Endophthalmitis after deadly-weapon-related open-globe injuries: risk factors, value of prophylactic antibiotics, and visual outcomes

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.

Clinical characteristics and prognostic factors of open globe injuries in a North Spain population: a 10-year review

OBJECTIVES

To describe the epidemiologic and clinical characteristics of open globe injuries (OGIs) treated in a tertiary hospital and analyse predictors of visual outcome.

METHODS

This retrospective observational study included all patients with OGIs admitted to Cruces University Hospital between 2010 and 2020. The descriptive analysis included demographic data, type of injury classified as "rupture", "penetration", "perforation", or "intraocular foreign body", trauma mechanism and setting, injury zone, Ocular Trauma Score, delay to surgery, length of hospital stay, antibiotic prophylaxis, initial and final best corrected visual acuity (BCVA), complications and further surgery. Univariate analysis and logistic regression were performed to identify prognostic factors, based on final BCVA.

RESULTS

Overall, 207 OGI cases were reported. The most common type of injuries were ruptures caused by domestic falls. Notably, 44.4% of eyes developed phthisis bulbi. In the univariate analysis, the following variables were significantly linked to visual outcome: age > 60 years, "rupture", "fall", posterior and/or combined zones of injury, lens damage, retinal/choroidal detachment, initial BCVA of no light perception, and Ocular Trauma Score ≤ 2 (p < 0.001). Delay to surgery, length of stay and further surgery did not have prognostic value. In the logistic regression, initial BCVA of no light perception (p < 0.001) and injury zone III (p = 0.005) remained significant predictors of poor outcome.

CONCLUSIONS

In the population studied, most OGIs were caused by domestic falls usually affecting elderly patients with comorbidities. Visual outcome depended on patients´ specific characteristics and the nature of the trauma itself, whereas environmental factors failed to show any prognostic value.

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.

Microbiological study on foreign body and vitreous samples of patients with intraocular foreign body

OBJECTIVE

To evaluate the relationship between the microbiological results of the vitreous humor and those of foreign body specimens in patients with intraocular foreign body (IOFB).

METHODS

Seventy-one patients with an IOFB were included in this descriptive prospective case series. All patients underwent immediate IOFB removal. Vitreous sampling was performed during vitrectomy. Foreign bodies were placed directly into culture media for microbiological study.

RESULTS

Thirteen (18.3%) patients developed endophthalmitis. The results of microbiological analysis of IOFB and vitreous humor specimens were negative in nine patients and positive in four. Fifty-eight (81.6%) patients with an IOFB had no evidence of endophthalmitis. Among them, seven patients showed positive microbiological results of foreign bodies with no manifestations of endophthalmitis. In five patients, a Staphylococcus epidermidis strain was observed in the culture of the IOFB specimen. Two patients had only positive smear test results of their vitreous humor specimen.

CONCLUSION

A correlation appears to be present between the microbiological results of the vitreous humor and IOFB specimens in patients with clinical findings of endophthalmitis but not in patients with a pure IOFB without clinical features of endophthalmitis. This may justify early use of intravitreal and intravenous antibiotics before the development of endophthalmitis.

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 Development of Endophthalmitis after Open Globe Injury in Children: A Case-Control Study

AIM

To identify risk-factors for developing endophthalmitis following open globe injury (OGI) in children.

METHODS

Retrospective, single-center, case-control study of children aged <18 years who sustained OGI.

RESULTS

Our cohort of 93 eyes consisted of 30 cases (Group A- endophthalmitis) and 63 controls (Group B- no endophthalmitis). Twenty-four eyes (80%) diagnosed with endophthalmitis presented after 24 hours of injury. The presence of central corneal zone-1 injuries (Odd ratio [OR]: 6.64, p= 0.001) and vitreous in wound (OR: 3.53) were associated with the risk of developing endophthalmitis. (p= < 0.05) Additionally the presence of iris prolapse (OR: 4.76) and posterior capsular rupture (PCR) (OR: 5.80) increased the risk of developing endophthalmitis.(p <0.05) . Streptococci was isolated in 15 eyes, Pseudomonas in 3 eyes, and Candida in 1 eye. The visual outcomes at three months were significantly worse in Group A (LogMAR 1.77±1.06) compared to Group B (LogMAR 0.65±0.68)(p<0.05).

CONCLUSION

Central corneal involvement, vitreous/ iris incarceration and PCR were important risk factors for development of PTE in children.

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.

The study of simultaneous bilateral ocular trauma in Northern India: clinical presentation, epidemiology and patterns of injury

PURPOSE

This study is aimed to determine the frequency, sociodemographic profile, clinical presentation, patterns of injury, treatment and outcomes of cases of simultaneous bilateral ocular trauma treated in a teaching hospital of Northern India.

METHODS

This retrospective study was conducted from May 2015 to April 2019. The medical records of patients presenting with bilateral ocular injuries were reviewed.

RESULTS

Among the 402 patients presenting with ocular injuries, 34 (8.5%) had simultaneous bilateral ocular trauma. The majority were male (70.6%), and the mean age was 26.82 ± 15.86 years (range: 2-70 years). The most frequently affected age group has been 16-25 years (35.3%). Most injuries occurred away from home (64.7%), mainly on roads (32.4%) or playgrounds (14.7%), and the vast majority (91.2%) were non-occupational in nature. Mechanical injuries were most frequent (47.1%), followed by cracker (17.7%), chemical (17.7%) and thermal (11.8%) injuries. Most cases occurred due to assault (26.5%), road traffic injury (20.6%) or sports/recreational activities (17.7%). The majority of victims were not using protective devices at the time of injury (82.4%) and had associated polytrauma (58.8%). Closed and open globe injuries accounted for 29.4% and 14.7% of cases, respectively, mostly involving zones I (55.0%) and II (40.0%). Orbital fractures occurred in 27.9% of eyes. Category I and II ocular trauma scores were noted in 5.9% and 7.4% of eyes, respectively. Overall, 13.2% were blinded as a result of the trauma.

CONCLUSION

Simultaneous bilateral ocular trauma is rare and occurs mostly following road traffic accidents, assault or recreational activities. In particular, young-adult males are more prone to bilateral ocular injuries, the majority of which are severe and associated with poor outcomes. The study also highlights that poor initial visual acuity, multiple ocular structure involvement, large open globe injury, presence of intraocular hemorrhage, posterior segment injury, multiple orbital fractures and lower OTS were the poor prognostic factors.

Risk Factors for Endophthalmitis Following Open Globe Injuries: A 17-Year Analysis

Background/Aims

To determine the rate of endophthalmitis and assess risk factors for development of endophthalmitis following open globe injury (OGI).

Methods

A retrospective chart review of all patients treated for OGI at the University of Michigan from January 2000 to July 2017 was conducted. Exclusion criteria included intravitreal injection or intraocular surgery in the 30 days prior to injury or less than 30 days of follow-up. A total of 586 out of 993 open globe injuries were included in the study. The main outcome measure was the rate of endophthalmitis.

Results

In this study, 25/586 eyes (4.3%) had endophthalmitis. Of these, 12/25 eyes (48.0%) presented with endophthalmitis and 13/25 eyes (52.0%) developed endophthalmitis after globe closure. Multivariate analysis identified time to globe repair (OR 4.5, CI 1.9-10.7, p = 0.0008), zone I injury (OR 3.6, CI 1.1-11.0, p = 0.0282), and need for additional surgery (OR 5.5, CI 1.5-19.7, p = 0.0092) as factors associated with increased risk of developing endophthalmitis. Subconjunctival antibiotic injection at the time of globe closure (OR 0.3, CI 0.1-0.7, p = 0.0036) was associated with decreased risk of developing endophthalmitis.

Conclusion

Prompt globe closure and subconjunctival antibiotics may reduce the risk of endophthalmitis in OGI. Furthermore, our practice of a one-time dose of systemic prophylactic antibiotics, and intravitreal antibiotics if intraocular foreign body (IOFB) removal is delayed, was not found to increase the rate of endophthalmitis.

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.

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.

Pars plana vitrectomy timing in deadly weapon-related open-globe injuries

OBJECTIVES

The objective of this study is to evaluate the effect of vitrectomy timing on anatomical and functional outcomes in cases with open-globe injuries caused by improvised explosive devices (IEDs).

METHODS

A retrospective review of ocular injuries caused by IEDs was undertaken. The eyes were classified into four groups based on the timing of vitrectomy: early (Group-1; 2-4 days), delayed (Group-2; 5-7 days), late (Group-3; 8-14 days) and very late (Group-4; >14 days).

RESULTS

The medical records of 351 patients were reviewed, and 212 patients were excluded. A total of 189 eyes of the remaining 139 patients were analysed. Visual improvements were statistically significant compared to the baseline values in all groups (p < 0.001). The early group showed better functional and structural outcomes when compared to the other groups. There was also no proliferative vitreoretinopathy (PVR) in the early group, while PVR was at the highest rate (25%) in the very late group and constituted the most significant reason for recurrent retinal detachment.

CONCLUSION

Both functional and anatomical outcomes were better in the early group. Delayed surgery may be indicated for some cases, but 1-week interval seems to be an optimal time-frame in open globe injuries due to IEDs.

The cereus matter of Bacillus endophthalmitis

Bacillus cereus (B. cereus) endophthalmitis is a devastating intraocular infection primarily associated with post-traumatic injuries. The majority of these infections result in substantial vision loss, if not loss of the eye itself, within 12-48 h. Multifactorial mechanisms that lead to the innate intraocular inflammatory response during this disease include the combination of robust bacterial replication, migration of the organism throughout the eye, and toxin production by the organism. Therefore, the window of therapeutic intervention in B. cereus endophthalmitis is quite narrow compared to that of other pathogens which cause this disease. Understanding the interaction of bacterial and host factors is critical in understanding the disease and formulating more rational therapeutics for salvaging vision. In this review, we will discuss clinical and research findings related to B. cereus endophthalmitis in terms of the organism's virulence and inflammogenic potential, and strategies for improving of current therapeutic regimens for this blinding disease.

HW. Post-Traumatic Endophthalmitis Caused by <b><i>Oerskovia turbata</i></b>

Purpose

To present a previously unreported cause of bacterial endophthalmitis manifesting as delayed post-traumatic endophthalmitis ultimately responsive to total capsulectomy.

Case Report

A patient presented with chronic endophthalmitis that occurred after ocular trauma with organic material and Oerskovia turbata was eventually isolated. After a prolonged treatment course, including two pars plana vitrectomies and total capsulectomy, the patient achieved 20/80 visual acuity at 1-year follow-up.

Conclusion

This is the first reported patient with endophthalmitis due to O. turbata, a Gram-positive bacillus found in soil that rarely causes human infection. The infection had a delayed presentation despite early prophylactic antibiotics and was ultimately eliminated with total capsulectomy. Removal of lens and lens capsule may be necessary in the management of post-traumatic endophthalmitis unresponsive to more conservative therapy, particularly in cases involving atypical organisms and lens capsule violation.

Staphylococcus epidermidis Endophthalmitis Masquerading as Panuveitis After an Imperceptible Ocular Trauma

Endophthalmitis after a penetrating trauma occurs in 3% to 30% of cases. Prompt recognition and treatment are paramount to avoid irreversible visual loss. We present a case of severe panuveitis following ocular trauma with a tree branch that did not cause any evident ocular wound and discuss the difficulties in achieving a diagnosis that can allow proper treatment. A healthy 21-year-old man presented with acute anterior uveitis. He was managed elsewhere with oral acyclovir and topical steroids for presumed herpetic uveitis. He subsequently developed severe panuveitis with profound decrease in vision. Diagnostic vitrectomy was performed and vitreous samples were positive for Staphylococcus epidermidis. Systemic and intravitreal antibiotic therapy was initiated and after 5 days, the patient recovered with a remarkable improvement in visual acuity to 6/12. Post-traumatic endophthalmitis can result from an imperceptible trauma with no obvious compromise of the globe.

Gun-related eye injuries: A primer

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

Incidence and Risk Factors of Intraocular Foreign Body-Related Endophthalmitis in Southern China

Purpose

To investigate the incidence and risk factors of intraocular foreign body- (IOFB-) related endophthalmitis.

Methods

A total of 1701 patients diagnosed with IOFB between January 1, 2005 and June 30, 2015 were included. Two groups of patients were defined according to the presence or absence of endophthalmitis, and a comparison of personal information, IOFB characteristics, and wound location were performed.

Results

In total, 279 patients (16.4%) developed endophthalmitis, older age (P=0.01) was a risk factor. IOFBs retained in the crystal lens or wall of the eyeball conferred lower risks (P=0.01 and 0.04, respectively) compared to the vitreous chamber. The coexistence of different IOFB types and plant IOFBs conferred higher risks (P=0.02 and 0.03, respectively), while glass/plastic IOFBs conferred a lower risk (P=0.03) compared to metallic IOFBs.

Conclusions

Age, IOFB locations, and types were related to development of endophthalmitis, while IOFB number, size, or timing of primary repairs was not related.

Prophylactic intravitreal antibiotics reduce the risk of post-traumatic endophthalmitis after repair of open globe injuries

PURPOSE

To investigate efficacy of prophylactic intravitreal antibiotics in reducing incidence of endophthalmitis after repair of open globe injuries. At King Abdulaziz University Hospital, a standard protocol of intravenous vancomycin and ceftazidime was used in all cases.

METHODS

Charts of 353 patients who presented between January 2010 and January 2014 with open globe injury were retrospectively reviewed. In addition, the standard protocol in this cohort included prophylactic intravitreal antibiotics in high-risk cases at time of primary repair. High-risk cases were identified based on the presence of one or more of the following risk factors: dirty wound, retained intra-ocular foreign body (IOFB), rural setting, delayed primary repair of >24 hr and ruptured lens capsule. Rate of endophthalmitis in this recent cohort was compared with that of a previous cohort admitted for primary repair between May 1996 and May 2008 (641 patients). In the previous cohort, protocol did not include prophylactic intravitreal antibiotics.

RESULTS

Rates of clinically suspected endophthalmitis and culture-positive endophthalmitis were higher in previous cohort (24 of 641 eyes; 3.7% and 12 of 641 eyes; 1.9%, respectively) compared to recent cohort (six of 353 eyes; 1.7% and two of 353 eyes; 0.6%, respectively). In high-risk groups, rates of suspected endophthalmitis and culture-positive endophthalmitis were higher in previous cohort (19 of 345 eyes; 5.5% and 12 of 345 eyes; 3.5%, respectively) compared to the recent cohort (five of 200 eyes; 2.5% and two of 200 eyes; 1.0%, respectively).

CONCLUSION

Prophylactic intravitreal antibiotics reduce risk of endophthalmitis after repair of open globe injuries.

POSTTRAUMATIC ENDOPHTHALMITIS: An 18-Year Case Series

PURPOSE

To describe the demographics, characteristics, management, and visual outcomes of eyes diagnosed with endophthalmitis after open globe injury.

METHODS

Retrospective cohort analysis of all patients diagnosed with endophthalmitis after open globe injury from 1997 to 2015 at University Hospital, Newark, NJ.

RESULTS

Twenty-six eyes were identified (all male patients; mean age: 37 ± 15 years). Cultures were positive in 16 eyes (62%), with Staphylococcus species (7 eyes, 44%) being the most common organism. Twelve eyes (46%) presented with open globe injury and concurrent endophthalmitis; 14 eyes (54%) developed endophthalmitis a mean of 14 days after open globe repair (OGR; 1 outlier of 98 days excluded). All eyes were managed with systemic and intravitreal antibiotics. The presence of intraocular foreign body (P < 0.05) and delayed primary OGR (P < 0.03) were significantly more common with concurrent versus post-OGR endophthalmitis. Four (29%) eyes in the post-OGR endophthalmitis group had corneal wound leak after OGR. Four (15%) eyes with no light perception vision were enucleated. Ten (40%) of 25 eyes with documented best-corrected visual acuity had final best-corrected visual acuity ≥20/200; final best-corrected visual acuity ranged from no light perception to 20/20.

CONCLUSION

The presence of intraocular foreign body and delayed presentation were significantly more common with concurrent endophthalmitis. Twenty-nine percent of eyes that presented with endophthalmitis after OGR had a wound leak. Final best-corrected visual acuity ≥20/200 was achieved in 40% of cases.

Risk Factors for Culture-Positive Endophthalmitis after Repair of Open Globe Injuries

Purpose

To identify risk factors for the development of culture-positive endophthalmitis after repair of open globe injuries.

Methods

We retrospectively reviewed the medical records of 629 consecutive patients with open globe injuries admitted to King Abdulaziz University Hospital between May 1996 and January 2008.

Results

Endophthalmitis developed in 12 (1.9%) patients. The following factors were significantly associated with endophthalmitis by univariate analysis: delayed presentation (>24 hours) (p=0.008), rural address (p=0.013), and dirty wound (p=0.012). Logistic regression analysis identified dirty wound to be associated with the development of endophthalmitis (odds ratio = 11.6; 95% confidence interval [CI] = 2.67–50.6). On logistic regression analysis, presence of retained intraocular foreign body (IOFB) in association with rural address (odds ratio = 11.0; 95% CI = 1.44–83.3) or dirty wound (odds ratio = 9.2; 95% CI = 1.22–69.1) was associated with development of endophthalmitis. Endophthalmitis was a significant negative predictor for final good visual outcome (p=0.00261) and was significantly associated with hypotony (p=0.033).

Conclusions

Delayed presentation, rural address, and dirty wound were associated with development of endophthalmitis. Retained IOFB in association with rural address or dirty wound was associated with a particularly high risk of endophthalmitis.

The use of Prophylactic Antibiotics in Trauma

Infection is an important cause of morbidity and mortality in trauma. In this literature review, the microbiological profiles and the use of prophylactic antibiotics in various traumatic situations are discussed. This review includes abdominal and chest trauma, craniocerebral trauma, long bone fractures, open globe injuries and animal bite injuries.

Microbiological Isolates and Antibiotic Susceptibilities: A 10-Year Review of Culture-Proven Endophthalmitis Cases

PURPOSE

To review the microbiological spectrum and antibiotic sensitivities of the pathogens that cause culture-proven endophthalmitis and to understand the status and trends of antibiotic susceptibility at a public hospital over a 10-year period.

METHODS

The data of 577 culture-proven endophthalmitis isolates collected between April 2004 and April 2014 were reviewed retrospectively. The antibiotic sensitivities were determined according to the criteria of the Clinical and Laboratory Standards Institute. The changes in antibiotic susceptibility over the 10 years were subjected to χ² tests for trends.

RESULTS

Among these isolates, 65% were gram-positive organisms (375), 16.6% were gram-negative organisms (96), and 18.4% were fungi (106). The predominant pathogens were Staphylococcal species (Staphylococcus epidermidis in 175, other coagulase-negative Staphylococci in 41, and Staphylococcus aureus in 54 cases), followed by Bacillus cereus isolates. The Aspergillus species was the most frequently isolated fungus, and Pseudomonas aeruginosa was the most frequently isolated gram-negative bacteria. The antibiotic susceptibilities of gram-positive bacteria were as follows: vancomycin, 97.6%; levofloxacin, 85.1%; gentamicin, 78.7%; rifampin, 77.2%; ofloxacin, 77.2%; chloramphenicol, 76.4%; and ciprofloxacin, 73.7%. The antibiotic susceptibilities of gram-negative isolates were as follows: ceftazidime, 50.5%; ciprofloxacin, 82.2%; amikacin, 81.3%; tobramycin, 80.2%; imipenem, 79.7%; and gentamicin, 78%. Over the 10-year study, there were significant changes in the antibiotic susceptibilities to the following five antibiotics: vancomycin, imipenem, penicillin G, amikacin, and trimethoprim-sulfamethoxazole (TMP-SMX).

CONCLUSIONS

Vancomycin remains the most appropriate empirical antibiotic for gram-positive bacteria. The susceptibilities of the gram-negative organisms to ciprofloxacin and amikacin were greater than that to ceftazidime. Trends toward increases in the susceptibilities to the following five antibiotics were observed: vancomycin, imipenem, penicillin G, amikacin, and TMP-SMX.

Survey of Intraocular Antibiotics Prophylaxis Practice after Open Globe Injury in China

Purpose

To elucidate the Chinese practice of intraocular antibiotics administration for prophylaxis after open globe injury.

Methods

A cross-sectional questionnaire survey was performed online by scanning a Quickmark (QR) code with smartphones at the 20^th Chinese National Conference of Ocular Trauma in November 2014.

Results

A total of 153 (30.6%) of all participators at the conference responded. Of the respondents, 20.9% were routinely administered with prophylactic intraocular injection of antibiotics at the conclusion of the primary eye repair, and 56.9% were used only in cases with high risk of endophthalmitis development. The intraocular route of delivery was mainly included with intracameral injection (47.9%) and intravitreal injection (42.0%). Cephalosporins (53.8%) and vancomycin (42.0%) were the main choices of antibiotic agents, followed by fluoroquinolones (24.3%), and aminoglycosides (13.4%). Only 21.9% preferred a combination of two or more two drugs routinely. In addition, significantly more respondents from the referral eye hospital (92.7%) replied using intraocular antibiotics injection for prophylaxis compared to those respondents from the primary hospital (69.4%) (p = 0.001, Fisher’s exact test).

Conclusions

Intraocular antibiotics injection for post-traumatic endophthalmitis prophylaxis is widely used in China. However, the choice of antibiotic agents and the intraocular route of delivery vary. A well-designed clinical trial is needed to establish a standardized protocol of intraocular antibiotics administration for post-traumatic endophthalmitis prophylaxis.

Staphylococcus aureus and its Bearing on Ophthalmic Disease

PURPOSE

To review antibiotic resistance associated with S. aureus endophthalmitis and the virulence of S. aureus.

METHODS

Review of the current and prospective approaches for treating S. aureus endophthalmitis.

RESULTS

Bacterial endophthalmitis remains to be a major threat for vision. S. aureus endophthalmitis specifically, carries a poor visual prognosis making early diagnosis and treatment crucial. Methicillin resistant Staphylococcus aureus (MRSA) endophthalmitis represents a significant number of S. aureus endophthalmitis cases. MRSA with reduced susceptibility to glycopeptide antibiotics such as vancomycin (vancomycin intermediate S. aureus, VISA) have also emerged in the ocular infections, and there has been a rise in S. aureus resistance to new and old generation fluoroquinolones that are commonly used for prophylaxis after intravitreal injections and intraocular surgeries.

CONCLUSIONS

With the rise in the number of penetrating procedures in the ophthalmology practice and the parallel rise in antibiotic resistance, prophylaxis and awareness of the antimicrobial resistance profiles remain crucial and the identification of novel antimicrobials is essential.

Pediatric open globe injury: A review of the literature

Open globe injury (OGI) is a severe form of eye trauma estimated at 2-3.8/100,000 in the United States. Most pediatric cases occur at home and are the result of sharp object penetration. The aim of this article is to review the epidemiology, diagnosis, management, and prognosis of this condition by conducting a systematic literature search with inclusion of all case series on pediatric OGI published between 1996 and 2015. Diagnosis of OGI is based on patient history and clinical examination supplemented with imaging, especially computed tomography when indicated. Few prospective studies exist for the management of OGI in pediatric patients, but adult recommendations are often followed with success. The main goals of surgical management are to repair the open globe and remove intraocular foreign bodies. Systemic antibiotics are recommended as medical prophylaxis against globe infection, or endophthalmitis. Other complications are similar to those seen in adults, with the added focus of amblyopia therapy in children. Severe vision decline is most likely due to traumatic cataracts. The ocular trauma score, a system devised to predict final visual acuity (VA) in adults, has proven to be of prognostic value in pediatric OGI as well. Factors indicating poor visual prognosis are young age, poor initial VA, posterior eye involvement, long wound length, globe rupture, lens involvement, vitreous hemorrhage, retinal detachment, and endophthalmitis. A thorough understanding of OGI and the key differences in epidemiology, diagnosis, management, and prognosis between adults and children is critical to timely prevention of posttraumatic vision loss early in life.

Corneal and anterior segment foreign body trauma in dogs: a review of 218 cases

OBJECTIVES

To review clinical data on dogs that suffered a corneal and anterior segment foreign body (CASFB) trauma and to determine the risk factors for foreign body (FB) trauma and subsequent enucleation.

ANIMALS STUDIED

Dogs with CASFB presented to the Animal Health Trust (AHT) from January 2000 to December 2012.

PROCEDURES

Clinical data for CASFB cases were compared to those available for the remaining AHT ophthalmic population over the same period. The depth of the FB trauma was divided into five categories. The type of FB and method of removal were described for each category. The degree of secondary uveitis and lens involvement was graded and correlated with subsequent enucleation.

RESULTS

The mean age (standard deviation) of 218 identified CASFB cases was 3.96 (2.95) years. Risk factors for CASFB trauma were dogs younger than 5 years, English Springer Spaniels, Labrador Retrievers, and working dogs. Most dogs required general anesthesia for FB removal, and hypodermic needles were the most commonly used instrument. The lens was involved in some cases with a full-thickness CASFB trauma (n = 49, 45%), but most suffered a minor lens trauma (n = 37, 76%). The lens trauma and phacoclastic uveitis were managed medically in most dogs (n = 37, 76%), and phacoemulsification was only elected as initial treatment in some dogs (n = 10, 20%). Enucleation was required overall in 6% of dogs. Statistically significant associations were found between enucleation and depth of FB trauma, degree of uveitis, and severity of lens trauma (P < 0.001).

CONCLUSIONS

Young dogs, English Springer Spaniels, Labrador Retrievers, and working dogs had an increased risk of CASFB trauma. Risk factors for enucleation were full-thickness FB penetration, severe lens trauma, and severe uveitis.

Ophthalmic injuries from a TASER

The TASER (TASER International) is an energy-conducting weapon, that is becoming more frequently used by law enforcement officials to subdue combative individuals. Though generally regarded as a safe alternative, the use of such weapons has been reported to cause serious injuries. We describe a case in which ocular injuries were sustained by impalement with a TASER dart. Emergency physicians should be aware of the potential for serious ophthalmic injuries from TASERs and how such injuries should be managed.

The effects of amphotericin B on angiogenesis in chick chorioallantoic membrane

OBJECTIVE

Amphotericin B (AmB) is widely used as a mainstay in the treatment of sight-threatening fungal endophthalmitis. From the time that itraconazole was discovered to have a previously unknown anti-angiogenic activity, we have suspected that AmB may have possible effects on ocular angiogenesis. The purpose of this study was to evaluate the in vivo anti-angiogenic effect of AmB in the chick chorioallantoic membrane (CAM) model.

MATERIALS AND METHODS

Atak-S type fertilized eggs obtained from the Poultry Institution were used. The eggs were kept under 37 °C at 85-90% relative humidity throughout the experiment. Amphotericin B was prepared in two different concentrations (AmB 125 μg/1 mL and 0.125 μg/1 mL). The CAMs treated with sterile distilled water was specified as controls. About 0.1 mL of each containing 12.5 and 0.0125 µg of AmB, respectively, were dropped to CAM surface. Thirteen eggs were used for each group. The results were evaluated at the 48th hour of the administration of the drugs and recorded by digital camera.

RESULTS

A reduction of angiogenesis in CAM area which treated with 125 μg/1 mL of AmB was appreciable macroscopically. The affected areas showed impaired radial arrangement of small vessels with the presence of avascular zone at periphery. The dose of 0.125 μg/1 mL AmB did not show any visible anti-angiogenic effect. Numerous blood vessels with a radially arranged pattern developed toward the periphery after 48 h of treatment. In the CAMs that treated with distilled water, physiological angiogenesis was observed in allantoic vessels. Vessel formation seems to be similar in CAMs treated with 0.125 μg/1 mL AmB with the presence of visibly non-malformed alive embryos.

CONCLUSIONS

The present study gives the impression that AmB has the capacity to serve as an anti-angiogenic treatment. As it is a preliminary CAM study only, further studies on both animals and humans are required.

Predictors of visual outcome in traumatic cataract

Traumatic cataract resulting from open- or closed-globe ocular trauma is one of the most common causes of blindness. Visual outcome is unpredictable because this is not determined solely by the lens. There is a lack of a standard classification, investigations, and treatment guidelines related to the outcome, with considerable debate regarding predictive models. We review the predictors of visual outcome following surgical treatment of traumatic cataracts, which may act as a guide to clinicians.

Intraocular penetration of systemic antibiotics in eyes with penetrating ocular injury

PURPOSE

To determine whether penetrating scleral or corneal injury can enhance intraocular penetration of systemic moxifloxacin, vancomycin, and ceftazidime.

METHODS

Thirty rabbits were divided into 3 groups for each antibiotic and then further subdivided to receive either scleral or corneal injury to the right eye. The left eye served as a control. Intravenous antibiotics were given following injury, and eyes were subsequently enucleated. Vitreous antibiotic concentration was determined by high-performance liquid chromatography analysis. Plasma concentration was measured for comparison.

RESULTS

Intravitreal moxifloxacin concentration was unchanged by injury. Minimum inhibitory concentration (MIC90) was achieved in the vitreous against the most common gram-positive endophthalmitis-causing organisms. Intravitreal vancomycin levels were not enhanced by injury and did not reach the MIC90 for gram-positive organisms commonly causing intraocular infection. Intravitreal ceftazidime was increased in the injured eyes, 67% and 73% higher in scleral and corneal injury eyes. It reached MIC90 of many gram-negative bacteria.

CONCLUSIONS

Intravitreal antibiotic penetration of systemic antibiotics with or without penetrating ocular injury varies depending on the antibiotic. For prevention or treatment of gram-positive-bacteria-causing endophthalmitis, intravitreal vancomycin is necessary and provides the most reliable coverage. Systemic ceftazidime can be used for many gram-negative bacteria, but intravitreal injection is recommended for better coverage, especially for more-potent organisms. Systemic moxifloxacin can be considered for most gram-positive and -negative infections due to its excellent intraocular penetration and broad coverage, but the patient's previous history of its topical use and increasing resistance patterns must be considered.

Causative organisms of post-traumatic endophthalmitis: a 20-year retrospective study

Background

A wide range of organisms that enter the eye following ocular trauma can cause endophthalmitis. This study was to investigate the spectrum of pathogens and antibiotic susceptibility of bacterial isolates from a large cohort of post-traumatic endophthalmitis cases.

Methods

A retrospective study of 912 post-traumatic endophthalmitis patients treated at a tertiary eye-care center in China was performed. The associations between risk factors and the most common isolated organisms were investigated by Chi square Test. The percent susceptibilities for the first 10 years (1990–1999) and the second 10 years (2000–2009) were compared by Chi square test. p < 0.05 was considered statistically significant.

Results

Three-hundred-forty-seven (38.1%) cases of endophthalmitis were culture-positive, and 11 (3.2%) showed mixed infections (Gram-negative bacilli and fungi), yielding a total of 358 microbial pathogens. Culture proven organisms included 150 (41.9%) Gram-positive cocci, 104 (29.1%) Gram-negative bacilli, 44 (12.3%) Gram-positive bacilli, and 60 (16.8%) fungi. The coagulase-negative staphylococcal (CNS) species S. epidermidis (21.8%) and S. saprophyticus (12.0%) were the predominant pathogens, followed by Bacillus subtilis (8.7%), Pseudomonas aeruginosa (7.8%), and Escherichia coli (6.4%). Delayed repair over 24 h (p < 0.001) and metallic injury (p < 0.01) were significantly associated with positive culture of CNS. The most frequent fungal species were Aspergillus (26/60), followed by yeast-like fungi (18/60). P. aeruginosa was relatively sensitive to ciprofloxacin (83.3%), cefoperazone (75%), tobramycin (75%), cefuroxime (75%), and ceftazidime (75%) during the second decade. Multi-drug resistance was observed in the predominant Gram-negative bacteria.

Conclusion

We identified a broad spectrum of microbes causing post-traumatic endophthalmitis, with Gram-positive cocci the most frequently identified causative organism, followed by Bacillus species, fungi, and mixed infections. CNS infection was statistically associated with delayed repair and metallic injury. Variation in antibiotic susceptibility was observed among isolated bacteria and between different periods. Ciprofloxacin and ceftazidime in the first and second decades of the study, respectively, showed the highest activity against bacterial post-traumatic endophthalmitis. For infections caused by P. aeruginosa, a combination therapy of ciprofloxacin, tobramycin, and one of the cephalosporins might provide optimal coverage according to data from the second decade.

Post-Traumatic Endophthalmitis: A Mini-Review

Post-traumatic endophthalmitis comprises 25-30% of all endophthalmitis cases. Post-traumatic endophthalmitis is an important clinical condition that may have serious anatomical and functional consequences. The type of pathogenic microorganism, nature of the injury, the presence of a foreign body, and the geographical region in which the trauma occurred are all important factors influencing both treatment and prognosis. Unlike postoperative endophthalmitis, there is not a confirmed treatment protocol recommended by the Endophthalmitis-Vitrectomy Study Group in traumatic cases. In this study, we examine the incidence, risk factors, diagnosis, microbiological features, and treatment principles of post-traumatic endophthalmitis in order to guide clinicians who often encounter eye trauma related to this potential complication.

Controversies in traumatic cataract classification and management: a review

Traumatic cataract is one of the important causes of blindness after ocular trauma, either open or close globe. Visual outcome is unpredictable because it is not only lens that decides visual outcome. There is no standard classification, investigation, or treatment guidelines for the same. There are controversies regarding predictive models. We would like to highlight these controversies and try to reach certain guidelines that may help clinicians to manage traumatic cataracts.

Residual lens cortex material: potential risk factor for endophthalmitis after phacoemulsification cataract surgery

PURPOSE

To evaluate the bacterial growth potential of residual lens cortex after phacoemulsification with the development of endophthalmitis.

SETTING

University medical center.

DESIGN

Experimental study.

METHOD

Staphylococcus aureus and Staphylococcus epidermidis were dispensed into aqueous humor or serial dilutions of lens cortex that were obtained from cataract patients during phacoemulsification. After a 24-hour incubation, the colony-forming unit (CFU) was quantified. Eighty rabbits had phacoemulsification. Complete lens cortex removal was performed in 40 rabbits, while a quarter of lens cortex was retained in 40 rabbits. Staphylococcus aureus, with an inoculum size of 32 CFU, 56.3 CFU, and 108.6 CFU, was injected intracamerally at the conclusion of surgery and the production of endophthalmitis was measured 72 h later. The aqueous and vitreous humor samples were collected for microbiological diagnosis.

RESULTS

The increase in bacterial growth of S aureus and S epidermidis was statistically significantly greater in each dilution of lens cortex than in aqueous humor (P < .001, Student t test). With inoculum of 32.0 CFU or 56.3 CFU of S aureus, there was a statistically higher incidence of bacterial culture-proven endophthalmitis in the residual lens cortex eye group than in the normal aphakic eye group (P < .05, Fisher exact test).

CONCLUSIONS

Lens cortex was associated with a significant increase in bacterial growth compared with aqueous humor. Therefore, eyes with residual lens cortex seem more prone to develop endophthalmitis if anterior chamber bacterial contamination occurs during phacoemulsification.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Posttraumatic endophthalmitis: report No. 2

PURPOSE

To study predisposing factors of endophthalmitis in patients with open-globe injury.

METHODS

All 2,340 patients with open-globe injury admitted to our center over 5 years were studied retrospectively, and patients with endophthalmitis were compared with other patients.

RESULTS

The number of endophthalmitis cases among patients with open-globe injury was 117 eyes, accounting for an incidence of 5.1%. The risk of endophthalmitis was significantly higher among male patients with pure corneal injuries (6.8%), intraocular foreign bodies (9.3%), traumatic lens rupture (7.1%), trauma resulting from needles (22.2%), and shorter lacerations. The existence of hyphema or iris prolapse was associated with lower rates of endophthalmitis. The mean gap between injury time and operation time was longer in the endophthalmitis group (2.1 ± 1.8 vs. 1.1 ± 1.3 days). Patients with endophthalmitis had significantly lower ocular trauma scores compared with other patients.

CONCLUSION

Posttraumatic endophthalmitis is more likely among patients with open-globe injury that are needle related and among those who have intraocular foreign bodies, traumatic lens rupture, smaller wounds, or wounds exclusively in the cornea. Lower ocular trauma scores in this group of patients with penetrating trauma indicated a greater risk of poor visual prognosis. Therefore, it is suggested that necessary measures and immediate treatment be undertaken in high-risk patients.

[Open-globe injuries and intraocular foreign bodies involving the posterior segment]

Open globe injuries involving the posterior segment remain a major cause of visual loss in young adults. They occur more frequently in male than in female populations. The majority is due to domestic accidents, since work-related injuries have been decreasing due to proper education and use of safety equipment. However, leisure-related open globe injuries are on the increase. Prompt recognition and treatment of open globe injuries are essential. At presentation, it is necessary to collect etiological data such as cause, nature, time and place of injury. Anti-tetanus immunization must be confirmed. The presenting visual acuity and clinical examination data must be recorded. The lesion type is classified in accordance with the Birmingham Eye Trauma Terminology. Ocular ultrasound or computed tomography is performed for patients suspected of having an intra- or periocular foreign body. Functional prognosis is negatively influenced by a posterior or large rupture, the presence of an intraocular foreign body, the presence of retinal lacerations or retinal detachment, or the occurrence of posttraumatic infectious endophthalmitis. Recent advances in microsurgical techniques such as pars plana vitrectomy and new visualization techniques may improve the anatomical and functional prognosis for these patients. However, postoperative proliferative vitreoretinopathy remains a major concern: it is responsible for a significant rate of secondary retinal detachment with negative consequences for visual prognosis.

Ocular injuries from improvised explosive devices

PURPOSE

To document the characteristics, treatments, and anatomical and functional outcomes of patients with ocular trauma from improvised explosive devices (IEDs).

METHODS

Retrospective review of ocular injuries caused by IEDs, admitted to our tertiary referral centre.

RESULTS

In total, sixty-one eyes of the 39 patients with an average age of 24 years (range, 20-42 years) were included in the study. In total, 49 (80%) eyes of the patients had open-globe and 12 (20%) had closed-globe injury. In eyes with open-globe injury, intraocular foreign body (IOFB) injury was the most frequently encountered type of injury, observed in 76% of eyes. Evisceration or enucleation was required as a primary surgical intervention in 17 (28%) of the eyes. Twenty-two (36%) eyes had no light perception at presentation. Patients were followed up for an average of 6 months (range, 4-34 months). At the last follow-up, 26 (43%) of 61 eyes had no light perception. Postoperative proliferative vitreoretinopathy (PVR) developed in 12 (50%) of the 24 eyes that underwent vitreoretinal surgery, and four of these eyes became phthisical. There were no cases of endophthalmitis. The presence of open-globe injury and presenting visual acuity worse than 5/200 were significantly associated with poor visual outcome (<5/200, P<0.05). In eyes with open-globe injury, the presence of an IOFB was not associated with poor visual outcome (P>0.05).

CONCLUSION

Ocular injuries from IEDs are highly associated with severe ocular damage requiring extensive surgical repair or evisceration/enucleation. Postoperative PVR is a common cause of poor anatomical and visual outcome.

Endophthalmitis: Pathogenesis, clinical presentation, management, and perspectives

Endophthalmitis is a rare but sight-threatening complication that can occur after ocular surgery or trauma or as a consequence of systemic infection. To optimize visual outcome, early diagnosis and treatment are essential. Over recent decades, advances in hygienic standards, improved microbiologic and surgical techniques, development of powerful antimicrobial drugs, and the introduction of intravitreal antibiotic therapy have led to a decreased incidence and improved management of endophthalmitis. However, endophthalmitis still represents a serious clinical problem. This review focuses on current principles and techniques for evaluation and treatment of endophthalmitis. In addition, it addresses recent developments regarding antimicrobial treatment and prophylaxis of infectious endophthalmitis.

Exogenous Endophthalmitis in Pediatric Age Group

PURPOSE

To identify the microbiological spectrum and visual outcome of exogenous infectious endophthalmitis in the pediatric age group.

METHODS

We reviewed the medical records of all children 14 years and younger with culture-positive endophthalmitis treated at King Khaled Eye Specialist Hospital and King Abdulaziz University Hospital between January 1, 1980, and December 31, 2004.

RESULTS

Forty-nine children were identified. There were 32 males and 17 females with a mean age of 5.7 +/- 2.8 years (range 1-13 years). Thirty-five (71.4 %) cases occurred after penetrating open globe injuries and the remaining 14 (28.6%) followed ocular surgery. Primary vitrectomy was performed on 29 (59.2%) eyes. The mean follow-up was 28.4 +/- 28.4 months (range 1.2-98.5 months). A single species was isolated in 42 (85.7%) eyes, and multiple organisms in seven (14.3%) with a total of 56 infecting organisms. The most common isolates were Streptococcus species and coagulase-negative Staphylococci comprising 44.6% and 21.4% of the isolates, respectively. Final visual acuity was 20/200 or better in 15 (34.1%), counting fingers in 8 (18.2%), light perception to hand motions in 8 (18.2%), no light perception in 13 (29.5%) eyes, including 3 that have been enucleated or eviscerated, and not available in 5 patients. None of the children who had nonvirulent organisms had a final visual acuity of no light perception compared with 39.4% of children who had virulent organisms (p = 0.011). Visual outcome of counting fingers was attained in 26% of children who were treated with primary vitrectomy compared with 5.9% of children treated with antibiotics alone on presentation (p = 0.0484). Visual outcome was no light perception in 18.5% of children who underwent primary vitrectomy compared with 47.1% of children treated with antibiotics alone.

CONCLUSIONS

The most common organisms identified were Streptococcus species and coagulase-negative Staphylococci. Culture of a nonvirulent organism, and treatment with primary vitrectomy were associated with better visual outcomes. Visual outcomes were generally poor.

Effect of intravitreal triamcinolone acetonide in the treatment of experimental Staphylococcus epidermidis endophthalmitis

PURPOSE

To investigate the effect of intravitreal injection of triamcinolone acetonide (TA) in the treatment of experimental Staphylococcus epidermidis endophthalmitis.

MATERIALS AND METHODS

Experimental endophthalmitis induced in one eye of 38 rabbits by intravitreal injection of Staphylococcus epidermidis. The infected rabbits were randomly divided into three groups. The rabbits in group 1 (n = 15) received intravitreal injection of 1 mg vancomycin hydrochloride. Group 2 eyes (n = 15) received intravitreal TA (4 mg) plus vancomycin hydrochloride (1 mg). Group 3 eyes (8 eyes) received normal saline. Clinical examination in each group was performed two, seven, and 15 days after inoculation of the bacteria. The eyes were enucleated for histopathologic evaluation on the 15th day. Clinical and histological scoring systems were used to evaluate clinical and histological severity of the intraocular infection.

RESULTS

The mean clinical scores of three study groups at the 7th day were 5.8 +/- 2.3, 3.3 +/- 1.5, and 9.5 +/- 2.1, respectively. The mean of this value at 15th day were 6.2 +/- 2.6, 3.9 +/- 2.1, and 10 +/- 2.2, respectively. At the 7th and 15th day, the mean clinical score of group 2 was significantly lower when compared with the other two groups. Mean histopathologic scores of group 1, group 2, and group 3 were 11 +/- 2.7, 7.9 +/- 2.9, and 14.0 +/- 3.1, respectively. Histopathologic studies revealed less tissue destruction for eyes treated with TA. There was a significant positive correlation between the severity of clinical signs and pathologic damage in all three experiment groups; however, it was weakest in the IVTA treated group.

CONCLUSION

A standard clinical dose of intravitreal TA attenuates the clinical signs and tissue destruction in a rabbit model of Staphylococcus epidermidis endophthalmitis.

Low rate of endophthalmitis in a large series of open globe injuries

PURPOSE

To determine the percentage of patients in whom endophthalmitis developed after open globe injury.

DESIGN

Retrospective, noncomparative, consecutive case series.

METHODS

Charts of all patients (675 in total) treated surgically for open globe injury at the Massachusetts Eye and Ear Infirmary (MEEI) between January 1, 2000 and July 31, 2007 were reviewed. Cases with at least 30 days of follow-up were included in statistical analyses (558 in total). A standardized treatment protocol was used in all cases. Intravenous vancomycin and ceftazidime were started on admission and were stopped after 48 hours. Patients were discharged on topical antibiotics, corticosteroids, and cycloplegia. Surgical repairs were performed by the chief of trauma, a full-time position rotating yearly, who is on call for all open globe trauma. Data collection variables included timing of injury and repair, mechanism of injury, details of surgical repair, and details of follow-up such as duration, presence of complications, and vision. A primary outcome measure of endophthalmitis and secondary outcome measure of risk factors for endophthalmitis were studied.

RESULTS

During 7.5 years, 675 open globe injuries were treated at MEEI. Of these, 558 had at least 30 days of follow-up (mean, 11 months) and were used in statistical analyses. The overall percentage of endophthalmitis was 0.9% (3 culture-positive cases and 2 culture-negative cases). Four of the 5 cases achieved final acuity of 20/80 or better. Risk factors for endophthalmitis included intraocular foreign body (P = .03; odds ratio, 7.52) and primary intraocular lens placement (P = .05).

CONCLUSIONS

A standardized protocol including surgical repair by a dedicated eye trauma service and 48 hours of intravenous antibiotics was associated with a posttraumatic endophthalmitis percentage of less than 1%.