-negative bacteremia (7.6% vs. 4.9%, P = 0.000003), and concomitant candidemia (10.4% vs. 7.0%, P = 0.0000004) were associated with frailty. Hospital stays were significantly longer (median, 14 days; interquartile range, 19 days; P < 0.00001) and total charges billed to insurance were significantly greater (median, $96 398; interquartile range, $154,682; P < 0.00001) among frail EE patients.

CONCLUSIONS

Frailty syndrome is independently associated with development of EE in the setting of bacterial septicemia; frailty-associated EE may occur in patients with malnutrition and particular bacterial subtypes, and it predisposes to higher rates of in-hospital death and health care resource usage.

Post-traumatic endophthalmitis prophylaxis: a systematic review and meta-analysis

Purpose

The goal of this study is to determine if certain aspects of endophthalmitis prophylaxis strategies are superior to others.

Design

This investigation is a systematic review and meta-analysis.

Methods

All studies specifying a type of prophylaxis strategy and resulting rates of endophthalmitis were included. Time course, method of administration, and antibiotic regimen, and confounding factors were collected and included for meta-regression.

Results

Time courses greater than 24 h did not significantly improve outcomes. Likewise, intraocular and/or intravenous antibiotic administration methods did not significantly outperform oral administration. No antibiotic regimens performed differently from vancomycin/ ≥ 3rd generation cephalosporin except for ciprofloxacin monotherapy which yielded significantly worse outcomes.

Conclusions

Future antibiotic strategies should strongly consider the risks of antibiotic treatment > 24 h and administration methods other than the oral antibiotic forms. In addition, providers should be wary of using ciprofloxacin monotherapy for endophthalmitis prophylaxis when treating open globe injuries.

The impact of primary repair timing on longitudinal visual outcomes after open globe injury

BACKGROUND

The urgency with which to repair open globe injuries is a debated topic that lacks grounding in longitudinal visual outcomes data. We aim to test the association between primary repair timing and visual recovery potential following OGI.

SUBJECTS/METHODS

We performed a retrospective cohort study of medical records from a US academic medical center (7/2017 to 11/2021). We included all patients with a principal diagnosis of OGI, a documented date and time of injury, presentation, repair, and ≥ 3 months of complete follow-up data on visual outcomes. We excluded those with prior OGI in the same eye. We also tested the correlation of injury to repair time (ITR) in hours with best corrected visual acuity (BCVA, in logMAR units) at last follow-up in the general cohort and select subpopulations and the impact of repair delay on visual improvement over the follow-up period.

RESULTS

One hundred twenty-nine patients with OGI were analyzed (91 patients with ≥ 3 months of follow-up). The majority were male (105/129, 81%) with a median age of 45 years. Most OGI involved zone 1 (57%), followed by zone 3 (24%), and zone 2 injuries (19%). Median ocular trauma score (OTS) was 60 (IQR 37-70); mean presenting BCVA was logMAR 1.9 (median 2.3, IQR 1.0-2.7). Median ITR was 22 h (IQR 15-30 h, range 5-199 h). ITR time did not significantly correlate with final BCVA (n = 91, β = - 0.003, 95% CI - 0.009-0.002, P = 0.233), nor did it significantly increase the odds of developing ocular complications or requiring secondary ocular surgeries (OR 0.985, 95% CI 0.967-1.002, P = 0.085). Additionally, the rate of BCVA improvement over subsequent months of follow-up did not significantly differ based on ITR time. Presenting BCVA (R² = 0.701, P < 0.001) and OTS (R² = 0.477, P < 0.001) significantly correlated with final BCVA, independent of repair delays.

CONCLUSIONS

In this cohort of OGI patients, repair timing does not significantly correlate with final BCVA, and delays beyond 24 h do not significantly correlate with worse visual recovery potential. Repair time alone should be emphasized to a lesser extent as a prognosticator of visual potential, in favor of significant predictors such as the ocular trauma score and presenting visual acuity.

Risk factors for globe removal after open-globe injury in agricultural regions

This study aimed to identify the prevalence and risk factors for globe removal among patients with open-globe injuries (OGIs) in agricultural regions. A retrospective chart review of patients with OGIs was performed between January 2010 and December 2019. Univariable and multivariable logistic regression models were used to identify the factors associated with globe removal in OGI. This study included 422 patients (422 eyes). The highest prevalence of OGI was observed in the middle age group (> 20 to 40 years). The most common cause of OGIs was agriculture-related injury (54.7%), followed by industry or workplace-related injury (20.4%), and assault (5.0%). Intraocular foreign bodies, endophthalmitis, and panophthalmitis were reported in 57.6%, 28.4%, and 5.7% of cases, respectively. Eight eviscerations and 43 enucleations were performed, accounting for 12.1% of OGIs. The most common indication for globe removal was panophthalmitis. Multivariable analysis revealed that the predictive factors significantly associated with globe removal were assault injuries (adjusted odds ratio (aOR) = 5.53; p = 0.026), presenting logarithm of the minimum angle of resolution visual acuity (aOR = 311.79; p < 0.001), and endophthalmitis and panophthalmitis (aOR = 3.58 and 734.94, respectively; p < 0.001). This knowledge would aid in patient counseling and encourage health promotion.

Update on Current Microbiological Techniques for Pathogen Identification in Infectious Endophthalmitis

Infectious endophthalmitis is a vision-threatening medical emergency that requires prompt clinical diagnosis and the initiation of treatment. However, achieving precision in endophthalmitis management remains challenging. In this review, we provide an updated overview of recent studies that are representative of the current trends in clinical microbiological techniques for infectious endophthalmitis.

INCIDENCE AND RISK FACTORS OF POSTOPERATIVE ENDOPHTHALMITIS AFTER PRIMARY SURGICAL REPAIR COMBINED WITH INTRAOCULAR FOREIGN BODY REMOVAL

PURPOSE

To analyze the incidence and risk factors of postoperative endophthalmitis after primary surgical repair and intraocular foreign body (IOFB) removal within 24 hours of injury.

METHODS

The records of all patients treated surgically for open globe injury and IOFB removal at the Eye Hospital of Shandong First Medical University between January 1, 2015, and June 30, 2020, were retrospectively reviewed. Variables included time from injury to operation, cause of injury, details of surgical repair, and follow-up. The incidence and risk factors of endophthalmitis after IOFB removal were studied.

RESULTS

During 5 years, 99 patients with IOFB were reviewed. Of these, 19 patients were diagnosed with endophthalmitis on admission, and 5 were suspected of having endophthalmitis during operation. Fifty-four cases had no clinical signs of endophthalmitis on admission and during operation and were treated with operation within 24 hours after the injury. Two patients (2 of 54; 3.70%) developed endophthalmitis after IOFB removal, and the causative agent in both cases was Bacillus cereus.

CONCLUSION

The incidence of infectious endophthalmitis after primary surgical repair combined with IOFB removal (≤24 hours) was 3.70% in patients who received a series of standard treatments, and B. cereus infection might be a risk factor.

Endophthalmitis, Visual Outcomes, and Management Strategies in Eyes with Intraocular Foreign Bodies

Purpose

Patients and Methods

Results

Conclusion

LAWN TRIMMER-RELATED OPEN-GLOBE INJURIES IN TAIWAN

PURPOSE

Work-related ocular trauma remains the leading cause of unilateral visual impairment worldwide. Many preventable work-related ocular injuries continue to occur, even at home. This study describes the characteristics, surgical techniques, and prognostic factors of lawn trimmer-related open-globe injuries in eastern Taiwan.

METHODS

This was a retrospective, consecutive case series study. Slit-lamp biomicroscopy, dilated fundoscopy, and orbital computed tomography (CT) images were collected.

RESULTS

Twenty-six eyes of 26 patients were enrolled in the study. Fifteen patients (57.7%) had an intraocular foreign body (IOFB). The IOFB was metallic in 13 cases and glass and stone in the other 2 cases. Seven IOFBs (46.7%) were retained in the anterior chamber, 7 (46.7%) in the posterior segment, and 1 (6.7%) in the intraconal space. Univariate analysis showed that the presence of IOFB trended toward the development of endophthalmitis; however, this was not statistically significant (hazard ratio, 2.25; 95% confidence interval 0.35-14.61; P = 0.658). Eleven patients had metallic IOFBs noted on CT scans with metal artifacts, whereas two patients had small metallic IOFBs without metal artifacts. One patient had a glass IOFB mimicking metal artifacts on the CT scan. In one case, CT failed to reveal the IOFB, and an intralenticular metallic foreign body was incidentally found intraoperatively.

CONCLUSION

Our study provides a broad characterization of lawn trimmer-related open-globe injuries. The informative and diverse findings of IOFBs on CT scans will help clinicians detect and recognize IOFBs more precisely and perform the surgery without causing further damage.

A Comparative Evaluation of Globe Trauma Features in a Tertiary Care Hospital Before and During the COVID-19 Pandemic

Objectives

To compare the clinical features, preoperative evaluation, and surgical approaches of globe trauma patients presenting to the emergency department before and during the coronavirus disease 2019 (COVID-19) pandemic.

Materials and Methods

We retrospectively analyzed 54 eyes of 54 patients with traumatic globe perforation who underwent primary globe repair. The patients were divided into two groups according to the official start of the COVID-19 pandemic in Turkey: Group 1, 1 May 2019-11 March 2020 and Group 2, 11 March 2020-1 January 2021. The demographic features, trauma history, time from trauma to admission and from admission to surgery, COVID-19 serology (polymerase chain reaction [PCR]) result, ophthalmological examination findings at admission, surgical interventions, and postoperative clinical features were obtained from the patients' records.

Results

The mean ages of the patients in Group 1 (n=21) and Group 2 (n=33) were 42.76±20.72 and 37.78±23.47 years, respectively (p=0.431). During the pandemic, garden/farm injuries increased while workplace injuries decreased. In Groups 1 and 2 respectively, time from trauma to admission was 461.4±1228.6 and 935.4±2039.6 min (p=0.342), time from admission to surgery was 604.2±679.8 and 392.7±306.9 min (p=0.125), and length of hospital stay was 7.23±4.96, and 3.78±2.28 days (p<0.005). All patients had a COVID-19 PCR test and all resulted negative. There was no significant difference between the groups in terms of the clinical features of the ocular and adnexal injuries, surgical interventions, or postoperative complications (p>0.05). Preoperative visual acuity was found to be an important prognostic factor associated with postoperative visual acuity.

Conclusion

Globe injuries require urgent intervention in terms of visual morbidity. Patterns of injury differ during the pandemic due to both restrictions and lifestyle changes. During the pandemic, patients were discharged as soon as possible after emergency treatment to minimize the time spent in the hospital.

Epidemiological characteristics and prognostic factors of post-traumatic endophthalmitis

Objective

To examine the prognostic factors and features of post-traumatic endophthalmitis.

Methods

This retrospective study enrolled adult patients (>18 years old) diagnosed with post-traumatic endophthalmitis. Their medical records were reviewed and the patient demographic characteristics, features of injury, management, outcomes and microbiology data were analysed.

Results

A total of 131 eyes from 131 patients were enrolled. Post-traumatic endophthalmitis was more common in male patients (122 of 131 patients: 93.1%), in those aged 30–44 years (51 of 131 patients: 38.9%), in those injured with a metallic object (86 of 131 patients; 65.6%), in those with a penetrating injury (90 of 131 patients; 68.7%) and those that were injured at work (106 of 131 patients; 80.9%). The mean ± SD time of presentation to the hospital and developing endophthalmitis was 40.60 ± 19.32 h and 5.19 ± 2.55 days, respectively. Of the cultures, 84 of 131 (64.1%) were negative and 22 of 131 (16.8%) were positive for Staphylococcus species. Patients with delayed presentation, an intraocular foreign body, traumatic cataract, retinal detachment, larger wounds, positive smears and cultures and work-related injuries had worse outcomes.

Conclusion

Immediate presentation to an ophthalmic centre and timely diagnosis and intervention may lead to better outcomes.

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.

ENDOPHTHALMITIS IN OPHTHALMOLOGICAL REFERRAL CENTRE IN COLOMBIA: AETIOLOGY AND MICROBIAL RESISTANCE

AIMS

To describe the aetiology and microbial susceptibility profile of endophthalmitis cases treated at an ophthalmological referral centre in Colombia.

MATERIAL AND METHODS

A retrospective descriptive study was carried out with all endophthalmitis cases referred to the Fundación Oftalmológica de Santander FOSCAL (Floridablanca, Colombia) from 1 January 2012 to 31 December 2015.

RESULTS

121 eyes of 121 patients were evaluated. 77.7% of them were male and the mean age was 42.9 years. Five of them (4.1%) corresponded to endogenous endophthalmitis, and 116 (95.9%) to exogenous endophthalmitis. Of the latter, 66.9% were associated with trauma (almost one-half of them associated with intraocular foreign body), and 29.5% with intraocular surgery. The most common isolated microorganisms in the exogenous endophthalmitis group corresponded to methicillin-resistant and methicillin-sensitive strains of Staphylococcus epidermidis and Staphylococcus aureus, which were mostly susceptible to imipenem, vancomycin and moxifloxacin and resistant to ceftazidime.

CONCLUSION

Endophthalmitis is a potentially sight-threatening condition, especially in cases of inadequate treatment. Therefore, antimicrobial therapy should be guided by vitreous humour culture to assure that the causative microorganism is susceptible to the selected agent. The results of our study lead us to propose vancomycin, moxifloxacin or imipenem as first-line antimicrobial options.

Effect of Lockdown and Unlock Following COVID-19 on the Presentation of Patients With Endophthalmitis at a Tertiary Eye Center Over One Year

Introduction Endophthalmitis is an emergency where patients need immediate intervention to salvage both vision and the globe. Regular follow-up care and close monitoring of the status of the patient are crucial in determining the final outcomes of the treatment. While there is ample literature on the epidemiology and demography of endophthalmitis across the globe, no information exists on the effect of the coronavirus disease 2019 (COVID-19) pandemic on the presentation patterns of endophthalmitis. Objectives To describe the impact of the lockdown and unlock phases of the COVID-19 pandemic on the presentation of endophthalmitis at a tertiary eye care center in India. Methods This cross-sectional hospital-based study included 1,253 patients presenting between March 25, 2017, and March 31, 2021. The data on the patients diagnosed with endophthalmitis in one or both eyes presenting during the lockdown and unlock phases were compared with the respective time periods in the previous three years before COVID-19. Results The patient numbers dropped to 42.18% (27/64) of pre-COVID-19 volumes during the lockdown phase. There was a near-complete recovery of the outpatient numbers to 85.71% (26/30) of pre-COVID-19 volumes by March 2021. This gradual incremental trend was seen in etiology due to post-surgery (88%) and endogenous (159%) infections while post-traumatic (67%) and post-infection (0%) infections were lower than pre-COVID-19 volumes by March 2021. There was a slight increase in the proportion of patients with acute endophthalmitis (88.93% vs 86.20%; p=0.76) presenting during the COVID-19 phase as compared to the pre-COVID-19 phase. The proportion of patients requiring inter-state travel showed complete recovery to 107% of pre-COVID-19 distribution by March 2021. Conclusion The first year of the COVID-19 pandemic saw a decline of over half the number of patients with endophthalmitis accessing eye care services. There was an increase in the presentation of endogenous endophthalmitis and a decrease in post-traumatic forms. Patients requiring inter-state travel recovered during the unlock phase.

Comparative Genomic and Pan-Genomic Characterization of Staphylococcus epidermidis From Different Sources Unveils the Molecular Basis and Potential Biomarkers of Pathogenic Strains

Coagulase-negative Staphylococcus (CoNS) is the most common pathogen causing traumatic endophthalmitis. Among which, Staphylococcus epidermidis is the most common species that colonizes human skin, eye surfaces, and nasal cavity. It is also the main cause of nosocomial infection, specially foreign body-related bloodstream infections (FBR-BSIs). Although some studies have reported the genome characteristics of S. epidermidis, the genome of ocular trauma-sourced S. epidermidis strain and a comprehensive understanding of its pathogenicity are still lacking. Our study sequenced, analyzed, and reported the whole genomes of 11 ocular trauma-sourced samples of S. epidermidis that caused traumatic endophthalmitis. By integrating publicly available genomes, we obtained a total of 187 S. epidermidis samples from healthy and diseased eyes, skin, respiratory tract, and blood. Combined with pan-genome, phylogenetic, and comparative genomic analyses, our study showed that S. epidermidis, regardless of niche source, exhibits two founder lineages with different pathogenicity. Moreover, we identified several potential biomarkers associated with the virulence of S. epidermidis, including essD, uhpt, sdrF, sdrG, fbe, and icaABCDR. EssD and uhpt have high homology with esaD and hpt in Staphylococcus aureus, showing that the genomes of S. epidermidis and S. aureus may have communicated during evolution. SdrF, sdrG, fbe, and icaABCDR are related to biofilm formation. Compared to S. epidermidis from blood sources, ocular-sourced strains causing intraocular infection had no direct relationship with biofilm formation. In conclusion, this study provided additional data resources for studies on S. epidermidis and improved our understanding of the evolution and pathogenicity among strains of different sources.

Fungal Endophthalmitis: A Comprehensive Review

Endophthalmitis is a serious ophthalmologic condition involving purulent inflammation of the intraocular spaces. The underlying etiology of infectious endophthalmitis is typically bacterial or fungal. The mechanism of entry into the eye is either exogenous, involving seeding of an infectious source from outside the eye (e.g., trauma or surgical complications), or endogenous, involving transit of an infectious source to the eye via the bloodstream. The most common organism for fungal endophthalmitis is Candida albicans. The most common clinical manifestation of fungal endophthalmitis is vision loss, but other signs of inflammation and infection are frequently present. Fungal endophthalmitis is a clinical diagnosis, which can be supported by vitreous, aqueous, or blood cultures. Treatment involves systemic and intravitreal antifungal medications as well as possible pars plana vitrectomy. In this review, we examine these essential elements of understanding fungal endophthalmitis as a clinically relevant entity, which threatens patients’ vision.

Comparison of causative microorganisms of posttraumatic endophthalmitis with and without retained intraocular foreign bodies

Background

The goals of this work were to report the demographic characteristics of patients with clinically diagnosed endophthalmitis with or without intraocular foreign bodies (IOFBs) and to analyze the causative microorganisms.

Methods

A retrospective analysis was conducted on 1257 patients with clinically diagnosed posttraumatic endophthalmitis who were admitted to Zhongshan Ophthalmic Center between January 1, 2013, and August 31, 2020.

Results

Of the 1257 patients with clinically diagnosed posttraumatic endophthalmitis, 452 (36.0%) patients had IOFBs. Male dominance was more common among the patients with IOFBs than the patients without IOFBs. The average age of the patients with IOFBs was older than that of the patients without IOFBs. The most common microbial pathogens in these two groups were Gram-positive cocci and Gram-negative bacilli. Gram-positive bacilli were more common in the patients with IOFBs than in those without IOFBs (17.9 vs. 9.4%), and Bacillus spp. accounted for 12.6 and 5.5%, respectively. Fungi were less abundant in the patients with IOFBs than in those without IOFBs (8.0 vs. 15.6%).

Conclusions

Patients with IOFBs were mostly male and older than those without IOFBs. Gram-positive bacilli were more common and fungi were less common in patients with IOFBs than in those without IOFBs.

Changing patterns of posterior segment trauma during the COVID-19 pandemic: A regional analysis from the Bodhya Eye Consortium

Purpose

To assess changes in the presentation patterns of posterior segment trauma during the COVID-19 pandemic from six tertiary eye care institutes of North and Central India.

Methods

A multicenter, hospital-based, retrospective comparative analysis of patients presenting with posterior segment trauma was done during the COVID-19 (Group A) (March 25, 2020 - September 30, 2020) period and the pre-COVID-19 (Group B) (March 25, 2019 - September 30, 2019) period.

Results

A total of 405 patients were diagnosed with posterior segment trauma (Group A: 206, Group B: 199). The time interval between onset of trauma and presentation was higher in Group A (16.59 ± 29.87 days) as compared to Group B (9.41 ± 19.19 days) (P = 0.004). A majority of patients in Group A had a history of prior consultation before presentation (P = 0.049). In Group A, 120 (58.2%) patients sustained ocular trauma at home as compared to 80 (40.2%) patients in Group B (P < 0.0001). Patients presenting with light perception were significantly more in Group A (43.7%) as compared to Group B (30.2%) (P = 0.004). In Group B, 37.6% patients had presenting visual acuity of counting finger or better as compared to 27.6% patients in Group A (P = 0.07). Patients in Group A had a significantly higher proportion of post-traumatic endophthalmitis with delayed presentation (P = 0.011) and retinal detachment (P = 0.041). Patients undergoing surgery for foreign-body removal were significantly fewer in Group A (P = 0.05).

Conclusion

Although the number of patients presenting with posterior segment trauma was comparable in Groups A and B, a greater number of patients sustained home injuries during the COVID-19 pandemic. A majority of these patients had delayed presentation with poor presenting visual acuity and a higher tendency of retinal detachment.

Mechanism and prognostic indicators for explosion-related eye trauma: eye injury vitrectomy study

PURPOSE

To explore the clinical features, surgical interventions and prognosis of injured eyes following explosion and to develop the risk factors for poor prognosis.

METHODS

A nested case-control study. To the date of 31 December 2018, 99 explosion-related eye globes were selected from the Eye Injury Vitrectomy Study database, which is a multicenter prospective cohort study and began in 1990s. All cases selected underwent vitreoretinal surgery or enucleation and were followed up for at least 6 months. Clinically meaningful preoperative variables and outcomes were used to develop logistic regression models.

RESULTS

The unfavourable outcomes were defined as silicone oil-filled eyes, phthisis bulbi, enucleation and anatomically restored eyes whose final BCVA is worse than initial vision after 6 months of follow-up. The proportion of unfavourable outcomes was 92.0%, 60.9% and 66.7% in large festive fireworks, detonator and beer bottle groups respective. The anatomic and visual outcome of injured eyes with combined injury of blast wave and projectile were worse than that of ruptured eyes (Fisher's exact = 0.041). The extrusion of iris/lens (OR = 3.20, p = 0.015), PVR-C (OR = 6.08, p = 0.036) and choroid damage (OR = 5.84, p = 0.025) is independent risk factors of unfavourable prognosis for explosion-related eye trauma.

CONCLUSION

The extrusion of iris/lens, PVR-C and choroid damage is the independent risk factors for unfavourable outcomes in explosion-related eye trauma. There is a unique injury mechanism in explosion-related eye trauma.

SUMMARY STATEMENT

Through the nested case-control study, the extrusion of iris/lens, PVR-C, and choroid damage are the independent risk factors for unfavorable outcomes in explosion-related eye trauma. The mechanism of open globe mixture and close globe mixture in explosion-related eye trauma need more cases and participating units to explore together in the future.

Good Visual Outcome in Post Traumatic Exogenous Endophthalmitis Caused by Trichophyton Species

Trichophyton species is a dermatophytic fungus commonly found in the skin, nails, hair, and other organic matters such as palm trees and soil. We report a rare case of a 23-year-old man who had a penetrating injury to the eye from the leaves of a palm tree and subsequently developed exogenous endophthalmitis. Culture from the vitreous tap revealed Trichophyton sp as the causative organism. Early vitrectomy and adequate intravitreal injection of amphotericin B resulted in good visual outcomes in an otherwise blinding condition. This is the first reported case of exogenous endophthalmitis secondary to Trichophyton species. Early diagnosis and prompt treatment may help improve visual outcomes.

Intraocular Foreign Bodies: Clinical Characteristics and Factors Affecting Visual Outcome

Objective

To investigate the clinical characteristics and factors affecting visual outcome in patients with intraocular foreign bodies (IOFBs) and determine the risk factors for the development of endophthalmitis. Study Design. A retrospective case-series study design was adopted.

Subjects

In total, 242 patients (242 eyes) who were hospitalized and underwent surgical treatment for IOFB at the Second Hospital of Hebei Medical University between January 1, 2008, and December 31, 2019, were included.

Methods

The demographic data, cause of injury, characteristics of IOFBs, postinjury ocular manifestations, and surgical details of the subjects were collected, and the factors affecting visual outcome and endophthalmitis development were analyzed.

Results

The most common cause of IOFBs was the propulsion of foreign bodies into the eye due to hammering (149 cases, 61.57%), followed by foreign body penetration (57 cases, 23.55%). Most of the subjects were young adult men who sustained injuries in the work environment. Poorer visual outcomes were found in subjects with initial presenting symptoms visual acuity (PVA) < 0.1, largest IOFB diameter ≥ 3 mm, IOFBs located in the posterior segment, wound length > 5 mm, entrance wound length larger than the largest IOFB diameter, concomitant retinal detachment, concomitant vitreous hemorrhage, concomitant endophthalmitis, and concomitant proliferative vitreoretinopathy (PVR). Factors related to the development of endophthalmitis included lens capsule rupture, time of stage 1 repair surgery ≥ 24 h after trauma, removal of IOFBs ≥ 24 h after trauma, and nonadministration of intravitreal antibiotic injection.

Conclusion

Among patients with IOFBs, initial PVA < 0.1, entrance wound length larger than the largest IOFB diameter, concomitant endophthalmitis, and concomitant PVR were risk factors for poor visual outcomes. Lens capsule rupture was a risk factor for endophthalmitis development, and the administration of intravitreal antibiotic injection was a protective factor against endophthalmitis development.

Immune Inhibitor A Metalloproteases Contribute to Virulence in Bacillus Endophthalmitis

Endophthalmitis is a devastating infection that can cause blindness. Over half of Bacillus endophthalmitis cases result in significant loss of useful vision. Bacillus produces many virulence factors that may contribute to retinal damage and robust inflammation. We analyzed Bacillus immune inhibitor A (InhA) metalloproteases in the context of this disease, hypothesizing that InhAs contribute to Bacillus intraocular virulence and inflammation. We analyzed phenotypes and infectivity of wild type (WT), InhA1-deficient (ΔinhA1), InhA2-deficient (ΔinhA2), or InhA1, A2, and A3-deficient (ΔinhA1-3) Bacillus thuringiensis. In vitro analysis of growth, proteolysis, and cytotoxicity were compared. WT and InhA mutants were similarly cytotoxic to retinal cells. Mutants ΔinhA1 and ΔinhA2 entered log phase growth earlier than WT. Proteolysis by the ΔinhA1-3 mutant was decreased, but this strain grew similar to WT in vitro. Experimental endophthalmitis was initiated by intravitreally infecting C57BL/6J mice with 200 CFU of B. thuringiensis WT or InhA mutants. Eyes were analyzed for intraocular Bacillus and myeloperoxidase concentrations, retinal function loss, and gross histological changes. Eyes infected with ΔinhA1 or ΔinhA2 strains contained greater numbers of bacteria than eyes infected with WT throughout the infection course. Eyes infected with single mutants had inflammation and retinal function loss similar to eyes infected with WT strain. Eyes infected with ΔinhA1-3 cleared the infection. RT-PCR results suggested that there may be compensatory expression of the other InhAs in the single InhA mutant. These results indicate that together, the InhA metalloproteases contribute to the severity of infection and inflammation in Bacillus endophthalmitis.

Outcomes and Prognostic Factors of Posttraumatic Endophthalmitis: A Three-Year Retrospective Study

Purpose

To describe the clinical features, management, and outcomes of patients with posttraumatic endophthalmitis (PTE) and to determine risk factors for poor visual prognosis.

Methods

We retrospectively reviewed the medical records of 42 consecutive patients presenting with PTE who were treated at our institution between 2017 and 2019. Each patient's data, including demographic characteristics, ocular injury details, surgical records, patient outcomes, and laboratory results, were collected and analyzed. Multivariate analysis was conducted to determine the factors associated with poor visual outcomes.

Results

In our series, male (n = 36, 85.7%) and patients below 60 years of age (20–40 years, 23.8%; 40–60 years, 57.14%) comprised most of the total cohort. On presentation, 39 (92.8%) of the 42 PTE patients presented best-corrected visual acuity (BCVA) worse than counting fingers. Pars plana vitrectomy (PPV) was performed in all the patients. 59.5% (n = 25) of the patients' BCVA improved after surgery and 33.3% (n = 14) achieved BCVA of 20/200 or better. The rate of evisceration was 7.1% (n = 3). Of the 42 specimens, the culture was positive in 10 (23.8%) eyes. By univariate analysis, factors including sex, occupation, systemic disease, source of trauma, lens injury, silicone oil tamponade, usage of intravitreal antibiotics, BCVA at presentation, and culture positive for any organism did not affect the final visual outcome. The features associated with poor BCVA (grouped as < 20/200 and ≥ 20/200) included older age (P=0.035), corneal-sclera wound (versus sclera wound) (P=0.047), retained intraocular foreign bodies (IOFBs) (P=0.006), treatment > 3 days (versus < 1 day) (P=0.033), and more times of surgeries (P=0.033).

Conclusions

PTE is a severe complication of penetrating globe injuries associated with irreversible visual loss. Our results highlighted the importance of conducting early therapeutic PPV and IOFB removal to achieve better visual outcomes.

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.

Post-Traumatic Endophthalmitis: Clinico-Microbiological Profile, Antimicrobial Susceptibility and Prognostic Factors at a Tertiary Eye Care Centre in Eastern India

Purpose: To analyse clinico-microbiological profile, antimicrobial susceptibilities, and visual prognostic factors in post-traumatic endophthalmitis (PTE).Methods: Retrospective clinico-microbiological data analysis for five years (2014-18). Prognostic factors for visual outcomes were analysed by multivariate logistic regression analysis.Results: Four hundred and eighteen patients with clinically diagnosed PTE were analysed. Culture positivity was found in 46.7% samples (44.5% vitreous, 83.3% non-vitreous). Pathogens isolated were Gram positive cocci (GPC, 49.3%, good susceptibility to vancomycin/cefazolin), Gram negative bacilli (GNB, 28.1%, <90% susceptibility to all antibiotics and 25.8% multidrug resistance), Gram positive bacilli (13.1%) and fungi (9.5%). Poor visual prognosis was associated with culture positivity, fungal or polymicrobial PTE, poor view of fundus and presence of membranes on ultrasound scans.Conclusion: GPC and GNB are the predominant pathogens in PTE, with GNB most commonly multidrug resistant. Culture positivity, polymicrobial and fungal PTE, poor view of fundus and vitreous membranes are markers of poor visual outcome.

Posttraumatic Bacillus cereus Endophthalmitis: Clinical Characteristics and Antibiotic Susceptibilities

Purpose

To report the clinical characteristics, antibiotic susceptibilities, and visual outcomes of patients with posttraumatic endophthalmitis caused by Bacillus cereus.

Methods

In this retrospective, noncomparative case series, the medical records of eyes with culture-proven Bacillus cereus endophthalmitis treated from January 2016 to December 2019 at a referral center were reviewed. Clinical features, antibiotic susceptibilities, and visual outcomes were assessed.

Results

A total of 19 eyes of 19 patients were identified. Three patients progressed to orbital cellulitis. Vitrectomy was performed in 13 eyes, and 11 required silicone oil tamponade. Finally, seven eyes underwent silicone oil removal surgery during follow-up. Only two patients retained a visual acuity better than FC. Four patients underwent evisceration, and three patients had NLP. The cultured Bacillus cereus was sensitive to levofloxacin, ofloxacin, tobramycin, and neomycin at 100%.

Conclusions

The visual outcomes of posttraumatic Bacillus cereus endophthalmitis were generally poor regardless of the prophylactic and therapeutic measures administered. Vitrectomy combined with silicone oil tamponade could help to save the eyeball. Bacillus cereus has a good susceptibility to ofloxacin, levofloxacin, tobramycin, and neomycin; therefore, fluoroquinolones and aminoglycosides can be used to treat Bacillus cereus infection.

Prognostic factors and long-term outcomes of eye-globe perforation: Eye injury vitrectomy study

PURPOSE

To delineate anatomic and visual outcomes of injured eye globes with perforating, and to develop the prognostic indicators for perforating eyes.

METHODS

The case series study, from a multicenter prospective cohort database. To the date of December 31st, 2018, of 63 perforating globes were selected. All cases underwent vitreoretinal surgeries or enucleations, and were followed up for at least 6 months. Demographic characteristics, basic examination for traumatized eyes, and intraocular tissue damages were recorded by surgery-in-chief. At the follow-up visit, best corrected VA, intraocular pressure, the intraocular tamponade material, retinal anatomic outcome of eye-globes, and phthisis or enucleation were evaluated.

RESULTS

Fifty injured eyes (79%) were caused by sharp objects and 13 eyes (21%) were injured by a missiles. Twenty-two injured eyes can be anatomically restored with final vision of more than 4/200 through vitreoretinal surgery. The PVR-C (OR = 5.67, P = 0.01), area of retinectomy more than 2 times of optic disk (OR = 5.16, P = 0.04), and macular damage (OR = 6.38, P = 0.01) were correlated with unfavorable outcomes.

CONCLUSION

The injured eyes with perforation can be saved through vitreoretinal surgery, the PVR-C, retinectomy more than 2 times of optic disk, and macular damage were independent risk factors for poor long-term prognosis.

Post-traumatic endophthalmitis with Moraxella in a child

Purpose: To describe a case of post-traumatic endophthalmitis with Moraxella in a child. Methods: Case report of an 11-year-old boy who presented with redness and profound visual loss in his left eye for 3 days following trauma with a sewing needle. Detailed ophthalmic examination showed hand movement vision, corneal edema with mobile hypopyon, as well as dot and clump echoes in Ultrasound B-scan. The clinical diagnosis of acute post-traumatic endophthalmitis was made. Result: The patient underwent pars plana vitrectomy and vitreous biopsy, and was given intravitreal antibiotics (vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, voriconazole 0.1 mg/0.1 ml). Non-pigmented small colonies growth was observed on culture plates which were identified as Moraxella. Conclusion: To date, no case report has been published regarding post-traumatic endophthalmitis due to Moraxella species in the pediatric age group.

Wood-Related Open-Globe Injuries

Purpose:

This work evaluates the clinical characteristics, visual outcomes, and complications of patients treated for open-globe injuries (OGIs) caused by wooden objects.

Methods:

A retrospective review of medical records was conducted on patients presenting to a tertiary trauma center with an OGI between January 2005 and December 2017. Medical records were isolated for wounds caused by wooden objects. Patient demographics were recorded, with presenting visual acuity (VA), physical examination findings, and wound characteristics. After primary globe repair, secondary complications, need for additional surgery, and visual outcomes were noted until final examination. Main outcome measures were final VA and secondary complications. The Ocular Trauma Score (OTS) was computed and assessed for clinical relevance related to visual outcomes.

Results:

Thirty-two patients met the inclusion criteria, with 15 (47%) being injured by plant material. Thirty of the patients were men (94%). A large portion of patients presented with hand motion or worse vision (48%), and there were high rates of hyphema (59%), vitreous hemorrhage (31%), retinal detachment (28%), and endophthalmitis (9%). Two patients eventually required enucleation. At last follow-up, 19 patients achieved 20/100 VA or better (59.4%), which correlated with their OTS ( P < .001).

Conclusions:

Despite the high clinical severity of wood OGIs, the potential for visual recovery remains high. The OTS appropriately assesses the severity of injuries and the likely prognosis in this cohort of patients.

Exogenous Fungal Endophthalmitis: Clues to Aspergillus Aetiology with a Pharmacological Perspective

Exogenous fungal endophthalmitis (EXFE) represents a rare complication after penetrating ocular trauma of previously unresolved keratitis or iatrogenic infections, following intraocular surgery such as cataract surgery. The usual latency period between intraocular inoculation and presentation of symptoms from fungal endophthalmitis is several weeks to months as delayed-onset endophthalmitis. Aspergillus spp., is the most common causative mould pathogen implicated in this ocular infection and early diagnosis and prompt antimicrobial treatment, concomitantly in most cases with expert surgical attention, reduce unfavorable complications and increase the possibility of eye function preservation. Topical, intravitreal and systemic antifungal molecules are the mainstay of a medical approach to the disease and azoles, polyenes and in particular cases echinocandins are the pharmacological classes most commonly used in clinical practice. This review discusses pharmacokinetics and pharmacodynamic of antifungal agents in their principal modes of administration with a focus on their ability to achieve high drug concentration in the vitreous and ocular tissues.

Poor prognostic factors in post-traumatic endophthalmitis following open globe injury

AIM

To demonstrate prognostic factors for poor visual outcome in patients with post-traumatic endophthalmitis (PTE) following open globe injury.

METHODS

A retrospective study was conducted on 66 patients (66 eyes) with PTE following open globe injury from 2005 to 2015. Potential factors accounting for good and poor visual outcome were statistically analyzed by Chi-square test and Logistic regression model.

RESULTS

In 66 cases, 39 cases (59%) had a poor visual outcome. Univariate and multivariate Logistic regression analysis identified retained intraocular foreign body (IOFB) as the only factor significantly associated with poor visual outcome [adjusted odds ratio, 4.62; 95% confidence interval (1.04-20.53); P=0.04]. The most common causative agents were gram-positive organisms (83%), of which Bacillus cereus (33%), was the most common pathogen. All cases received intravitreal antibiotic injections. Oral ciprofloxacin was the most used systemic antibiotic (33%). Pars plana vitrectomy was performed in 83% (55/66) of cases. At 6mo follow-up, mean BCVA was 1.74±0.72 logMAR units.

CONCLUSION

In patients with PTE following open globe injury, the only predictor of poor visual outcome is the presence of IOFB. Bacillus cereus is the most isolated microorganism.

Successful Treatment of Acute Endophthalmitis after Cat Bite: A Case Report and Review of the Literature

Endophthalmitis after cat bite has poor outcome particularly those associated with scleral injury. A 33-year-old Caucasian female was seen by her ophthalmologist 4 days after cat bite to her right eye with hand motion vision and obvious signs of acute endophthalmitis. She was treated with exploration and repair of scleral puncture wound, anterior chamber and vitreous cultures and intravitreal injections of vancomycin and ceftazidime. Cultures were positive for alpha hemolytic Streptococcus. She underwent a pars plana vitrectomy, cultures and repeat injection of the same antibiotics and intravitreal dexamethasone 2 days later. Cultures grew Bacillus. Endophthalmitis resolved and she regained 20/20 vision after cataract surgery 3 months later. Successful outcome of acute endophthalmitis following a cat bite to the sclera in this case was most likely due to prompt intravitreal antibiotics and early vitrectomy combined with supplemental intravitreal antibiotics and steroid therapy.

Antimicrobial guide to posterior segment infections

PURPOSE

This review article is meant to serve as a reference guide and to assist the treating physician in making an appropriate selection and duration of an antimicrobial agent.

METHODS

Literature review.

RESULTS

Infections of the posterior segment require prompt medical or surgical therapy to reduce the risk of permanent vision loss. While numerous options exist to treat these infections, doses and alternative therapies, especially with contraindications for first-line therapy, are often elusive. Antimicrobial agents to treat posterior segment infections can be administered via various routes, including topical, intravitreal, intravenous, and oral.

CONCLUSIONS

Although there are many excellent review articles on the management of endophthalmitis, we take the opportunity in this review to comprehensively summarize the appropriate antimicrobial regimen of both common and rare infectious etiologies of the posterior segment, using evidence from clinical trials and large case series.