Twenty years of endophthalmitis: Incidence, aetiology and clinical outcome

Rates of endophthalmitis before and after transition from povidone-iodine to aqueous chlorhexidine asepsis for intravitreal injection

OBJECTIVE

To assess the rate of post-intravitreal injection endophthalmitis between 2 asepsis groups: aqueous chlorhexidine 0.1% and povidone-iodine 5%.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Patients with infectious endophthalmitis post intravitreal injection (n = 58) at a single centre from July 2009 to July 2022.

METHODS

Retrospective chart review of all patients receiving intravitreal injections (216 593 injections) at a single centre over 14 years. Patients from July 2009 to February 2017 received povidone-iodine 5%, and patients from March 2017 to July 2022 received aqueous chlorhexidine 0.1%. Assessed characteristics of endophthalmitis cases included demographics, visual function, intervention type, and microbiological results.

RESULTS

The rate of endophthalmitis was comparable for povidone-iodine (1.4:5000) and aqueous chlorhexidine (1.3:5000) (p = 0.77). Vitreous cultures were negative for 55% of patients. Visual acuity (VA) outcomes did not differ between asepsis groups nor between culture positive/negative groups. Patients having vitrectomy (PPV) had worse final vision (p = 0.08) but there was no VA difference between early and late PPV.

CONCLUSIONS

Aqueous chlorhexidine 0.1% is a viable and safe alternative to povidone-iodine 5% for post-intravitreal injection endophthalmitis prophylaxis and may reduce ocular surface adverse events and discomfort.

Microbiological Characteristics and Risk Factors Involved in Progression from Fungal Keratitis with Hypopyon to Keratitis-Related Endophthalmitis

PURPOSE

To investigate the differences in microbiological characteristics, risk factors, drug resistance, and visual outcomes in three infections: fungal keratitis with hypopyon (FKH), keratitis-related fungal endophthalmitis (FKE), and fungal endophthalmitis without keratitis (FE).

METHODS

An analytical cross-sectional study.

RESULTS

In total, 14.57% of eyes with FKH progressed to endophthalmitis. Hypopyon, pre-existence of lens problems, topical steroid use and sever keratitis were significantly associated with the development of FKE. The risk factors of the FKH and FE group were mainly plant trauma and open globe trauma, respectively. Keratitis-related endophthalmitis (FKE) showed a significantly higher resistance than the other two groups. The FKH group had the best final visual acuity, while the FKE group had the worst.

CONCLUSION

Hypopyon height, pre-existing lens problems, topical steroid use and sever keratitis are risk factors for progression to endophthalmitis in eyes with fungal keratitis, and its progression is not affected by a single fungus. The antifungal drugs resistance in patients with endophthalmitis related to keratitis was significantly higher than that associated with other reasons. Timely diagnosis and risk factor assessment are essential for ensuring early treatment of FKE.

Risk Factors for Legal Blindness in 77 Japanese Patients with Endogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential predictive factors for visual prognosis in Japanese patients with endogenous endophthalmitis.

DESIGN

Retrospective observational multicenter cohort study.

METHODS

We examined the characteristics of 77 Japanese patients with endogenous endophthalmitis and performed statistical analyses of these real-world data. The primary endpoint was the identification of factors associated with visual prognosis. We examined differences between patients in the better vision and legal blindness groups at 12 weeks after treatment initiation.

RESULTS

The five risk factors for visual impairment at 12 weeks after treatment initiation were presence of pressure injuries, severe clinical symptoms (presence of eye pain and ciliary injection), pathogen identification, and poor best-corrected visual acuity at baseline. Staphylococcus aureus and fungus were associated with a better visual impairment outcome.

CONCLUSIONS

Endogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatments, as well as other advances in medical knowledge and technology.

Estimated direct and indirect health care costs of severe infectious keratitis by cultured organisms in Thailand: An 8-year retrospective study

PURPOSE

To evaluate the economic impact of treating severe infectious keratitis (IK) at one tertiary referral center in Thailand by analyzing the direct costs of treatment and estimating the indirect costs, and to determine whether cultured organisms had any effect on treatment expenditure.

METHODS

A retrospective study was conducted of patients with severe IK who had been hospitalized between January 2014 and December 2021 in Rajavithi Hospital. Data from medical records were collected from the time of the patients' admission until the point at which they were discharged and treated in the outpatient department and their IK was completely healed, or until evisceration/enucleation was performed. The direct costs of treatment included fees for services, medical professionals and investigation, as well as for operative and non-operative treatment. The indirect costs consisted of patients' loss of wages, and costs of travel and food.

RESULTS

A total of 335 patients were studied. The median direct, indirect and total costs were US$65.2, range US$ 6.5-1,119.1, US$314.5, range US$50.8-1,067.5, and US$426.1, range 57.5-1,971.5 respectively. There was no statistically significant difference between direct, indirect, or total treatment costs for culture-negative and culture-positive patients. Among those who were positive, fungal infections entailed the highest total cost of treatment, and this difference was statistically significant (p<0.001). In terms of direct and indirect costs, patients with fungal infections had the greatest direct costs, and this figure was statistically significant (p = 0.001); however, those with parasitic infections had the highest indirect treatment costs, and this was also statistically significant (p<0.001).

CONCLUSION

Severe IK can cause serious vision impairment or blindness. Indirect costs represented the majority of the expense at 73.8%. There was no difference between direct, indirect, and total treatment costs for patients who were culture-negative or positive. Among the latter, fungal infections resulted in the highest total cost of treatment.

An All-in-One Highly Multiplexed Diagnostic Assay for Rapid, Sensitive, and Comprehensive Detection of Intraocular Pathogens

PURPOSE

Intraocular infections are sight-threatening conditions that can lead to vision loss. Rapid identification of the etiologies plays a key role in early initiation of effective therapy to save vision. However, current diagnostic modalities are time consuming and lack sensitivity and inclusiveness. We present here a newly developed comprehensive ocular panel designed to improve diagnostic yields and provide a tool for rapid and sensitive pathogen detection.

DESIGN

Experimental laboratory investigation.

METHODS

A panel containing 46 pathogens and 2 resistance/virulence markers that are commonly detected in intraocular infections was developed. Genomic targets were scrutinized for stretches predicted to be specific for a particular species while being conserved across different strains. A set of primers for sample enrichment, and two 50mer NanoString compatible probes were then designed for each target. Probe-target hybrids were detected and quantified using the NanoString nCounter SPRINT Profiler. Diagnostic feasibility was assessed in a pilot clinical study testing samples from infectious retinitis (n = 15) and endophthalmitis (n = 12) patients, for which the etiologies were confirmed by polymerase chain reaction (PCR) or culture.

RESULTS

Analytical studies demonstrated highly sensitive detection of a broad spectrum of pathogens, including bacteria, viruses, and parasites, with limits of detection being as low as 2.5 femtograms per reaction. We also found excellent target specificity, with minimal cross-reactivity detected. The custom-designed NanoString ocular panel correctly identified the causative agent from all clinical specimens positive for a variety of pathogens.

CONCLUSION

This highly multiplexed panel for pathogen detection offers a sensitive, comprehensive, and uniform assay run directly on ocular fluids that could significantly improve diagnostics of sight-threatening intraocular infections.

Rapid treatment of endophthalmitis with intravitreal antibiotics is associated with better vision outcomes

BACKGROUND

To discover whether the timing of intravitreal antibiotics, from the time of presentation to injection, affects the visual outcomes of patients with endophthalmitis from all causes.

METHODS

A retrospective study of consecutive patients managed at Auckland District Health Board between 1 January 2004 and 1 July 2021. The main outcome measure was final visual acuity at follow-up and the proportion of subjects with severe vision loss (≤6/60).

RESULTS

Three hundred and seventy-four eyes were included in the study, with a median age of 69.7 years at presentation; 192 subjects (51.6%) were female. The median presenting visual acuity was hand movements and hypopyon was present in 194 subjects (51.9%). Cataract surgery was the most frequent aetiology in 115 subjects (30.7%), followed by intravitreal anti-vascular endothelial growth factor injections in 89 subjects (23.8%) and endogenous endophthalmitis in 54 subjects (14.4%). Median time to injection of intravitreal antibiotics was 3.5 h (Interquartile range 2-6). On multivariate analysis, early treatment with intravitreal antibiotics was associated with better visual outcome, particularly for those treated within 2 h, while poor presenting visual acuity and culture-positive endophthalmitis were associated with worse outcomes.

CONCLUSION

Rapid intravitreal antibiotic administration is associated with better final visual acuity outcomes, particularly for those receiving treatment within 2 h of presentation. Patients with severe vision loss on presentation, benefit the most with improved final visual acuity following expedited treatment.

Risk Factors for Legal Blindness in 237 Japanese Patients with Exogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential risk factors for visual prognosis in Japanese patients with exogenous endophthalmitis.

METHODS

In this retrospective observational multicenter cohort study, risk factors for legal blindness at 12 weeks after treatment initiation were evaluated based on patient characteristics, initial BCVA, causative events, pathogens, ocular symptoms, duration from symptom onset to initial treatment, and selected treatments.

RESULTS

Overall, 23.1% of eyes developed legal blindness. The six risk factors for legal blindness were presence of eye pain, pathogen identification, poor BCVA at the initial visit, longer duration from symptom onset to initial treatment, type of causative event, and type of causative pathogen. Regarding the type of causative pathogen, coagulase-negative staphylococci was associated with a better visual impairment outcome.

CONCLUSION

Exogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatment, as well as other advances in medical knowledge and technology.

Intravitreal injections as a leading cause of acute postoperative endophthalmitis-a regional survey in England

BACKGROUND

To evaluate the characteristics, treatment patterns and outcomes of acute postoperative endophthalmitis.

METHODS

Patients presenting with acute postoperative endophthalmitis between January 2017 to December 2019 were identified from hospital records in this multicentre retrospective cohort study. Clinical records were reviewed for visual acuity (VA) at various timepoints, cause of endophthalmitis, microbiological results, treatments and complications.

RESULTS

Forty-six eyes of 46 patients were included. Intravitreal injections were the leading cause of acute postoperative endophthalmitis (n = 29; 63%), followed by cataract surgery (n = 8; 17%), vitreoretinal surgery (n = 7; 15%), and secondary intraocular lens insertion (n = 2, 4%). The absolute risk of endophthalmitis was 0.024% (1:4132) for intravitreal injections, 0.016% (1:6096) for cataract surgery, and 0.072% (1:1385) for vitreoretinal surgery. The majority of patients (n = 38; 83%) had better VA at 6 months compared to presentation, although fewer (n = 13; 28%) maintained similar or better VA compared to before the precipitating surgery. Twenty-four cases yielded positive culture results, of which staphylococcus epidermidis was the most commonly isolated organism. Microbiological yield was not associated with better final visual outcomes. Patients who underwent therapeutic vitrectomy (n = 15; 33%) had poorer VA at presentation, but subsequently achieved visual outcomes comparable to those who received medical treatment alone. There was no difference in time to presentation, visual outcome and retinal detachment rates among the different causative procedures.

CONCLUSION

Intravitreal injections were the most common cause of endophthalmitis in our region, primarily because of their higher frequency compared to other intraocular procedures. In this cohort, the primary procedure had no effect on presentation, management or visual outcomes.

Highlighting the Microbial Contamination of the Dropper Tip and Cap of In-Use Eye Drops, the Associated Contributory Factors, and the Risk of Infection: A Past-30-Years Literature Review

The sterility of eye drop content is a primary concern from manufacturing until opening, as well as during handling by end users, while microbial contamination of the dropper tip and cap are often disregarded. The contamination of these sites during drug administration represents a risk of microbial transmission and ocular infection. In this review, we aim to assess microbial contamination of the dropper tip and cap of in-use eye drops, the associated contributory factors, and the risk of infection. We conducted a literature search of the MEDLINE, PubMed, and Cochrane Central databases. A total of 31 out of 1503 studies were selected. All the studies conducted in different settings that documented microbiologically contaminated in-use eye drops were included. Our review showed that microbial contamination of the dropper tip and cap of in-use eye drops ranged from 7.7 to 100% of the total contaminated tested samples. Documented contributory factors were conflicting across the literature. Studies investigating the association between eye infection and microbial contamination of the dropper tip and cap were scarce. New technologies offer a promising potential for securing the long-term sterility of eye drop content, tips, and caps, which could benefit from more research and well-defined study protocols under real-life scenarios.

Microbial contamination of multiple-dose preservative-free hospital ophthalmic preparations in a tertiary care hospital

Background

It is possible that preservative-free eye drops can be contaminated. The aim of this study was to assess the incidence of microbial contamination of preservative-free hospital-prepared anti-infective eye drops and investigate factors that contribute to contamination. This finding may help to raise awareness of this problem to medical healthcare staff and patients in order to prevent the transmission of microorganisms from eye drops to the patients through treatment of pre-existing eye diseases.

Methods

Two hundred and ninety-five eye drop bottles were collected from patients attending Rajavithi Hospital Ophthalmologic outpatient and inpatient department, including both those used by patients at home and those administered in the hospital by medical staff. Samples were taken from the tips of droppers and bottles, and the residual fluid inside the bottles was then cultivated onto different culture plates. The culture results were identified and analyzed according to various factors related to both individual users and the bottles.

Results

Seven different types of eye drops were collected and 71 (24.06%) of the 295 bottles were contaminated. Vancomycin eye drops were the most contaminated. Twenty-six different types of pathogens were identified, most frequently mold (42.98%), and the amount of contamination was higher in tips than in residual fluid inside the bottle. There was no statistically significant difference in contamination between patients used eye drops collected in outpatient units (32.14%) and medical staff used eye drops collected in inpatient settings (23.22%). The only factor that was statistically significant was the number of eye drops used per person. We found that samples from patients who used only up to 2 eye drops suffered contamination (42.8%) more than those from their counterparts who used at least 3 (22.18%), P ​= ​0.02.

Conclusions

Of these preservative-free hospital preparations anti-infective eye drops, 24.06% were contaminated. The number of eye drops used per person was statistically significant in triggering contamination. There is a possibility of number of eyedrops use person may trigger contamination.

Association Between Endophthalmitis and the Incidence of Acute Coronary Syndrome in Patients With Ankylosing Spondylitis: A Nationwide, Population-Based Cohort Study

Purpose

Ankylosing spondylitis (AS) is a risk factor for acute coronary syndrome (ACS). However, the influence of infectious insults, such as endophthalmitis, on the risk of ACS among AS patients has not been studied yet. In this study, we aimed to investigate the relationship between endophthalmitis in patients with AS and the incidence of ACS.

Methods

This retrospective cohort study extracted medical records from the Taiwan Longitudinal Health Insurance Database (LHID) from January 1, 2000, to December 31, 2015. The primary outcome was the incidence of ACS. Univariate and multivariate Cox regression analyses with and without Fine and Gray’s competing risk model and Kaplan–Meier survival curve were used for the analyses. Spearman’s rank correlation coefficient was performed for sensitivity analysis.

Results

We identified 530 AS patients with endophthalmitis and 2,120 AS patients without endophthalmitis for comparison. The incidence rate of endophthalmitis in our study population was 2.66%. The overall incidence rate of ACS was 1,595.96 per 100,000 person-years in AS patients with endophthalmitis and 953.96 per 100,000 person-years in AS patients without endophthalmitis (adjusted HR = 1.787; 95% CI: 1.594–2.104, p < 0.001). In comparison to those without comorbidities, higher adjusted HRs were found in AS patients with endophthalmitis and comorbidities such as diabetes mellitus, hyperlipidemia, hypertension, cerebrovascular accident, congestive heart failure, chronic obstructive pulmonary disease, asthma, and coronary artery disease. Besides, the age ≥ 60 years revealed a high risk for ACS in AS patients with endophthalmitis.

Conclusion

Endophthalmitis was found to be an independent risk factor for ACS in patients with AS. Further clinical studies are required to elucidate the underlying mechanisms and status of systemic inflammation during endophthalmitis.

Molecular Diagnostics for Ocular Infectious Diseases: LXXVIII Edward Jackson Memorial Lecture

PURPOSE

To review the use of molecular diagnostic techniques in the management of ocular infectious disease.

DESIGN

Retrospective review.

METHODS

A combination of literature review and personal recollections are used.

RESULTS

Although the broad term molecular diagnostics may encompass techniques to identify pathogens via protein or metabolomic signatures, this review concentrates on detection of pathogen nucleic acid as an indicator of infection. The introduction of the polymerase chain reaction (PCR) in 1985 opened a new era in analysis of nucleic acids. This technique was soon applied to the detection of potential pathogen DNA and RNA, including viruses, bacteria, and parasites in infectious eye disease. Advances in PCR have allowed class-specific diagnostics (ie, pan-bacterial and pan-fungal), quantitation of pathogen DNA, and multiplexed testing. The Human Genome Project in the early 2000s greatly accelerated development of DNA sequencers, ushering in the era of "Next Generation Sequencing" and permitting pathogen-agnostic methods for the detection of potential infectious agents. Most recently, new technologies such as nanopore sequencing have reduced both cost and equipment requirements for whole-genome sequencing; when coupled with real-time sequence analysis methods, these methods offer the promise of true, real-time, point-of-service ocular infectious disease diagnostics.

CONCLUSIONS

Molecular methods for pathogen detection have greatly advanced the diagnosis of ocular infectious disease. Further methodologic advances will have a direct impact on the management of these conditions.

Bilateral simultaneous postoperative endophthalmitis (BSPOE): Review of cases reported over the past 50 years

ABSTRACT

A detailed retrospective analysis and literature review were conducted for all previously published reports of bilateral simultaneous postoperative endophthalmitis (BSPOE) since 1970. There have been seven (nine including the companion paper, and 1 reported elsewhere) cases of BSPOE after immediately sequential bilateral cataract surgery (ISBCS) reported over 50 years. Generally, in these cases, the surgical protocol recommended by the International Society of Bilateral Cataract Surgeons (iSBCS) was breached or uncertain. Bacterial causes were Pseudomonas aeruginosa (3), Staphylococcus epidermidis (3), Burkholderia cepacia complex (1), negative (1) and not determined (1). Visual recovery was light perception, or worse, for Pseudomonas cases, generally good for Staphylococcus and Burkholderia cases, and mixed in cases of unknown etiology. Therefore, BSPOE is rare, and causes vary. Strict adherence to the iSBCS General Principles of Excellence in ISBCS, 2009 surgical protocol and care with operating room construction seem to considerably lessen the risk.

Bacterial Burden Declines But Neutrophil Infiltration and Ocular Tissue Damage Persist in Experimental Staphylococcus epidermidis Endophthalmitis

Coagulase-negative staphylococci (CoNS), including Staphylococcus (S) epidermidis, are responsible for ~70% of all post-surgical endophthalmitis, a potentially blinding eye infection. However, the pathobiology of CoNS endophthalmitis is limited to epidemiological and clinical case studies with few experimental studies. Here, we report both in vitro and in vivo models to study the pathobiology of S. epidermidis endophthalmitis in mice. We found that S. epidermidis is rapidly cleared from mouse eyes, and a relatively higher dose (i.e., 10⁷ CFU/eye) was needed to cause endophthalmitis. Our time-course study revealed that bacterial load peaked at 24 h post-infection followed by a gradual decline up to 72 h. A similar time-dependent decrease in levels of inflammatory mediators and Toll-like receptor (TLR) expression was also observed. In contrast, neutrophil infiltration continued to increase up to 72 h coinciding with significant retinal tissue damage and loss of visual function. In vitro, S. epidermidis induced the activation of various inflammatory signaling pathways (i.e., NF-kB, ERK, and P38) and the production of both cytokines and chemokines in mouse BMDMs, human RPE, and retinal Muller glia. Altogether, we show that bacterial burden is reduced in S. epidermidis endophthalmitis, while tissue damage and visual function loss continue. Thus, our study provides new insights into the pathogenesis of CoNS endophthalmitis.

Clinical Characteristics and Outcomes in 314 Japanese Patients with Bacterial Endophthalmitis: A Multicenter Cohort Study from J-CREST

Bacterial endophthalmitis is an intraocular infection that causes rapid vison loss. Pathogens can infect the intraocular space directly (exogenous endophthalmitis (ExE)) or indirectly (endogenous endophthalmitis (EnE)). To identify predictive factors for the visual prognosis of Japanese patients with bacterial endophthalmitis, we retrospectively examined the bacterial endophthalmitis characteristics of 314 Japanese patients and performed statistics using these clinical data. Older patients, with significantly more severe clinical symptoms, were prevalent in the ExE group compared with the EnE group. However, the final best-corrected visual acuity (BCVA) was not significantly different between the ExE and EnE groups. Bacteria isolated from patients were not associated with age, sex, or presence of eye symptoms. Genus Streptococcus, Streptococcus pneumoniae, and Enterococcus were more prevalent in ExE patients than EnE patients and contributed to poor final BCVA. The presence of eye pain, bacterial identification, and poor BCVA at baseline were risk factors for final visual impairment.