Post-traumatic fungal endophthalmitis--a prospective study

EFFICACY OF VITRECTOMY COMBINED WITH INTRAVITREAL ANTIBIOTICS FOR SEVERE POST-TRAUMATIC ENDOPHTHALMITIS

PURPOSE

To explore clinical efficacy of vitrectomy combined with intravitreal antibiotics in treating severe endophthalmitis after open-globe trauma in patients.

METHODS

The records of all patients who received vitrectomy combined with intravitreal for the severe post-traumatic endophthalmitis with light perception or worse between 2010 and 2022 were retrospectively reviewed. Patients received vitrectomy combined with intravitreal antibiotics, repeated intravitreal antibiotics with or without vitreous aspiration, and retinal repair after the infection was controlled. Efficacy of severe post-traumatic endophthalmitis was analyzed.

RESULTS

One hundred and twenty-one patients (121 eyes) were included in this study. The mean BCVA improved from 4.03 ± 0.18 logarithm of the minimum angle of resolution to 1.75 ± 1.41 logarithm of the minimum angle of resolution ( P < 0.001) at the end of the follow-up period, which increased in 106 eyes (87.60%). Infection was successfully controlled in all eyes, 88 eyes within two operations. Pathogens including streptococci (odds ratio [OR] = 6.68, P < 0.001), fungi (OR = 15.23, P < 0.001), and mixed infection (OR = 6.67, P < 0.05) were related to the number of operations. Finally, 60 eyes (49.59%) received silicone oil filling, 25 received gas tamponade, and the remaining 36 received no tamponade; complete vitrectomy was performed in all eyes with intraocular tamponade. All eyes for gas tamponade and no tamponade had been remained stable without retinal detachment and proliferative vitreoretinopathy after 6-month follow-up. The rate of recurrent retinal detachment after silicone oil tamponade was 4.96% (six eyes), including 1.65% (two eyes) of proliferative vitreoretinopathy; these eyes underwent reoperation of retinal detachment repair.

CONCLUSION

Vitrectomy combined with intravitreal antibiotics may be an effective treatment option for severe post-traumatic endophthalmitis.

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.

Eye fungal infections: a mini review

Ocular fungal infections annually affect more than one million individuals worldwide. The management of these infections is problematic, mainly due to the limited availability of effective antifungal agents. Thus, ocular infections are increasingly recognized as important causes of morbidity and blindness, especially keratitis and endophthalmitis. Thus, this review aims to demonstrate the importance of fungal eye infections through the description of the main related aspects, with emphasis on the treatment of these infections. For this purpose, a search for scientific articles was conducted in databases, such as Medline, published from 2000 onwards, addressing important aspects involving fungal eye infections. In addition, this work highlighted the limited therapeutic arsenal available and the severity associated with these infections. Thus, highlighting the importance of constantly updating knowledge about these pathologies, as it contributes to agility in choosing the available and most appropriate therapeutic alternatives, aiming at positive and minimally harmful results for that particular patient.

Trends of ocular fungal infections in North China (2001-2020)

OBJECTIVES

To analyze the epidemiologic features, culture positivity, the fungal spectrum of different sites of ocular infection in North China over 20 years from 2001 to 2020.

METHODS

11, 635 patients suspected of ocular fungal infection were reviewed. The demographic profile, fungal positive culture rate among different sites, the distribution, and trends of main pathogens among cornea and intraocular fluid were analyzed.

RESULTS

Among 11, 635 samples, the positive culture rate of ocular fungal infection was 23.6%. Most of samples (83.1%) were from cornea, and their culture positivity was 26.9%. Fungal keratitis occurred more often during the harvesting season (October to December; 34.0%) than in other seasons (average: 22.0%). Fusarium sp. (53.2%), Aspergillus sp. (15.9%) and Alternaria sp. (12.5%) were the most common fungal species of ocular mycotic infections in the past two decades in north China. 2562 organisms were identified from cornea, of which 1443 (56.3%) were Fusarium sp., 403 (15.7%) and 329 (12.8%) were Aspergillus sp., and Alternaria sp., respectively. Of the 120 fungi isolated from the intraocular fluid, the most common was Aspergillus sp. (33.3%), followed by Fusarium sp. (24.2%) and Candida sp. (15.0%).

CONCLUSIONS

Fusarium sp., Aspergillus sp. and Alternaria sp. were the most common organisms in cases of fungal keratitis, while Aspergillus sp., Fusarium sp. and Candida sp. were the most frequent isolates for fungal endophthalmitis.

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.

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.

Fungal endophthalmitis: Analysis of 730 consecutive eyes from seven tertiary eye care centers in India

PURPOSE

To evaluate the clinical and microbiological features of a large cohort of culture-confirmed fungal endophthalmitis across India.

DESIGN

Cross-sectional hospital-based retrospective medical records review.

PARTICIPANTS

Seven large tertiary eye care centers from different regions of India.

METHODS

The patient data were pooled from the electronic/physical medical records of each participating center. Fellowship-trained vitreoretinal specialists clinically managed all patients, and in-house microbiology laboratories performed all microbiology work-ups. The clinical and microbiology procedures were broadly uniform across all participating centers. The essential treatment consisted of vitreous surgery and intravitreal and systemic therapy with antifungal agents.

MAIN OUTCOME MEASURES

Clinical outcome by the causative event and causative fungus.

RESULTS

In the 2005-2020 period, seven centers treated 3830 cases of culture-proven endophthalmitis, and 19.1% (n=730) were culture-confirmed fungal endophthalmitis. It included 46.9% postoperative (87.4% post-cataract surgery), 35.6% traumatic and 17.5% endogenous endophthalmitis. The fungi included 39.0% Aspergillus (high in central, east and south zones), 15.1% Candida (high in west zone), 15.9% Fusarium (high in north and west zone). The time to symptoms was between 1w-4w in more than a third of patients except in traumatic endophthalmitis. Less than half of patients had hypopyon on presentation. Presenting visual acuity (PVA) in most patients was <20/400. Nearly all patients needed a vitrectomy and an average of two intravitreal injections of antifungal agents. At least 10% of eyes needed therapeutic keratoplasty, and up to 7% of eyes were eviscerated. Following treatment, the final (best corrected) visual acuity (FVA) was > 20/400 in 30.5% (n= 222) eyes; > 20/40 in 7.9% (n=58) eyes; and 12% (n=88) eyes lost light perception. Post-hoc analysis showed significantly more males in traumatic than post-operative (p<0.0001) and endogenous (p = 0.001) endophthalmitis; higher isolation of Candida species in endogenous than post-operative (p = 0.004) and traumatic (p<0.0001) endophthalmitis, better PVA in eyes with Candida species infection (p<0.0001) and poorer FVA in eyes with Aspergillus species infection.

CONCLUSIONS

Fungal endophthalmitis is not uncommon in India. The inclusion of antifungal agents with antibiotics as the first empirical intravitreal therapy before microbiological confirmation could be considered when fungal infection is suspected.

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.

Vitrectomy combined with intravitreal antifungal therapy for posttraumatic fungal endophthalmitis in eastern China

Background

To evaluate the effect and prognostic factors of vitrectomy combined with intravitreal antifungal therapy for posttraumatic fungal endophthalmitis in Eastern China.

Methods

We retrospectively reviewed the medical records of patients who developed fungal endophthalmitis after penetrating ocular trauma at an ophthalmic center in Eastern China. All patients underwent vitrectomy and intravitreal injection of antifungal drugs.

Results

Thirty-five patients (35 eyes) were included. Twelve eyes suffered plant trauma, 17 eyes metal trauma, and 6 eyes other trauma. The culture results for all 35 eyes showed filamentous fungi, including Aspergillus in 26 eyes (74.3%). Twenty-three eyes underwent vitrectomy once and 12 eyes were treated twice. Four eyes were iridectomized because of a fungal lesion behind the iris. Fungal endophthalmitis was effectively controlled in 33 eyes (94.3%), whereas 2 eyes were ultimately enucleated. Visual acuity was significantly better after treatment than before treatment (P = 0.0006). According to the preoperative vision, the affected eyes were divided into two groups: group 1A (light perception) and group 1B (better than light perception). The final visual acuity in group 1B was significantly better than that in group 1A (P = 0.0289).

Conclusions

Vitrectomy combined with intravitreal antifungal therapy is an effective treatment for posttraumatic fungal endophthalmitis. Preoperative visual acuity is a significant factor affecting the prognosis of visual acuity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-020-01703-7.

A Case of Fungal Endophthalmitis Caused by Paecilomyces lilacinus that Might Have Spread from the Sclera into the Intraocular Space

The aim of this report was to describe a case of fungal endophthalmitis possibly caused by Paecilomyces lilacinus(PL) penetrating the sclera from a conjunctival abscess. This case study involved an 83-year-old male patient with a past history of scleral buckling, subtenon steroid injection, and cataract surgery. The vitreous opacity and a conjunctival abscess appeared in the inferonasal quadrant of his right eye at 5 months after cataract surgery. PL was isolated from a cultured conjunctival discharge specimen obtained from the patient's right eye. Although the treatment with antifungal agents relieved the conjunctival abscess, the vitreous opacity became worse. Thus, vitrectomy was subsequently performed. Intraoperative findings revealed severe vitreous opacity in the inferonasal quadrant, adjacent to the sclera at the site of the conjunctival abscess. Our findings indicate that fungal endophthalmitis appeared to have been caused by PL in the conjunctival abscess that may have penetrated the sclera and spread into the intraocular space.

Lenticular fungal infection caused by Aspergillus in a patient with traumatic corneal laceration: a case report

Background

To report a case of lenticular infection caused by Aspergillus, which was diagnosed 13 weeks after traumatic corneal laceration.

Case presentation

A 60-year-old woman presented with traumatic corneal laceration including anterior lens capsule rupture and traumatic cataract after being hit with a chestnut in the right eye. There were multiple injuries due to tiny thorns of the chestnut, including the conjunctiva, sclera, cornea, and anterior lens capsule. But no visible foreign body was detected by slit-lamp examination. Topical corticosteroid was prescribed to resolve the conjunctival inflammation induced by the thorns of chestnut, which could have caused persistent irritation. As conjunctival injection and edema being decreased during outpatient clinical follow-up, embedded conjunctival foreign body was detected and surgically removed (1st surgery). Approximately 10 weeks after the trauma, severe inflammation of the anterior segment accompanied with hypopyon developed suddenly and at the same time embedded scleral foreign body was revealed. After removal of scleral foreign body (2nd surgery), unspecified mold species was cultured from the scleral foreign body in SDA (Sabouraud dextrose agar) plate. Suspicious corneal foreign body was removed as 3rd surgery and phacoemulsification of traumatic cataract was planned as 4th surgery. Aspergillus was finally detected from removed anterior capsule and fibrotic membrane during the operation. Fungal infection resolved successfully after administration of topical (1% voriconazole and 5% natamycin) and systemic (fluconazole) antifungal agents and phacoemulsification of traumatic cataract.

Conclusion

Chestnut thorns can damage multiple ocular tissues simultaneously. Lens capsular rupture could result in fungal inoculation and lead to delayed lenticular fungal infection with complicated cataract formation. In cases of ocular trauma due to organic substances such as thorns and branches, the possibility of fungal infection should be considered.

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.

Diagnostic and Management Strategies of Aspergillus Endophthalmitis: Current Insights

Fungal endophthalmitis is subsequent to endogenous or exogenous infection and represents an important complication of ocular surgery which may lead to significant visual loss and blindness. The prognosis is poor because of delayed diagnosis and limited availability of effective antifungal drugs with good ocular penetration. Furthermore, the critical issue in diagnosing fungal infection of the eye is microbiological identification of the etiologic agent in clinical samples. Aspergillus is among the most frequent isolated organisms in fungal endophthalmitis. Early diagnosis is essential to prevent severe complications and blindness. Treatments include local, systemic and surgical therapeutic strategies. The purpose of the present review is the analysis of the current procedures adopted to promptly diagnose and treat Aspergillus endophthalmitis.

Isavuconazole for Treatment of Experimental Fungal Endophthalmitis Caused by Aspergillus fumigatus

Fungal endophthalmitis remains a significant cause of vision impairment and blindness. Moreover, the prognosis is poor, in part due to delay in diagnosis and to limited availability of effective antifungal agents with good ocular penetration. Thus, it is imperative to evaluate the therapeutic efficacy in fungal endophthalmitis of newer antifungal agents. In this study, we assessed the efficacy of isavuconazole in treating Aspergillus fumigatus endophthalmitis in an exogenous mouse model of the disease. Briefly, endophthalmitis was induced by intravitreal (IVT) injection of A. fumigatus spores into immunocompetent C57BL/6 (B6) mouse eyes. Mice were randomized into five groups that received isavuconazole via (i) oral gavage, (ii) IVT injections, (iii) intravenous injection, (iv) IVT injection followed by oral gavage, and (v) IVT injection followed by intravenous injection. Our data showed that isavuconazole treatment via all routes reduced fungal burden in A. fumigatus-infected eyes. This coincided with the preservation of retinal structural integrity (histology analysis) and retinal function (electroretinography [ERG] analysis), resulting in significantly improved disease outcome. Furthermore, isavuconazole treatment reduced the levels of inflammatory cytokines (tumor necrosis factor α [TNF-α], interleukin 1β [IL-1β], and IL-6) and cellular infiltration in the eyes. Notably, oral administration of isavuconazole was as effective in ameliorating endophthalmitis as intravitreal injection of the drug. Collectively, our study demonstrates that isavuconazole is effective in treating A. fumigatus endophthalmitis in mice, indicating its potential use in human ocular infections.

Intraocular Lymphoma or Infection? Subretinal Aspirate Confirms the Diagnosis

Purpose

To demonstrate the importance of subretinal biopsy to reach a diagnosis when vitreous biopsy is negative or inconclusive.

Methods

A 54-year-old Caucasian gentleman presented with bilateral anterior uveitis at JCUH. He initially responded to topical steroids and dilating agents. Subsequently he developed bilateral panuveitis and cataract with poor response to treatment. Detailed workup had been done to rule out infectious etiology. A suspicion of lymphoma was considered and vitreous biopsy sample was taken from one eye, which was inconclusive. Then, to help with definitive diagnosis vitreous sample, subretinal aspirate and retinal biopsy were taken.

Results

Subretinal aspirate revealed Aspergillus niger. Treatment was initiated accordingly.

Conclusions

Subretinal aspirate and retinal biopsy can help with diagnosis of unusual clinical panuveitis like presentation.

Microbial characteristics of post-traumatic infective keratitis

PURPOSE

To determine the demographics, risk factors, clinical and microbiological characteristics, and treatment outcome of post-traumatic infective keratitis.

METHODS

Consecutive patients with post-traumatic infective keratitis presenting to the Ophthalmology Department of a tertiary referral hospital in Singapore between March 2012 and March 2016 were prospectively identified. A standardized data collection form was used to document patient demographics, microbiological diagnosis, antibiotic sensitivity, and pretreatment and posttreatment ocular characteristics. Any contact lens-induced keratitis was excluded from the study.

RESULTS

In total, 26 patients were included for analysis. The mean age was 40.0 years (SD ± 19.4) and 84.6% of the patients were male. The majority of the patients (69.2%, n = 18) had sustained work-related injury in their eyes. Gram-negative organisms were predominant isolates (75.0%, n = 12) in culture-positive corneal scrapings (n = 16). Pan-sensitive Pseudomonas aeruginosa was the commonest organism isolated among the culture-positive cases (56.2%, n = 9). Three patients (18.7%) had developed fungal keratitis and Acanthamoeba was isolated in 1 patient (6.2%) with polymicrobial keratitis. Infections resolved with medical treatment in 22 eyes (84.6%) and 4 eyes (15.3%) required therapeutic corneal transplantation.

CONCLUSIONS

A shift of practice in post-traumatic infective keratitis should be considered in tropical countries to include Gram-negative cover. Work safety practices with vigilance in initiating treatment and education by front-line physicians such as ophthalmology and general practitioners should be reinforced.

Isolated endogenous Fusarium endophthalmitis in an immunocompetent adult after a thorn prick to the hand

Purpose

To report the case of an immunocompetent adult presenting with endogenous Fusarium endophthalmitis.

Observations

A woman in her thirties presented with symptoms and signs of a unilateral anterior uveitis. After initial improvement with topical corticosteroids, she continued to develop a panuveitis with an associated drop in vision to counting fingers. A vitreous biopsy confirmed Fusarium solani by 18S rRNA fungal gene detection and PCR sequencing. Despite treatment with pars plana vitrectomy, intravitreal amphotericin B and systemic voriconazole her visual outcome was poor. Detailed review of her antecedent history revealed the route of acquisition to be a thorn prick to the hand two weeks prior to presentation.

Conclusions and importance

This patient's endophthalmitis most likely resulted from cutaneous inoculation of Fusarium solani with subsequent hematogenous spread. Endogenous Fusarium endophthalmitis is well recognized in the immunocompromised but is very rarely seen in the immunocompetent. This case highlights the importance of thorough history-taking and consideration of fungal endophthalmitis in the differential diagnosis of a treatment-refractory uveitis.

Posttraumatic Endophthalmitis in children: Epidemiology, Diagnosis, Management, and Prognosis

Pediatric posttraumatic endophthalmitis presents with great complexities and challenges arising due to delayed presentation, difficulty in eliciting an accurate history, or trauma with unusual and highly contaminated objects. The possibility of initial misdiagnosis as panuveitis, metastatic endophthalmitis, and masquerade syndrome is also very high, which results not only in several unwarranted investigations being performed, but also a delay in the initiation of treatment. The standard treatment remains primary repair of the wound, intravitreal therapy with broad spectrum antibiotics, and parsplana vitrectomy. Despite appropriate intervention, visual outcome in children with posttraumatic endophthalmitis is dampened by additional factors like poor compliance with postoperative instructions and high risk of amblyopia. Hence, it is important to recognize that posttraumatic endophthalmitis in children differs from that in adults in several ways. We made a very tailored effort to review the published literature pertaining to posttraumatic endophthalmitis in children and herein present the results of our search.

Ocular infections caused by Candida species: Type of species, in vitro susceptibility and treatment outcome

PURPOSE

To report clinical and microbiological profile of patients with ocular candidiasis.

MATERIALS AND METHODS

Patients with ocular candidiasis were retrospectively identified from microbiology records. Significant isolates of Candida species were identified by Vitek 2 compact system. Minimum inhibitory concentration (MIC) of antifungal agents such as amphotericin B, itraconazole, voriconazole, fluconazole and caspofungin was determined by E test and of natamycin by microbroth dilution assay. Data on treatment and outcome were collected from medical records.

RESULTS

A total of 42 isolates of Candida were isolated from patients with keratitis-29, endophthalmitis-12 and orbital cellulitis-1. The most common species isolated was Candida albicans (12-keratitis, 4-endophthalmitis, 1-orbital cellulitis). All except one isolate were susceptible to amphotericin B. MIC of caspofungin was in the susceptible range in 28 (96.5%) corneal isolates while 12 out of 29 (41.3%) corneal isolates were sensitive to fluconazole. Resistance to voriconazole was seen in four corneal isolates. All isolates were susceptible to natamycin and all except two isolates were resistant or susceptible dose-dependent to itraconazole. Outcome of healed ulcer was achieved in 12/18 (66.6%) patients treated medically, while surgical intervention was required in 11 patients. Among the isolates from endophthalmitis patients, 11/12 were susceptible to amphotericin B, 6/12 to voriconazole and all to natamycin. Ten out of 11 patients (one patient required evisceration) with endophthalmitis were given intravitreal amphotericin B injection with variable outcome.

CONCLUSIONS

Ocular candidiasis needs early and specific treatment for optimal results. Candida species continue to be susceptible to most commonly available antifungals including amphotericin B, voriconazole and natamycin.

Causative Microorganisms of Infectious Endophthalmitis: A 5-Year Retrospective Study

This study aimed to identify the microbial etiology of infectious endophthalmitis and to determine the antibacterial susceptibilities of bacterial isolates at an eye hospital in South China. A retrospective analysis was carried out on 330 patients with clinically diagnosed infectious endophthalmitis who underwent microbiological evaluation from January 2010 to December 2014. Of the 330 patients, 193 patients (58.5%) had posttraumatic endophthalmitis, 67 patients (20.3%) had postoperative endophthalmitis, 61 patients (18.5%) had endogenous endophthalmitis, and 9 patients (2.7%) had postcorneal infective endophthalmitis. Of the 105 cases (31.8%) of culture-positive endophthalmitis, 79 cases (75.2%) had bacterial growth and 26 cases (24.8%) had fungal growth. In posttraumatic endophthalmitis, Gram-positive bacteria were the predominant species, followed by Gram-negative bacteria and fungi. In endogenous endophthalmitis, Gram-negative bacteria were the predominant species, followed by fungi and Gram-positive bacteria. In postsurgical endophthalmitis, all infections were bacterial. However, in postcorneal infective endophthalmitis, all infections were fungal. Overall, levofloxacin showed the highest activity against bacterial isolates. There was a significant difference in the susceptibility to tobramycin between the isolates from posttraumatic and postoperative endophthalmitis (p < 0.05). The results of this study identify the microbial spectrum of infectious endophthalmitis in this clinical setting.

Current Perspectives of Prophylaxis and Management of Acute Infective Endophthalmitis

Endophthalmitis is an intraocular inflammatory condition which may or may not be caused by infective agents. Noninfectious (sterile) endophthalmitis may be attributable to various causes including postoperative retained soft lens matter or toxicity following introduction of other agents into the eye. Infectious endophthalmitis is further subdivided into endogenous and exogenous. In endogenous endophthalmitis there is hematogenous spread of organisms from a distant source of infection whereas in exogenous endophthalmitis direct microbial inoculation may occur usually following ocular surgery or penetrating eye injury with or without intraocular foreign bodies. Acute infective endophthalmitis is usually exogenous induced by inoculation of pathogens following ocular surgery, open-globe injury and intravitreal injections. More infrequently the infective source is internal and septicemia spreads to the eye resulting in endogenous endophthalmitis. Several risk factors have been implicated including immunosuppression, ocular surface abnormalities, poor surgical wound construction, complicated cataract surgery with vitreous loss and certain types of intraocular lens. Comprehensive guidelines and recommendations on prophylaxis and monitoring of surgical cases have been proposed to minimize the risk of acute endophthalmitis. Early diagnosis and prompt management of infective endophthalmitis employing appropriately selected intravitreal antibiotics are essential to optimize visual outcome.

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.

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.

Outbreak of fungal endophthalmitis due to Fusarium oxysporum following cataract surgery

Outbreak of exogenous Fusarium endophthalmitis after cataract surgery was evaluated. Twenty patients developed postoperative endophthalmitis. In 19 eyes, pars plana vitrectomy (PPV) was performed, in 14 cases (74 %) with primary intraocular lens explantation. In one case, the PPV was not performed because of poor general condition of the patient. Symptoms of endophthalmitis (damaged vision, iritis, tyndallization in anterior chamber, hypopyon) occurred at intervals of 16-79 days (mean 31.3 days). Fungal etiology was documented in 12 eyes (60 %). Fusarium oxysporum was evidenced by culture and/or microscopy and confirmed by PCR and sequencing analysis. Eighteen (90 %) patients were treated with oral voriconazole (400 mg/day) for a period of 4-6 weeks. The final visual acuity was 6/15 in 1 case (5 %), 6/60 and worse in 17 eyes (85 %), and in 2 cases (10 %), enucleation had to be performed. Viscoelastic filling material was suggested the most likely source of infection. Endophthalmitis caused by Fusarium spp. are a potentially big threat for patients with serious impact on vision. Successful management of the infection is highly dependent on early diagnosis including species identification and antifungal susceptibility testing, and on aggressive and long-term treatment.

A multicentre prospective study of post-traumatic endophthalmitis

PURPOSE

Study the clinical and microbiological characteristics and the prognostic factors of post-traumatic endophthalmitis.

METHODS

Seventeen eyes were included between 2004 and 2010, with clinical and microbiological data collected prospectively. Conventional cultures and panbacterial PCR were performed on aqueous and vitreous samples.

RESULTS

Clinical signs of endophthalmitis were observed soon after trauma (1.5 ± 2.5 days). Laceration with an intraocular foreign body (IOFB) was noted in 53% of the patients. At admission, all patients had aqueous humour (71%) and/or vitreous (53%) samples. Fifteen patients (88%) underwent a pars plana vitrectomy. Bacteria were identified in 77% of the cases: Staphylococcus epidermidis (n = 5), Streptococcus (n = 4), Bacillus (n = 2), Pseudomonas stuzeri (n = 1), and Streptococcus salivarius and Gemella haemolysans (multibacterial infection, n = 1). Progression toward phthisis was observed in 35% of the cases; 41% of the patients recuperated visual acuity (VA) ≥20/40. A good final visual prognosis (≥20/40) was significantly associated with initial VA better than light perception (0% versus 70%, p = 0.01) and absence of pupillary fibrin membrane (80% versus 20%, p = 0.05). There was no correlation between visual prognosis and age, the type of laceration (corneal or scleral) or presence of an IOFB. We found a statistical trend toward an association between bacterial virulence and poor final VA.

CONCLUSION

This series showed that better final VA outcomes were associated with initial VA better than light perception, S. epidermidis or culture-negative cases and absence of retinal detachment during the clinical course.

Endophthalmitis: A review of recent trends

Endophthalmitis is a feared complication of trauma, surgical procedures and septicemia. Although uncommon, its potential for significant visual loss is well recognized. Especially over the past decade, complicated surgeries and medical techniques have increased and seriously ill patients are being sustained in ever increasing numbers. New pathogens are being recognized and known ones reclassified thanks to advances in molecular analysis. Continuously evolving PCR methodologies also add a new dimension to the diagnosis of infectious endophthalmitis. As well, medical literature is now truly international, encompassing studies from around the world that expand our understanding of ocular infectious disease. This report reviews some of these changes as they relate to endophthalmitis and particularly to the spectrum of organisms involved.

Intravitreally implantable voriconazole delivery system for experimental fungal endophthalmitis

PURPOSE

To investigate the therapeutic efficacy and optimal drug dose of an intravitreally implantable voriconazole (VCZ) drug delivery system (DDS) in experimental endophthalmitis of Aspergillus fumigatus.

METHODS

Vitrectomy was performed in albino rabbits with intravitreal inoculation of susceptible A. fumigatus. The animals were randomized into groups of control, polylactic-co-glycolic acid implantation, VCZ injection, and intravitreal VCZ DDS containing 0.5, 0.9, and 1.2 mg of VCZ, respectively. The therapeutic effect was assessed by clinical observation, histology, and microbiology.

RESULTS

The inflammation in the VCZ injection and DDS groups was milder than the untreated and polylactic-co-glycolic acid groups (P ≤ 0.046). The 0.9-mg and 1.2-mg DDS groups presented milder anterior chamber and vitreous inflammation than the injection group during the first 3 weeks (P ≤ 0.044), but only the 1.2-mg DDS group had clearer vitreous thereafter (P ≤ 0.037). Smear and fungal culture showed negative results in all DDS groups. Normal histologic structure of the retina was observed in the eyes recovering from endophthalmitis.

CONCLUSION

The therapeutic effect of intravitreal VCZ DDS on fungal endophthalmitis appears to be significantly better than intravitreal injection of VCZ. The optimal dose of VCZ in the DDS in this study was 1.2 mg.

Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002-2009)

PURPOSE

To evaluate acute-onset postoperative endophthalmitis occurring at an academic medical center and to compare rates over the last 25 years at a single institution.

DESIGN

Retrospective, consecutive case series.

METHODS

Medical records were reviewed for all patients diagnosed with acute-onset postoperative nosocomial endophthalmitis from 2002 through 2009 associated with surgery at Bascom Palmer Eye Institute.

RESULTS

The 8-year frequency of acute-onset postoperative endophthalmitis was 0.025% (14 of 56 672 intraocular surgeries). The rate was 0.028% (8/28 568) for cataract surgery and 0.011% (2/18 492) for pars plana vitrectomy (PPV). Both PPV endophthalmitis cases followed 20-gauge surgery and no cases followed small-gauge, transconjunctival PPV (n = 2262). Three cases occurred following penetrating keratoplasty (3/2788, 0.108%). The most common bacterial isolate was Staphylococcus (n = 7, 50%). Initial treatment involved ocular paracentesis (n = 8, 57%) or vitrectomy (n = 5, 36%), in combination with injection of intraocular antibiotics (n = 14, 100%). Vancomycin and ceftazidime were used in 13 eyes (93%) and intraocular steroids were given initially to 9 eyes (64%). Final visual acuity was > or =20/200 in 9 eyes (64%) and 2 eyes (14%) were no light perception. At this institution since 1984, there has been a statistically significant trend for a decreasing rate of acute-onset postoperative endophthalmitis (1984-1994: 0.09%; 1995-2001: 0.05%; 2002-2009: 0.025%; P < .001).

CONCLUSION

At a university teaching hospital involving resident, fellow, and faculty surgeons, the frequency of acute-onset postoperative nosocomial endophthalmitis is low, has not increased in the era of sutureless clear corneal cataract surgery, and has steadily decreased when compared to prior time periods from the same institution.

Invasive aspergillosis in developing countries

To review invasive aspergillosis (IA) in developing countries, we included those countries, which are mentioned in the document of the International Monetary Fund (IMF), called the Emerging and Developing Economies List, 2009. A PubMed/Medline literature search was performed for studies concerning IA reported during 1970 through March 2010 from these countries. IA is an important cause of morbidity and mortality of hospitalized patients of developing countries, though the exact frequency of the disease is not known due to inadequate reporting and facilities to diagnose. Only a handful of centers from India, China, Thailand, Pakistan, Bangladesh, Sri Lanka, Malaysia, Iran, Iraq, Saudi Arabia, Egypt, Sudan, South Africa, Turkey, Hungary, Brazil, Chile, Colombia, and Argentina had reported case series of IA. As sub-optimum hospital care practice, hospital renovation work in the vicinity of immunocompromised patients, overuse or misuse of steroids and broad-spectrum antibiotics, use of contaminated infusion sets/fluid, and increase in intravenous drug abusers have been reported from those countries, it is expected to find a high rate of IA among patients with high risk, though hard data is missing in most situations. Besides classical risk factors for IA, liver failure, chronic obstructive pulmonary disease, diabetes, and tuberculosis are the newly recognized underlying diseases associated with IA. In Asia, Africa and Middle East sino-orbital or cerebral aspergillosis, and Aspergillus endophthalmitis are emerging diseases and Aspergillus flavus is the predominant species isolated from these infections. The high frequency of A. flavus isolation from these patients may be due to higher prevalence of the fungus in the environment. Cerebral aspergillosis cases are largely due to an extension of the lesion from invasive Aspergillus sinusitis. The majority of the centers rely on conventional techniques including direct microscopy, histopathology, and culture to diagnose IA. Galactomannan, β-D glucan test, and DNA detection in IA are available only in a few centers. Mortality of the patients with IA is very high due to delays in diagnosis and therapy. Antifungal use is largely restricted to amphotericin B deoxycholate and itraconazole, though other anti-Aspergillus antifungal agents are available in those countries. Clinicians are aware of good outcome after use of voriconazole/liposomal amphotericin B/caspofungin, but they are forced to use amphotericin B deoxycholate or itraconazole in public-sector hospitals due to economic reasons.

Intravitreal injection of therapeutic agents

BACKGROUND

Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study.

METHODS

A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated.

RESULTS

The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects.

CONCLUSION

The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.

Exogenous fungal endophthalmitis: microbiology and clinical outcomes

OBJECTIVE

To report the fungal isolates, treatment strategies, and clinical outcomes for a large series of patients with exogenous fungal endophthalmitis.

DESIGN

Retrospective, single institution, consecutive case series.

PARTICIPANTS

All patients treated at Bascom Palmer Eye Institute between January 1, 1990, and June 30, 2006, for culture-proven exogenous fungal endophthalmitis.

METHODS

Microbiologic and medical records were reviewed for all patients with intraocular cultures positive for fungal organisms and clinically diagnosed exogenous endophthalmitis.

MAIN OUTCOME MEASURES

Fungal isolates, treatment strategies, visual acuity, and rate of enucleation.

RESULTS

Culture-positive exogenous fungal endophthalmitis occurred in 41 eyes, including 18 cases (44%) associated with fungal keratitis, 10 cases (24%) occurring after penetrating ocular trauma, and 13 cases (32%) after intraocular surgery. Filamentous fungi (molds) accounted for 35 cases (85%), and Candida species (yeasts) accounted for 6 cases (15%). Although most keratitis cases were caused by Fusarium (13 of 18; 72%), Aspergillus was the most common isolate in postoperative cases (5 of 13; 38%). Open-globe cases were caused by a broader spectrum of fungi. As initial treatment, 30 (73%) patients received intraocular amphotericin B, but at least 3 antifungal agents were used in 24 (59%) cases. At least 1 pars plana vitrectomy was performed in 25 (61%) eyes, and 29 (71%) eyes underwent 3 or more procedures, including surgeries and intraocular injections. Although a final vision of 20/400 or better was achieved in 22 (54%) eyes, all but 1 of these were either in the keratitis (11 of 18) or the postoperative (10 of 13) groups. Conversely, although 10 (24%) of 41 eyes were enucleated, 7 of these were among the open-globe patients.

CONCLUSIONS

This report highlights the differences between the clinical categories of exogenous fungal endophthalmitis. Although 85% of all cases were caused by molds, most commonly Fusarium and Aspergillus, the most common fungal genera varied by clinical category. Amphotericin B was the most commonly used antifungal agent, but most cases were treated with at least 3 different antifungal agents. Final visual outcomes were variable, with the open-globe-associated patients having the poorest outcomes. Overall, 44% of patients achieved a final visual acuity of 20/80 or better.

[Mycotic infections of the eye]

Mycotic infections of the eye continue to be an important cause of ocular morbidity. Etiological factors and symptoms are useful for the diagnosis of fungal infections. Mycotic keratitis may be seen after trauma with vegetable material, or in previously diseased eyes. The most common pathogens are Candida, Fusarium, Aspergillus. Clinical features, like the pyramidal Hypopyon, can differentiate fungal from bacterial infections. Mycotic Endophthalmitis refers to intraocular inflammation caused by Candida, Aspergillus, and Cryptococcus. Exogenous mycotic endophthalmitis follows intraocular surgery or trauma. Endogenous mycotic endophthalmitis is frequently an ocular manifestation of a systemic disease. Early diagnosis should be made to ensure prompt initiation of antifungal therapy, to prevent visual loss.